Foreign pathology of open fracture

2021-01-30 12:00 AM

In addition to soft bleeding, open fractures can also include artery damage, possibly due to puncture or rupture of the fracture

 

Outline

An open fracture is a type of fracture with a soft wound and the wound is open to the socket.

Open fractures are caused by many reasons and are the leading cause of traffic accidents caused by motorbikes and cars. In peacetime, the rate of open fracture accounts for about 8-10% of motor organ damage. During the war this rate is usually as high as 40-45% of all wounds.

Open fractures are usually 40-70% combined with trauma elsewhere (head, chest, abdomen ...).

Open fractures are also frequently associated with soft tissue damage that causes cavity compression syndrome, which is accompanied by ligament damage to neighbouring joints.

Pathology and pathophysiology

In terms of anatomical damage, open fractures can be seen

Damage to blood vessels, nerves.

Ligament damage of the adjacent joint.

Software damage.

Bone damage.

In terms of the pathophysiology, two issues must be considered.

Infection.

Soft wound healing and healing.

Carefully analyze all cases of open fractures. There are issues that we need to take care of.

Bleed

Fractures in general cause significant bleeding. According to the statistics of

  1. Willenegger, the amount of blood lost is as follows:

Type of fracture

Loss of blood (ml)

medium

Max

A broken leg bone

300

600

Fracture of the femur

600

1.000

Fracture of the pelvis

1.700

2.400

If plus bleeding of soft wounds then blood loss at open fractures is important. At the same level, an open fracture will lose more blood than a closed fracture. Especially in the case of soft tissue being widely crushed like a bomb fracture the more blood loss is.

In addition to a soft bleeding wound, an open fracture may also include artery damage, possibly due to a puncture or rupture at the tip of the bone. It is necessary to promptly detect and properly handle.

Tissue damage

The most damaged software is the crushed muscle bundles that lose function. In addition, if the nerve is damaged, the patient can paralyze and lose sensation. Damage to the bones and joints causes the muscles of the limbs to be greatly reduced. Pay attention to carefully examine the ligaments in the adjacent joints, many cases of damage are missed.

Risk of infection

The wound becomes infected because of the following factors:

In the presence of pathogenic bacteria in the wound.

There are favourable conditions at the wound to help bacteria grow quickly (tissue crushing necrosis, hematoma ...).

The broken bone fragments are cut off from their nourishment, but do not cause infection, it is essential for bone healing. If an infected soft tissue becomes pus, these pieces of bone will form dead bones and cause infection.

Soft wound healing like. Large soft tissue wounds, if self-healing, will create a bad, sticky, easily ulcerative fibrosis. If you want the wound to heal with a really soft, good skin scar, you must sew the edges of the skin closed.

The wound is not infected.

No more hematoma and necrotic tissue.

No dirty foreign objects.

Skin stitches are not stretched.

The edges of the wound are well nourished by blood.

If the above conditions are not met, especially if the filtration is not well enough, it is best to leave the wound open to ensure good drainage. When the wound is over, the second skin will be closed.

What does heal need? Factors for healing are:

Firmly immobilize the broken bone.

Excellent recovery of blood circulation interrupted in the fracture area. Broken bones that do not insert muscle in the middle will heal bones quickly as the contact area with the fragments increases. For open fractures, 2 factors that interfere with bone healing are:

Infection.

Loss of blood supply to nourish the bones (due to trauma or removal by a surgeon).

Classification of open fractures

The first to classify an open fracture is J. Cauchoix (1961), who is interested in the size of the skin loss, the degree of soft tissue crushing and the complexity of the fracture. In addition to the above factors, Rittmann also focuses on direct or indirect injury mechanisms.

Most types of open fractures help guide treatment and prognosis, but it has many defects such as foreign matter in the wound and damage to the structure of blood vessels and nerves. This issue has been addressed in recent years.

Tscherne and Ocstern (1982) present a classification of open fractures of 4 degrees, based on soft tissue damage and fracture, in which a degree 4 fracture indicates a fracture or a near fracture, because if suture is reconnected it is also an open fracture.

Gustilo (1984) divided open fracture as 3 levels, only level 3 was divided into 3 groups: IIIA, IIIB, IIIC. Currently many countries use this classification. Here is the specific description:

Grade I:

Tearing <1cm.

The wound was completely clean, mostly due to a rupture from the inside out.

Minimal muscle pounding.

The fracture line is a simple horizontal line or a short diagonal line.

Level II:

Widespread soft tissue lesions, which can be stub or completely flaky skin.

Laceration> 1cm.

The muscles crash from mild to moderate, sometimes causing compression of the cavity.

Broken bone with simple horizontal fracture line or short diagonal with small fragment.

