Open Fractures

Open fractures are fractures with a broken skin cover, which occur mainly in bones covered only by a thin cover of soft tissues.

There are two types of skin opening:


 * piercing the skin from the inside with a fragment;


 * less severe, most often diaphyses on the lower leg, the surrounding tissues are usually not more severely damaged;


 * damage to the skin from the outside by direct tissue injury;


 * for high energy trauma;
 * we sterilely cover such an injury at the site, record the extent of the damage, do not remove the cover at the ambulance (high risk of nosocomial infection), wait until the place of definitive treatment (in the hall);
 * the rule of treatment within 6 hours after the injury applies.

Classification
Currently, the Tscherne classification is accepted :


 * in the first place, it determines the prognosis of the injury with respect to soft tissue injuries;
 * the letter G indicates closed fractures (geschlossene) and O open (offene).

Degrees of injury:
 * G 0 – fracture resulting from indirect violence without damage to soft tissues;
 * GI – superficial contusion of the skin cover with surface abrasion;
 * G II – deep contaminated abrasion, demarcated skin and muscle contusion, caused by direct external force, considerably dislocated;
 * G III – complicated contusion of the skin and soft tissues, compartment syndrome, decollement, mostly comminutive;
 * OI – small wound with skin contusion, puncture with a bone fragment;
 * O II – wound (approx. 2 cm) with limited contusion of skin and tissues, small contamination;
 * O III – heavily contaminated wound, extensive contusion of tissues, nerve and vascular lesions;
 * O IV – total or subtotal amputation ;
 * subtotal amputation – accompanied by interruption of anatomical structures, mainly large vessels, complete ischemia of the periphery;
 * total amputation – tissue damage is such that not even a quarter of the circumference of the limb is preserved.

First Aid

 * prevent further tissue damage;
 * we gently reposition the limb by pulling on the periphery;
 * disinfection, sterile covering, immobilization;
 * in case of bleeding, we will apply a pressure bandage, record the time data.

In the hospital

 * stabilization of the general condition, anti-shock treatment;
 * we do not remove the cover, we obtain information about the wound from the PP provider;
 * we check vaccination against tetanus, we apply tetanus toxoid (TAT 0.5 mg), and globulin (TEGA) in case of heavy contamination;
 * already in the clinic we also apply ATB to aerobes and anaerobes;


 * if we do not detect an allergy, the method of choice is PNC-G 5 million units, 2 g of oxacillin;
 * alternative in case of allergy – clindamycin with gentamycin;


 * then x-ray, possibly sono , angio ...;
 * the maintenance procedure must be performed within 6 hours after the injury;
 * whether to save or amputate tells us roughly the MESS score (certain points for the type of injury, age, shock, extent...).

Operation

 * cleaning the wound in the vestibule - we remove the cover for the first time;
 * we clean the wound - mechanically, then - hydrogen peroxide, chloramine, physiological solution;
 * we transport to the hall, then we proceed as for another fracture;
 * we always drain the fracture site;
 * removal of necrotic tissue (debridement);
 * tissue vitality is assessed according to the 4Cs (contractility – muscle contraction, color – color, consistency – tissue quality, capillary bleeding);
 * collection of 3 microbiological samples;
 * we do not sew the fascia, there is a risk of compartment syndrome.

Related Articles

 * Types of fractures and their dislocations
 * Fracture healing disorders
 * Compartment syndrome
 * Crush syndrome

Source

 * BENEŠ, Jiří. Questions from Orthopedics and Traumatology  [online]. [feeling. 2011-01-28]. < http://jirben2.chytrak.cz/ >.