How are open fractures calssified
Gustillo
classification
· Type I:
Wound <1cm. low energy. Clean, little
contamination/crushing/muscle
damage/comminution
· Type II
Wound 1-10cm. Slight comminution. Can be closed.
· Type III:
Any large wound (>10cm) or wound with severe contamination or
tissue damage
(high velocity GSW, crushing injury, farm yard injury
· Type IIIa: Enough local soft tissue for
coverage of bone
· Type IIIb: not enough local soft tissue for
coverage (requires flap)
· Distinction between IIIa and IIIb can only
be made after debridemnet.
· Type IIIc: associated arterial injury.
How do you treat open fractures
· Abx (penicillin,
gent, metro), tetanus prophylaxis, debridement.
· Debridement
must be within 6 hours – radical muscle debridement and
conservative bone
debridement.
· Primary
closure can only be achieved in type 1 injuries. Wounds >6
hours should not
be closed.
· Cover bone,
tendon, nerve and vessel with fat muscle or fascia and leave
skin open
· Second look at
48 hours with delayed primary closure by 5 days
· Initial
fracture stabilization: Ex fix or IM nail
· Definitive
fracture treatment is undertaken at 4-8 weeks after soft tissue
problems have
resolved.
What is a mangled extremity
A limb injury
combining soft tissue
and ossesus damage +/- vascular injury to such a point that limb
survival able
is questionable.
The mangled
extremity severity score
(MESS) is used to objectively determine if a limb is amenable to
reconstrcuction.
The MESS uses
grading of severity of
skeletal inury, limb ischaemia, age and shock to produce a
numerical score. If
MESS ≥7 then predictive of amputation.
|
Parameter |
Points |
|
Skeletal/soft
tissue |
|
|
Low energy |
1 |
|
Medium
energy |
2 |
|
High energy |
3 |
|
Very high
energy (above + contamination) |
4 |
|
Limb
ischaemia |
|
|
Pusle
reduced perfusion normal |
1 |
|
Pulseless,
parasthesia |
2 |
|
Paralysed,
insensate, numb |
3 |
|
Shock |
|
|
SBP>90 |
0 |
|
Transient
hypotension |
1 |
|
Persistent
hypotension |
2 |
|
Age |
|
|
<30 |
0 |
|
30-50 |
1 |
|
>50 |
2 |
Even if a limb is
salvaged the
function and QoL may be inferior to amputation
Severe ipsilateral
foot trauma is
associated with poor outcome and should swy towards primary
amputation.
Nerve disruption
below knee level is
associated with loss of protective sensation and poor outcome
The outcome of
upper limb salvage is
better than lower limb.