Standards for

the Management

of open fractures

of the lower limb

Dr Nikki Walsh

18.2.2013

BOA/BAPRAS

2009 last update – 20 principal recommendations

Open fractures of lower limb – below knee

Few randomized trials

Evidence based plus data from associated areas and experience of the working party

Specialist centres

Orthopaedic surgeons and plastic surgeons

British Infection Society and Association of Medical Microbiologists reviewed guidelines on antibiotic prophylaxis

Recommendation 1:Specialist

Centres

MDT approach

Characteristics of open injuries requiring referral to specialist centre

Fracture pattern

Transverse or short oblique with similar level fibular fracture

Tibial fracture comminution with similar level fibular fracture

Segmental tibial fractures

Fractures with bone loss

Soft tissue Injury pattern

Skin loss

Degloving

Injury requiring excision of devitalised muscle via wound extension

Arterial injury

2. ED Management

ATLS

Careful assessment

Photograph

Minimal handling – no ‘provisional cleaning’

Control haemorrhage with pressure

Sterile dressing

IVAB’s

Anti-tetanus prophylaxis

Splintage – No provisional external fixators

Radiographic assessment to include 2 orthogonal views of tibia plus knee and ankle joint

3. Antibiotic prophylaxis

ASAP, ideally within 3 hours of injury

Cephalosporin 1.5g TDS until 1st debridement

At time of debridement

Cephalosporin

Gentamicin 1.5mg/Kg

Continued until soft tissue closure or 72 hours

On induction of anaesthesia for skeletal stabilization– above and

Vancomycin 1g or teicoplanin 800mg

Clindamycin if allergic to penicillin/cephalosporin

4. Timing of wound excision

Immediate

Gross contamination

Compartment syndrome

Devascularized limb

Multiple – injured patient

Marine/agricultural or sewage contamination

Senior orthopaedic and plastic surgeons working together

on a scheduled trauma operating list, within normal

working hours and within 24 hours of injury

5. Wound debridement

Excision of all devitalised tissue (except neurovascular bundles)

Wash with soapy solution and tourniquet applied

Prep with alcoholic chlorhexidine solution avoiding contact with open wound

Systematic debridement and assessment from superficial to deep and from the periphery to the centre of the wound

Classify wound and plan definitive reconstruction

If definitive skeletal stabilisation and soft tissue coverage is not undertaken in a single setting – apply VAC +/- antibiotic bead pouch

6. Debridement of bone

Extend traumatic wounds along nearest fasciotomy

incision

Deflate tourniquet before bone debridement to assess

viability

Careful surgical delivery of bone ends through the wound

Remove fragments which fail to ‘tug test’

Major articular fragments preserved as long as they can

be reduced and fixed with absolute stability

Lavage – high pressure pulsatile lavage Not

recommended

7. degloving

Thrombosis of subcutaneous veins usually indicates the

need to excise the overlying skin

Circumferential degloving often indicates that the involved

skin is not viable

Severe injuries – multi-planar degloving – second stage

debridement may be needed

8. Classification of open

fractures

Accurate, simple and reproducible system

Gustillo and Anderson best applied after wound excision

9. Temporary Wound dressings

VAC

Antibiotic impregnated beads under a semi-permeable

membrane

combination

10. Skeletal stabilisation

Spanning Ex-fix

Change from ex-fix to definitive fixation as early as

possible

Internal fixation safe if minimal contamination and soft

tissue coverage at same time.

Multiplanar/circular fixators if significant contamination,

bone loss and multilevel fractures of the tibia

11. Timing of soft tissue

reconstruction

Local flaps same time as fixation

Free flaps

on scheduled trauma lists

Dedicated specialist team

after CT scan, angiography as needed

Little evidence for 5 day rule

Microsurgery best performed in first week

Recommend definitive soft tissue reconstruction within first 7 days

12. Types of soft tissue

reconstruction

All open fractures covered with vascularised soft tissue

Low energy injuries can be covered by local

fasciocutaneous flaps

Diaphyseal tibial fractures with periosteal stripping best

covered by muscle flaps rather than fasciocutaneous flaps

Metaphyseal fractures – fasciocutaneous flaps including

free flaps

13. Compartment syndrome

Diagnose and treat early

Clinical picture may be distorted by nerve injury

Loss of pulses usually due to vascular injury

Measure intracompartment pressures

Inappropriate fasciotomy can be associated with significant morbidity

2 incision, 4 compartment decompression

Late diagnosis may result in amputation

14. Vascular injuries

Immediate management

Aim to restore vascularity within 3-4 hours of the injury

Maximum acceptable delay is 6 hours warm ischaemic

time

Shunting reduces ischaemic time

Stabilise skeleton, then replace shunts

Assess if limb is salvagable

15. Open fractures of foot and

ankle

Challenging as limited soft tissue flap options

Consider amputation vs final functional outcome

Initial fixation with spanning ex-fix, no fibular plate at initial stage

Difficulties with distal anchor points for ex-fix

Definitive fixation at same time as soft tissue coverage

Consider amputation with open hind foot, open mid-foot injuries.

Ist Metatarsal injuries treated aggressively. Ray amputation for

lesser MT’s.

16. Things go wrong with soft

tissues

Revision to healthy tissue

Leeches for limited tip congestion

Revascularization if needed

Some local fasciocutaneous flaps may be more prone to

develop complications in patients with comorbidities.

17. Bone complications

Wound leakage

Sepsis

Loss of alignment

Common causes include

Inadequate debridement

Haematoma formation

Inapproriate or delayed soft tissue cover

Unstable fixation

Each cause is sought and remedied promptly

18 Primary amputation

Damage control – uncontrollable haemorrhage, crush

injuries with warm ischaemic time > 6 hours

Incomplete traumatic amputations