MRCS Knowledge: Open Fractures

29/07/14 19:17 Filed in: MRCS Knowledge
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Today’s MRCS Core Knowledge focuses on the commonly tested topic of open fractures.

Background

Open fractures are high energy and communicate with the outside world increasing the risk of infection and damage to surrounding structures. There is a 40% to 70% rate of associated trauma elsewhere in the body when there is an open fracture.

Classifications

The Gustilo-Anderson Classification (1976, revised in 1984 to add grade III subgroups). Classified at time of debridement.

I Clean <1 cm
II 1-10cm, No extensive soft tissue damage
IIIA Contaminated wound (high-energy, gunshot, farm-yard) or extensive periosteal stripping with large skin wound (>10cm)
IIIB As IIIA but requires flap coverage (plastics)
IIIC As IIIA but requires vascular repair (vascular)

Risk of Infection (Sorger et al. 1999)
I = 0-12%
II= 2-12%
III = 9-55%

Tscherne Classification uses wound size, level of contamination and fracture pattern to grade open fractures.

Management

OpenFracture

Patients should be managed following ATLS protocols and the BOA/BAPRAS guidelines for open fractures. The primary concern is the neurovascular status of the limb distal to injury. The acute guidelines are outlined below:

  • Early Broad-spectrum IV antibiotics and Tetanus, continue antibiotics until 72hrs or skin coverage
  • Assess neurovascular status and for compartment syndrome, correct vascular impairment within 3-4 hrs (6 maximum)
  • Photograph wound then clean and dress with saline soaked gauze, minimise wound handling
  • Splint fracture above and below
  • Early transfer to a specialist centre if severe injury unless unsafe to transfer
  • Involve Plastic Surgeons for definite wound coverage

References:
  • Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58:453–8
  • Sorger et al. Once Daily, High Dose Versus Divided, Low Dose Gentamicin for Open Fractures. CORR Volume: No. 366, Sept 1999, pp 197-204
  • Gosselin RA, Roberts I, & Gillespie WJ: Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev 2004

Further Info:
For further info and commonly asked questions on open fractures and their management be sure to sign up to the Question Bank.

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