Grade III:

Soft lesions include muscles, skin, and vascular nerve structures. The high injury rate results in extensive soft crushing and intense compression. This category includes 3 groups:

IIIA: Large soft tissue tear, with the periosteum peeling off and the tip of the broken bone exposed. Broken bone or wound area within close range of bullets.

IIIB: Large soft tissue tear, with the periosteal peeling off and the broken head exposed. The fracture area is heavily contaminated.

IIIC: The wound is heavily crushed, the bone is broken, and there is damage to the blood vessels that require recovery.

In general, according to Gustilo as well as Tscherne, it is mainly soft tissue damage, associated with the degree of fracture (simple or complex). In which open fracture degree IV is a special pattern.

Symptoms

Injury shock

The two causes of traumatic shock are:

Bleed

Loss of blood due to soft necrosis, damage to blood vessels or from bones that flow out without stopping bleeding.

Pain

After a fracture due to not being immobilized immediately. When determining whether there is a problem fracture, first of all to consider whether there is shock due to trauma. Chances are, a fracture can be stunning.

clinical

Rapid pulse.

Lower blood pressure.

Preventive

The best pain relief is with anaesthesia.

A good immobilization of the broken bone combined with a dressing will stop the bleeding.

It is imperative not to transport a victim in the presence of severe shock or danger of shock.

Fatty embolism syndrome

Pathophysiology

In long stem fracture, hematoma increases pressure in the bone marrow, allowing bone marrow to penetrate the vessel wall in the endothelium, causing local obstruction and leading to pulmonary embolism that takes place in 3 stages:

Increased pressure in the bone marrow.

Bone marrow flow into the bloodstream (Stage I).

Pulmonary embolism (Stage II).

Respiratory failure (Stage III).

Favourable factors cause lipoatrophy

Large long fracture.

Broken bones.

Large soft tissue crushing fracture (grade III fracture).

The broken bone cannot be immobilized.

There have been associated respiratory failure.

Shock trauma, multiple injuries.

Diagnose

There are many authors presenting clinical and subclinical symptoms for the diagnosis of fatty vascular obstruction. It should only be diagnosed here according to Peltier (1988).

Conditions prone to obstruction due to fat:

Broken many long bones.

Don't freeze soon.

Transport shock.

There is shock trauma due to blood loss.

Advantageous factor

Osteoporosis.

Respiratory failure due to heart lung disease.

clinical

Rapid breathing, difficulty breathing, secreting phlegm.

Anxiety, delirium.

Haemorrhagic spots in the conjunctiva, pharynx, under the skin.

The PaO2 is below normal.

Platelets <150,000 / mm3.

Preventive

Need for fracture anaesthesia and early bone immobility.

Treatment and early recovery of traumatic shock.

Do not nailed the internal marrow early in the first 24 hours, and treat other associated lesions early.

Early detection of blood vessel obstruction due to fat, early oxygenation.

Cavity compression

As an increase in pressure in one or more chambers reduces blood flow through the cavity leading to ischemia, chamber compression accounts for 45% of the total number of acute CEK in which CEK in the leg’s accounts for the highest proportion.

Diagnosis of cavity compression is based

Natural, intense pain is increasing in the injured limb.

Pain when pressing into the compressed space.

Pain when passive prolongation, muscle in the cavity is squeezed.

The feeling of tingling is reduced to sensation.

Muscle movement disorders.

It is necessary to determine the CEK time and measure the chamber pressure to confirm the diagnosis.

Vascular complications

The blood vessel is pinched due to the displacement of the fracture.

Puncture sometimes.

Nerve compression

Mechanism:

Nerve is pinched due to.

Broken segments are displaced.

Hematoma.

Diagnose:

Acute compression is often manifested by sensory and motor disturbances. Late symptoms are typically associated with pain in the typical position such as the cylindrical canal, posterior groove of the carpal tunnel.

Complications of infection

In open fractures:

There must be the presence of germs in the wound.

The right environment for bacteria to grow.

Diagnose

To diagnose an open fracture, it is necessary to look for signs that support the following 2 things:

There is a fracture and a wound.

The wound connects to the fracture.

Based on the signs:

Seeing broken bones.

Fatty bleeding (fat in the bone marrow).

For bullet wounds, ballistics can be viewed.

Sometimes, the clinical examination cannot conclude, but must rely on dialysis, when surgery, carefully cut each layer, if there is an open fracture, it will be seen through the fracture. Rely on clinical and X-ray to classify open fractures. It is necessary to carefully examine complications of a fracture.

To solve

Treatment of life-threatening injuries, if any, such as complications from trauma to shock, hypotension, compression of the cavity, damage to blood vessels, nerves, organs ...

Management of open fractures according to treatment regimen is based on 3 main principles.

Cut the wound filter to remove the crushed tissue, rinse with normal saline.

Manipulate and immobilize the broken bone, waiting for the healing time to take place.

