Compound Fractures

 

Definition

 

Fracture with break in skin communicating with fracture or fracture hematoma

- contamination with micro-organisms

- leads to increased risk in infection and healing problems

 

Gustilo Classification

 

  Grade I Grade II Grade III A Grade III B Grade III C
Definition Wound < 1 cm Wound 1 - 10 cm Wound > 10 cm Requires skin graft / flap for coverage Vascular injury
Infection rate          
Antibiotics Cephalosporin Cephalosporin + Gentamycin

Cephalosporin + Gentamycin

+/- penicillin - farm injury

+/- Ciprofloxacin - fresh or salt water

Cephalosporin + Gentamycin

+/- Penicillin - farm injury

+/- Ciprofloxacin - fresh or salt water

Cephalosporin + Gentamycin

+/- Penicillin - farm injury

+/- Ciprofloxacin - fresh or salt water

 

Infection Rate

 

I:      0-2%

II:     2-7%

IIIA:  7%

IIIB:  10-50%

IIIC:  25-50% with 50% or more amputation

 

Management

 

Goals

 

Prevent infection

Manage the wound

Stabilise the fracture

Enable healing

 

Immediate

 

EMST / ATLS Principles

 

Assess Limb

- vascular

- neurology

- skin defect / contamination

- photos

 

Wound / fracture care

- irrigate wound

- apply betadine dressing

- stabilise with POP if possible

- appropriate antibiotics / tetanus

- early surgery for irrigation / debridement / stabilisation

 

Antibiotics

 

Guidelines

- grade 1: first generation cephalosporin

- grade 2: add gentamicin (increased rate of gram negative infections)

- farmyard / heavily contaminate add penicillin (clostridium / gas gangrene)

 

Patzakis JBJS Am 1974

- prospective, randomised controlled trial

- infection with preoperative cephalothin was 2.3% 

- infection 13.9% without antibiotic

 

Swabs

- studies finding of initial swab correlating with infecting organism has been discredited

- no real correlation between road-side organisms & subsequent infection

- subsequent infection are typically hospital acquired

 

Gustilo

- increased rate of gram negative infection in Grade II

- hence add aminoglycoside if Grade II

- add penicillin if soil contamination

- no evidence any other combination is better

 

Timing

- delay > 3 hours increases infection risk

- 48 - 72 hours post injury

- 48 - 72 hours post each procedure

 

Wound Management

 

Irrigation

 

Gustilo JBJSA 1987

- infection higher if < 10L washout

 

Anglen 1984

- pulse lavage 100 x effective than bulb

 

Debridement

 

Must remove all non viable tissue

- remove cortical bone with no ST covering

 

Timing of wound closure

 

Do so when wound is clean

 

No evidence of increased infection with primary closure

- may prevent secondary contamination

- risk of clostridial myonecrosis

 

DPC (delayed primary closure)

- prevent anaerobic conditions in wound

- facilitates drainage

- allows second debridement

- can seal the wound via vacuum dressing

 

Fracture Stabilisation

 

Advantage

- prevent soft tissue from further injury

- facilitates host response to bacteria despite presence of implants

- allows mobilisation and functional rehab

 

Femur

- IMN best for I, II, IIIA and B

- 10% deep infection in type III B

- best to plate in type IIIC before revascularisation

 

Tibia

 

Reamed v unreamed

- no difference in infection rate

 

IMN v External fixator

- reduced risk of revision surgery, malunion and superficial infection with IM nail

- no difference in infection rate or union

 

External fixator

- heavily contaminated wound

- non amenable to nail (i.e. very distal)

- vascular injury

 

Soft Tissue Reconstruction

 

Options

 

Proximal tibia - local pedicle gastrocnemius flap

Middle third - soleus flap

Distal third - free muscle flap (rectus / gracilis / lat dorsi)

 

Timing

 

Gopal et al JBJS Br 2000

- early < 72 hours v late > 72 hours

- 6% v 29% deep infection

- did not use antibiotic beads