Open Fracture

OUTLINE

Fracture An open fracture is a fracture with a wound, through which the fracture socket communicates with the outside.

Open fracture English is open fracture.

The leading cause of open fractures is traffic accidents, so there are often other injuries associated with it (40 – 70%). In war, a fire fracture is always an open fracture. In peacetime, the incidence of open fractures accounts for 10% of motor injuries.

Histopathology and pathophysiology

Histopathological lesions of open fractures include:

• Software damage
• Damage to blood vessels and nerves
• Ligament damage
• Bone damage.

In open fractures, all of the above lesions cause bleeding, which is a matter of concern in open fractures.

Bleed

Fractures in general cause bleeding, in open fractures blood flows in the bone through, so the amount of blood loss is more. According to Willinegger's statistics, the amount of blood loss is as follows:

• Calf fracture loss of 300-600 mL
• Femoral fractures take 600 to 1,000 mL
• Pelvic fractures take 1,700 to 2,400 mL.

Cộng với các tổn thương khác trong gãy xương hở thì lượng mất máu là đáng quan tâm, đặc biệt trong những trường hợp có tổn thương mô mềm rộng lớn hoặc có tổn thương mạch máu thì lượng máu mất rất nhiều.

Tissue damage

Tissue damage in open fractures affects function, ability to bone healing such as muscle rupture causing loss of movement, nerve damage causing motor and sensory paralysis, blood vessel damage causing hypotrophy, joint ligament damage causing joint loosening or decreased joint function, bone damage if complex Complications cause delayed or non-healing bone. In addition, tissue damage also causes bleeding to form hematomas in the tissue with crushed tissues, which is a good breeding ground for bacteria that cause infection.

Wound infection

This is a different problem of an open fracture compared to the closed fracture. However, in order to have an infection, two favorable conditions must be met:

• Presence of bacteria in the wound.
• There is a favorable environment for germs to grow.

In open fractures according to Muller only one third of open fractures are cultured with bacteria in the first hours, but in open fractures there is a favorable environment for the growth of bacteria such as hematoma and crushed tissue. In addition, the loose bone fragments in open fractures play a passive role in wound infection:

• If the wound is not infected, the loose bone fragment does not die and also helps the healing process better by increasing the contact area of the fracture surface.
• If the wound becomes infected, the loose bone will become dead bone, which maintains the infection.

Wound healing

A wound to heal well must have the following conditions:

• The wound is not infected
• There are no foreign objects in the wound
• In the wound there is no hematoma and tissues caseation
• The wound edge is well nourished
• Suture the wound without tension.

Bone healing

Factors favoring bone healing:

• Biological factors: is the blood that nourishes the fracture well. In an open fracture, there are bad factors such as infection, surrounding soft tissue damage and bone loss, which will make the fracture site less nourished, which is not a good condition for bone healing.
• Mechanical factors: is the fixation of the fracture, in open fractures, often complex fractures, sometimes loss of bone will make it difficult to fix the fracture, adversely affecting the healing process.

CLASSIFICATION AND INJURY INDICATORS

Classification of open fractures according to GUSTILO (1984)

Team

• The skin is torn about 1 cm
• The wound is completely clean, mostly due to broken bones poking from the inside out
• Minimal mechanical impact
• The fracture line is a simple horizontal or short diagonal line.

Degree II

• Tổn thương phần mềm rộng, có thể là lóc da còn cuống hoặc lóc hẳn skin flap
• Skin tear more than 1 cm
• Mild to moderate muscle contusions, sometimes present cavity compression
• Broken bones with simple transverse fractures or short diagonal fractures with small fragments.

Grade III

Extensive soft tissue involvement includes muscle, skin, and neurovascular structures. The high rate of injury leads to a lot of soft tissue destruction and results in intense compression. This category includes three groups:

• IIIa: wide soft tissue tear, complex fracture, with many dirty foreign bodies. The skin can be sutured to cover the wound
• IIIb: Wide soft tissue tear, with periosteum peeled off and fracture tip exposed. The fracture site is heavily contaminated. Can't suture cover skin, need to do muscle flap or skin flap
• IIIc: a lot of crushed wounds, complicated broken bones and major vascular damage that need urgent rehabilitation to save the limb.

In general, the Gustilo as well as Tscherne classifications focus on soft tissue damage, combined with the degree of fracture (simple or complex). In which, grade IV open fracture is a special form.

Trauma score (TS)

In open fractures, there are about 40 - 70% cases accompanied by damage to other organs (head, chest, abdomen, ...) collectively called multiple lesions. To assess whether the condition is severe or mild, life-threatening or not, based on vital signs to score. This score is called the injury index.

The trauma index is the combined result of 5 indices according to a given scale before examination for breathing rate, breathing pattern, blood pressure, peripheral circulation and Glasgow coma index.

Table 3.3. Injury Index Scoreboard

The Glasgow coma score (GCS) is an index used to assess the severity and mildness of traumatic brain injury, surveying according to three criteria: movement when stimulated, language response when asked and opened. ophthalmic examination (see also neurosurgery literature):

GCS < 4:85% cases will die within 24 hours. GCS from 4 to 8: severe traumatic brain injury.

GCS 8-11: The patient is viable but has sequelae. GCS > 12: good prognosis, but need further monitoring.

GCS = 15: normal.

TS = Sum of points ABCDE

This index is about 12, which can say that the patient is serious and needs to be transferred to a specialized center for treatment.

Attention: TS and GCS stats are only valid for 24 hours. Needs re-examination and close follow-up.

