Management of compound fractures

A compound fracture is a traumatic breach in the continuity of the bone which communicates with the skin wound. When it communicates with a body cavity which opens into external environment (paranasal sinuses) it is called internally compound.

Classification (Gustillo)

 

Treatment and outcome depends on this

 

Type I   Small wound, less than 1cm, through which the bone has protruded and usually retracted.

              Minimal soft tissue damage
 

Type II   Wound >1cm long

              Moderate soft tissue damage and contamination

Type III  Large wound considerable contamination

              Extensive soft tissue damage. High energy injury

                  A –Bone can be covered with soft tissue

                  B – Bone cannot be covered with soft tissue

                  C – Any fracture associated with major vascular injury

Management

 

1. Assess and resuscitate according to the standard protocols (ATLS®).
2. Request to administer             opioids ( pethedene 1 mg/ kg / morphine 0.1 mg/kg) , tetanus toxoid 0.5 mg i.m. , i.v. antibiotics (ampicillin+cloxacillin or cefuroxime + metronidazole +/- gentamicin)
3. Align limb as close to anatomical position.
4. Check

-          Peripheral circulation. If absent in resuscitated patient, call senior.

-          Control bleeding by applying direct pressure over the wound. Avoid tourniquets

-          Gross contamination. Remove large debris with sterile forceps and cover the wound.

-          Look for compartment syndrome

5. Do

-          Take photograph of wound (if possible)

-          Cover wound with sterile dressing

-          Splint the limb to minimize further soft tissue injury / reduce pain

-          X rays including proximal and distal joints

-          Urgent debridement (Type I, II, and IIIA) – under GA or regional anaesthesia

-          Inform senior (Type IIIB, IIIC)

Wound debridement

-         As soon as possible (Ideally within 6 hours of injury)

-         Under GA or regional anaesthesia

-         Prophylactic antibiotics (if not already given)

-         Shave / clean surrounding skin without contaminating wound

-         If profuse bleeding + - elevate and apply a tourniquet.

-         Irrigate wound with  copious amounts of N saline

-         Clean with antiseptics and drape the wound

-         Extend the wound to expose bone ends (take care of neurovascular bundles and over the tibia)

-         Excise the wound margins (only to remove devitalized skin / should not interfere with subsequent wound closure)

-          Remove all doubtfully viable tissues.

-          Do not repair cut nerves and tendons.

-         Deliver the bone ends to the wound and clean bone edges with a scoop

-         Irrigate wound thoroughly with N. saline.

-         Achieve haemostasis (after releasing the tourniquet)

-         Reduce the bone ends

-         Extended parts of small, non contaminated wounds may be sutured upto the margin of the initial wound.

-         All other wounds; do not suture skin. Pack loosely with sterile gauze and dress with bulky dressing.

-         Immobilize with POP plaster cast or  ¾ backslab, back slab depending type of wound. (avoid plain back slabs in the lower limb as it does not effectively splint the limb)

-         Fractures with extensive soft tissue injury or vascular injury may need external fixators ( call senior if available or apply Steinman pins incorporated to a plaster cast).

 

Post op

-          KUO routine observation and distal circulation, bleeding.

-          Continue anaelgesics / antibiotics

-          Wound inspection in 48 hours.

-          Orthopaedic opinion.