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Broken Bones in open condition
Definition
Broken bones where there is damage to the skin so that bacteria from outside can be infected hematoma caused by these fractures
The classification of open fractures: according to the Gustilo
Type I
Small cuts less than 1 cm, there is little tissue damage, there were no signs of severe trauma to the soft tissues. Fractures that occur are usually simple, tranversal, short oblique or komunitif
Type II
Exceeding 1 cm skin laceration but no great damage to tissue or skin avulsion. There was damage and tissue
Type III
There is great damage to the soft tissues including muscle, skin and structure neovaskuler with severe contamination. Divided into 3 sub-types:
1. Type IIIA: soft tissue close enough broken bones
2. type IIIB: accompanied by destruction and loss of janingan software, the bone can not do the cover of soft tissue
3. type IIIC: accompanied by arterial injury requiring immediate repair
Reduction open fracture:
1. Treat as a gravity
2. Initial evaluation and diagnosis of abnormalities that might be the cause of death
3. Give antibiotics in the emergency room, operating room and after surgery
4. Immediate debridement and irrigation are doing good
5. Repeat debridement next 24-72 hours
6. Fracture stabilization
7. Leave the wound open between 5-7 days
8. Perform immediate autogenous bone graft
9. Rehabilitation of the affected limb
Open fracture treatment stages
1. Cleaning wounds
2. Excision of dead tissue and presumed dead
3. Treatment of fractures and determining types of traction
4. Skin closure
5. Giving antibiotics
6. Prevention of tetanus
1. Cleaning wounds
2. Excision of dead tissue and presumed dead
3. Treatment of fractures and determining types of traction
4. Skin closure
5. Giving antibiotics
6. Prevention of tetanus
Complications of open fractures
1. bleeding, septic shock death
2. septikemi, toxemia due to pyogenic infection
3. tetanus
4. gangrenous
5. ma non-union and union
6. joint stiffness
7. secondary bleeding
8. chronic osteomyelitis
9. delayed union
Further treatment and rehabilitation of open fractures
1. Relieve pain
2. Obtain and maintain adequate position and flagmen fractures
3. Pursuing the union
4. Restoring optimal function by maintaining muscle and joint function and prevention of complications.
5. Restoring function with a maximum of physiotherapy.
Operating Principles
Principles of debridement is to clean up contamination found in the vicinity of fracture by making the appointments of non-viable tissue and foreign material, such as sand embedded in soft tissue. Conducted an assessment on surrounding tissue around the bone, injured blood vessels, tendons, muscles, nerves. Debridement of muscle tissue is considered contaminated if the weight and lose muscle contractility. Debridement of the tendons consider contractility tendon, while the debridement of the skin performed until bleeding arise. In grade IIIB open fracture and IIIC done serially repeated debridement in interval 24-72 hours to reach a definitive surgical debridement.
Technical Operations
Prior to debridement, antibiotics given profilaks conducted in the emergency room.The best are the ones sefalosforin. Usually used sefalosforin first class. In an open fracture Gustilo III tape, provided additional benefits such as aminoglycoside group, such as tobramicin or gentamicin. Group sefalosforin third group considered here.While on a suspected fracture of contaminated bacteria Clostridia, given penicillin.
Self protection equipment required when surgery is google, boots and gloves extra.
Before the surgery, performed by povine iodine wash, then drapping area of operation. The use is not recommended, because we will examine the tissue bleeding. Debridement performed first on the skin area. Later hospitalized with bleeding in venous performs coagulation. Open to assess muscle fascia and tendons. Muscle viability was assessed by 4C, "Color, Contractility, Circulation and Consistency. Perform removal of contamination with the medullary canal saw or rongeur. Medulary canal curettage avoided by reason of preventing infection towards the proximal. Performed with normal saline irrigation. The use of normal saline is 60-10 liters for an open fracture grade II and III. Bone is maintained by repositioning. Can be used external fixation in grade III4 fracture.
Closure of wounds done if possible. In type III fractures that can not be performed wound closure, performed an open wound care, until the wound can be closed completely.
Complications Surgery
Complications of surgical debridement is almost nothing. Complications occurred in the form of infection in soft tissue and bone to postoperative sepsis.
Mortality
Associated with hemorrhagic shock and the presence of fat embolism
Post-Surgical Care
Postoperative antibiotics was continued until 2-3 days post-debridement. Pus culture, if there is a pussy, pussy do culture. In open fractures that require surgical debridement grade repetition, the replay will be debrided until healthy enough tissue to the bone and definitive therapy can be started. On a delayed wound closure, performed the installation of split thickness skin flap, vascularized pedicle flaps (such as gastrocnemeus flap) and free flaps such as flaps or myocutaneus fasciocutaneus flaps.
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