Operative Fracture Care Research Articles

Diagnosis and immediate care of open fractures.

Any fracture in which the fracture haematoma communicates with the outside world is an ‘open fracture’. All open fractures must be treated as a surgical emergency with a clear treatment protocol using a team approach. The accident and emergency (A&E) department forms the initial part of that team. The guiding principles for the team are to prevent infection, unite the fracture and restore function - it is in the first of these that A&E plays an important role. The A&E team will also need an understanding of subsequent management to ensure good initial treatment and communication with the orthopaedic surgeons, patient and relatives.

Wound irrigation in musculoskeletal injury.

Wound irrigation to remove debris and lessen bacterial contamination is an essential component of open fracture care. However, considerable practice variation exists in the details of technique. Volume is an important factor; increased volume improves wound cleansing to a point, but the optimal volume is unknown. High-pressure flow has been shown to remove more bacteria and debris and to lower the rate of wound infection compared with low-pressure irrigation, although recent in vitro and animal studies suggest that it may also damage bone. Pulsatile flow has not been demonstrated to increase efficacy. Antiseptic additives can kill bacteria in the wound, but host-tissue toxicities limit their use. Animal and clinical studies of the use of antiseptics in contaminated wounds have yielded conflicting outcomes. Antibiotic irrigation has been effective in experimental studies in some types of animal wounds, but human clinical data are unconvincing due to poor study design. There are few animal or clinical studies of musculoskeletal wounds. Detergent irrigation aims to remove, rather than kill, bacteria and has shown promise in animal models of the complex contaminated musculoskeletal wound.

Update on the Management of Open Fractures of the Tibial Shaft

A retrospective study of 133 open tibial fractures in 129 patients treated at the Hennepin County Medical Center between 1986 and 1993 was done. The results of the treatment protocol in this patient group is presented and the current classification schemes, prevention of infection, debridement, antibiotics, soft tissue reconstruction, fracture stabilization methods, bone grafting, and exchange nailing are discussed. Recent studies that have documented interobserver disagreement in the classification of open fractures underscore the difficulties encountered in the initial assessment and treatment of open tibial shaft fractures. Despite repetitive and aggressive debridement, a certain number of fractures will remain contaminated and become infected. Infection after these severe injuries is probably multifactorial, and its prevention requires that the surgeon diligently adhere to the imperatives of open fracture care.

The rationale of operative fracture care.

The rationale of operative fracture care.

The Rationale of Operative Fracture Care

The Rationale of Operative Fracture Care

Interfragmentary lag screws and external fixation for severe open tibial fractures: a biomechanical and clinical study

The stability offered by the interfragmentary lag screw with a unilateral external fixator frame was studied in both experimental and prospective clinical studies. The in-vitro stability of the fixation with and without the interfragmentary lag screw was tested by a universal testing machine in compression, four-point bending, and torsion in 18 human tibiae. The in-vivo study was conducted prospectively in 18 patients with 19 severe open tibial fractures. All patients were treated with one definite surgical procedure on admission. The interfragmentary lag screw increased the sytem stiffness 47.4 times in compression, 9.9 times in bending, and 3.2 times in torsion. The immediate one-stage care of severe open fractures with a simple external fixation system in combination with the interfragmentary lag screw shortens hospitalization and may enhance healing.

Immediate Care of Crush Injuries and Compartment Syndromes With the Split-Thickness Skin Excision

Prospective evaluation of the one-stage procedure in 32 patients who suffered from 37 severe friction-avulsion injuries was carried out. Most injuries (81%) were in the lower extremity. Split-thickness skin excision was used for immediate diagnosis of flap vascularity and wound coverage. Split-thickness skin was harvested from the avulsed flap surfaces after they were temporarily sutured back to their original bed. Dermal capillary bleeding served as an indicator for tissue viability, thus delineating a clear line for debridement. All compartments were decompressed, and debridement of all devascularized tissues was performed. Most fractures were fixed with interfragmentary screws and external fixators. Viable parts of the avulsed flaps were sutured back to their original bed and exposed bones were covered with transposed muscles. Skin defects were grafted with the split-thickness skin that was harvested in the first stage and was meshed 1:3 to allow drainage. Most patients (26 out of 32) had only one surgical procedure for their extensive injuries. The split-thickness skin excision is effective in the establishment of debridement borders and helps in saving maximal viable flap area (49.4%). All wounds healed with no major wound complications. The split-thickness skin excision can be used immediately in the care of severe crush injuries, compartment syndromes, and open fractures as a one-stage procedure with the following advantages: (1) reliable diagnosis of flap vascularity, (2) immediate wound coverage with the possibility of drainage, (3) elimination of further debridements procedures, (4) elimination of distant skin donor wounds, and (5) less hospitalization.