Taking an antibiotic can help fight the infection.

Specific jobs

Cut the wound

This is a very important and practical thing in the treatment of open fractures. Its purpose is to remove crushed tissue, necrosis, hematoma, foreign body ... and also regenerate defects caused by bone damage such as manipulating bones, stitching muscles, tendons, vessels. blood, nerve and protect these components. Flushing the wound during surgery with plenty of water will remove germs of pathogenic bacteria that have entered the wound.

For skin and subcutaneous tissue

To cut off the skin, spit and trim it, depending on the area of ‚Äč‚Äčlimbs, this truncation may be more or less (in the hands need economical cutting). Extending the wound to both sides to expand the surgical field clearly see the damage and to drain blood after surgery. Should choose the appropriate direction and area when expanding (after surgery, this place does not expose bones, does not damage blood vessels, nerves and easy for fluid to drain out)

Scales

This organization is firm but less elastic so it easily causes compression. So, need to make vertical incisions at the same time also create more horizontal incisions to prevent tension. The pounding muscle must be cut off.

Mechanical

Broken muscle fibres must be removed because it is susceptible to necrosis and becomes the best source of germs. Cut off any muscles that do not twitch and bleed to the touch. Removing a lot of muscle will result in tissue defect, loss of function later and easily reveals bones, tendons, nerves, blood vessels. If the whole abdomen breaks, stitches must be done.

Close

The broken tendons are broken, cut off, cut across the tendons, they must be stitched again (it is possible to sew the second period if the wound is not clean).

Blood vessels and nerves

If it is the main blood vessel and nerve of the limb, it must be stitched again. Nerve can to sew the second period.

Broken bone

The ends of the fracture should be cleaned and reconditioned before taking appropriate immobilization measures. Large or small broken bones should not be removed. Removing a lot of bones increases the risk of prosthetic joints. These bone fragments have lost nutrients but are not the cause of infection. Only when the wound becomes infected it becomes dead bone and needs to be removed.

After dialysis, the skin should be exposed, but must find ways to cover bones, blood vessels, nerves and tendons. When the wound is not infected (on fine granulation tissue), it will stitch or graft the skin.

Motionless broken bones

A broken bone should be immobilized and immovable after it has been well established.

To immobilize it is possible to use a cast, pull weights, set it in place and limit the use of the internal fixation (as adding foreign objects to the fracture is more likely to cause infection). Today's fixed use is very popular and has a good effect.

Take antibiotics

Antibiotics only act as a supportive but not a substitute for dialysis, but thanks to antibiotics, dialysis is more convenient and less infectious. Antibiotics should be used as early as the day after the injury or just being admitted to the hospital, choose the one that has a broad and effective effect today (it should have been used with antibiotics, but it took many days to get them). Should use high doses and continuously for a few days (at least 3-5 days), in emergency should use an injection and preferably intravenous (to quickly reach the maximum concentration in the blood), when the wound is okay should be replaced with oral antibiotics.

Fractures come soon

These are cases when the patient comes 24 hours early. Treat as above. Also depending on the fracture. Some people have an open fracture such as an open fracture but have wounds that need to be monitored and treated such as a closed fracture (not cut open, just cast cast or pulled continuously) and add antibiotics. In many cases, due to the improper assessment, the wound becomes malfunctioning and becomes osteomyelitis. So, even if it is grade I. If the wound is very clean after surgery, the skin can be closed and drained. The more susceptible to infection, the more likely it is to undergo dialysis. For children, regardless of the severity of the fracture, it is necessary to cut the filter early.

Breakage is late

The problem here is that the wound has been reacted by the body by the white blood cell barrier, if antibiotics are used early and continuously, the strength is increased. However, the infectious drive has not been destroyed, not yet assured. To solve this problem, we should put into 3 situations:

The wound is heavily infected and spreads, threatening sepsis: Urgent surgery is required. To support the need to use strong antibiotics, high doses by intravenous infusion. Dialysis requires flushing with plenty of water and exposing the skin completely (but not showing bones ...).

Moderate wound infection: Can delay surgery (subacute) to have a good preparation time (antibiotics, resuscitation ...).

The wound is temporarily stable with red granular tissue, pus is gone, but the bones are still displaced: Should not interfere with the wound, to fix the broken bone, it is recommended to use immobilize in addition to restrict active manipulation. Only intervene in the fracture (to combine bones) when the wound is very stable (no fever, no pain, blood sedimentation rate returns to normal).

Preventive

Propaganda and education in the community about traffic and labour laws.

It is necessary to educate students in elementary schools about the causes of fractures in order to limit accidents occurring in daily life and in schools.

It is necessary to educate the community of good local first aid in fracture cases to limit complications in fractures.

The grassroots health facilities need an early diagnosis, correct treatment and referral to the specialized medical level for early treatment.