MESS (Mangled Extremity Severity Score)

This index examines soft tissue damage, limb ischemia, shock, age, and medical conditions such as diabetes, cardiovascular disease, kidney failure, etc. to assess the possibility of amputation. This indicator is valid for 24 hours and needs to be closely monitored and re-evaluated.

Table 3.4. MESS index

Evaluate:

• MESS = 6 – 7: The patient needs good resuscitation for early management (resection).
• MESS = 8: at risk of amputation.
• MESS > 9: absolute amputation.

SYMPTOMS

Consists of two main types:

• Life-threatening systemic complications
  • Injury shock
  • Blood vessel occlusion due to fat.
• Local complications
  • Nerve vascular damage
  • Cavity compression
  • Infection
  • Misalignment
  • Not immediately
  • Nutritional disorders.

Injury shock

Due to blood loss and pain in the broken limb, in an open fracture, the pain and bleeding is more than that of a closed fracture. stunned and worse shock.

Blood vessel occlusion due to fat

Conditions causing embolism due to fat:

• Shock due to blood loss
• Large or multi-bone fracture
• Crush the spreading software
• Can't break bones motionless Good.

The triglycerides in the blood move and cause embolism in other places such as the brain, lungs, kidneys, etc., making the fracture worse and this is a cause of death.

Cavity compression

Increased pressure in one or more compartments reduces blood flow through the cavity leading to ischemia, if prolonged high pressure will cause:

• Muscle injuries
• Nervous disorders.

Infection

It is a common complication in open fractures because of the favorable conditions for the presence of crushed tissue and the presence of bacteria.

Blood vessel damage

The large blood vessels passing through the broken bone can be compressed, torn or broken, if broken in an area without good anastomosis, it can cause limb necrosis due to lack of blood supply. In addition, damage to blood vessels causing hematoma will be the cause of compression of the cavity.

Nerve damage

Like blood vessels, nerves passing through a broken bone can be compressed or torn. We often see typical nerve compression complications in the following types of fractures:

• Liệt thần kinh quay trong broken arm bone
• Liệt thần kinh hông khoeo ngoài trong gãy chỏm xương mác
• Liệt thần kinh giữa trong gãy trên lồi cầu xương cánh tay.

Late complications

Including misalignment, non-healing, delayed bone healing and nutritional disorders, these complications are often related to the initial or partial damage caused by treatment, adversely affecting the function of the broken limb.

DIAGNOSE

clinical

Clinical diagnosis of an open fracture must include:

• There is a wound
• There is a broken bone
• There is an opening of the fracture through the wound to the outside.

Wound

The wound can be small or large, through the wound we can see the broken bone head, but especially we have to see if the wound shows any other damage such as blood sprayed into the nozzle due to damage to the artery.

Fracture

There are six symptoms of a fracture:

• Relative symptoms include swelling, pain, and decreased or lost function
• Absolute symptoms include deformity, abnormal movement, and crackling sound of broken bones.

The socket breaks through the wound to the outside

In this case we can see the following signs:

• Sometimes you can see broken bones
• Blood flows through the wound with fatty deposits of bone marrow
• Wounds caused by fire that cause bone fractures, there is always a cavity that connects with the wound to the outside
• Sometimes, open fractures cannot be diagnosed clinically at the outset, only diagnosed after surgical excision of the wound.

X-ray

Take at least two planes and take both ends of the broken bone to diagnose fracture location, fracture line, and displacement. X-ray Open fractures are often undiagnosed, and can only be diagnosed clinically based on open fractures.

HANDLE

First aid

Steps to do in first aid Open fracture:

• Wound dressings
• Fixing broken bones: usually using cloth bandages and splints to fix broken bones according to the principle of fixing a joint above and below the fracture socket.
• Preventing shock by giving sugar tea, if possible, give fluids
• Antibiotics: use broad-spectrum antibiotics such as 3rd generation cephalosporins
• Analgesic
• Anti-tetanus medication (SAT).

Real treatment

• First of all, it is necessary to deal with potentially life-threatening injuries, if any, such as complications of traumatic shock, vascular occlusion due to fat, compression of the cavity, damage to blood vessels, nerves and visceral organs.
• Treatment of open fractures according to the correct treatment protocol is based on three main principles:
  • Excision of the wound to remove crushed tissue and foreign bodies
  • Stabilize and immobilize broken bones
  • Taking antibiotics helps the body fight off germs. Here are the specific jobs:

Cut the wound

This is a very important and practical job in open fractures, its purpose is to remove necrotic tissue, hematomas, foreign bodies, etc., and also has the task of regenerating defects due to injury. such as reshaping bones, suturing muscles, tendons, blood vessels, nerves and protecting these components, washing the wound during surgery with plenty of water removes pathogens that have entered the wound.

Immobilize broken bones

Broken bones need firm immobilization after good manipulation. To immobilize, you can use casts, pull weights, and place external fixators, so limit the use of internal bone fixation because there is a risk of infection, especially in bad conditions such as late arrival, dirty wounds.

Use antibiotics

Antibiotics only play a supportive role, not a replacement for dialysis, but thanks to antibiotics, the treatment is more convenient, there are less infections, antibiotics should be used early or at the time of admission. has a broad spectrum of action and is currently as effective as the 3rd generation cephalosporin. In addition, if possible, antibiotics should be used according to the antibiogram, should be used in high doses and continuously for many days (5-7 days), in emergency should be used. Use injection and preferably intravenous injection to quickly reach the maximum concentration of antibiotics in the blood, when the wound is stable, other routes can be used.

Other Treatments

In addition to the main treatment steps mentioned above, wound care and nourishment also play a very important role in the treatment of open fractures to minimize complications, facilitate bone healing and Rehabilitation.