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

Small bowel resection and anastomosis

Indications

• Congenital lesions i.e.: atresia, duplication
• Traumatic perforation
• Critical ischaemia
• Crohn’s disease or other cause of stricture
• Tumours of the bowel or its mesentery

Preparation

• Adequate hydration and nasogastric intubation
• Appropriate prophylactic antibiotics

Defunctioning colostomy

Transverse colon or sigmoid colon may be used

Indications

·         Distal obstruction – due to carcinoma

·         Protection of low rectal anastomosis

·         High anal fistula

Laparotomy

Laparotomy  - opening

Surgical entry to the peritoneal cavity

• Emergency – Traumatic,  Non traumatic
• Elective

Indications (emergency)

• Non responsive patient / unstable patient following initial adequate resuscitation.
• Unequivocal clinical evidence of peritonitis
• Penetrating missile and penetrating abdominal (discuss with senior) trauma.
• Positive diagnostic peritoneal lavage.
• Air present under the diaphragm.

Skin suturing

Contra-indications

• Risk of infection is high (e.g. dog bites, heavily contaminated wounds, gun shot injuries)
• Risk of dehiscence is high due to ischaemia  (high tissue tension)

 Methods of approximation

• Sutures
• Staples
• Sterile plasters (steri strips)
• Tissue glue