Dr. Suman Paul provides a historical overview of the treatment of open fractures. Early civilizations like Egyptians recognized the need to cover open fracture wounds to minimize morbidity. Through the 19th century, amputation was often used for treatment after open fractures. Advances in the 20th century included debridement and stabilization principles from World War I, and the introduction of local antibiotics in World War II which reduced wound sepsis rates. The Gustilo classification system, introduced in 1976, provides guidelines for prognosis and treatment of open fractures based on the degree of soft tissue injury. Later classifications like the Bowen system in 2005 incorporated host risk factors to better predict infection risk. Common bacteria associated with open fractures include staph, strep,
Open fractures involve a break in the bone that communicates with the external environment through a break in the skin and soft tissue. They are often caused by high-energy trauma like traffic accidents or falls. The initial management involves thorough debridement to remove all non-viable tissue, irrigation to clean the wound, fracture stabilization, and antibiotic treatment. Further debridement may be needed over subsequent days to fully clean the wound. The goal is to prevent infection while stabilizing the fracture and achieving soft tissue coverage. Outcomes depend on adequate initial management and reconstruction as needed.
POLYTRAUMA AND DAMAGE CONTROL ORTHOPAEDICSDr Slayer
polytrauma is Injury to 2 or more organ systems leading potentially to a life threatening condition
Damage control orthopaedics is an approach to contain and stabilize an orthopaedic injury to improve patient’s physiology which are designed to avoid worsening pt’s condition due to “second hit” phenomenon
This document discusses the historical basis and current management of open fractures. It reviews key figures like Desault who coined the term "debridement" and emphasized early debridement to prevent infection. Current management involves thorough debridement and irrigation, antibiotic administration, initial wound management, and definitive stabilization of the fracture, either through external or internal fixation depending on the injury. Proper initial management and wound care can help prevent complications and allow for later reconstruction if needed.
The document provides a history and overview of external fixators. Some key points:
- External fixators were first developed in the 1840s and have since been improved, including the addition of threaded pins, rods, and adjustable clamps.
- They are used to stabilize and immobilize long bone fractures, especially open or complicated fractures.
- Components include Schanz pins, tubes, and universal clamps. Proper placement of pins is important for stability.
- External fixators can be used temporarily to stabilize injuries before definitive fixation, or as the final fixation in cases where soft tissue healing is problematic. They provide less invasive fracture stabilization than internal fixation.
AO Principles of Fracture treatment & Different Implants.Dr.Anshu Sharma
The document discusses AO principles of fracture treatment and different implant modalities. It covers the AO classification system, the four AO principles of fracture fixation focusing on restoration of anatomy and stability, methods of fracture reduction, types of fracture fixation including absolute and relative stability, importance of preserving blood supply, and postoperative care including early mobilization. Key implant modalities discussed include screws for cortical and cancellous bone as well as lag screw fixation.
This document discusses the evolution of approaches to treating patients with multiple traumatic injuries, including polytrauma. It describes how the concept of early total care (ETC), involving early definitive fixation of fractures, was later found to potentially cause harm in unstable patients. This led to the emergence of damage control orthopedics (DCO), which focuses on temporary stabilization and minimizing surgical insult in critically injured patients. DCO principles include provisional fixation, delayed definitive treatment until the patient is more stable, and categorizing patients as stable, unstable or borderline to guide surgical timing and approach. The document also discusses related concepts like early appropriate care (EAC) and damage control for spine injuries.
1) Pilon fractures involve injuries to the distal tibial articular surface and were first described in 1911.
2) They account for 5-7% of tibial fractures and result from high-energy impacts.
3) Treatment is challenging due to articular comminution, bone loss, and soft tissue injury. Surgical management aims to reconstruct the articular surface and metaphysis while treating soft tissues.
This document discusses the classification of soft tissue injuries associated with fractures. It describes several classification systems, including Tscherne, Gustilo-Anderson, and AO, that grade soft tissue injuries based on factors like wound size, contamination, and bone and muscle involvement. Proper classification of soft tissue injuries is important for determining fracture management and predicting healing to help standardize treatment protocols.
This is a lecture presentation on applying external fixator on open fracture specially on tibia. This method is a classical method. Various new and dynamic fixators are there but the basics are the same.
This document discusses the management of open fractures. It defines an open fracture as one where the skin and soft tissue is broken, communicating with the fracture site. Initial management involves assessing injuries, covering wounds, antibiotics, and debridement to remove dead tissue. Fractures are then stabilized, either externally or internally. Wounds are closed primarily if possible or allowed to heal secondarily. Complications can include early issues like infection or late problems like nonunion. Grading and scoring systems help determine prognosis and need for amputation. The goal is always limb salvage when possible.
This document discusses tibial pilon fractures, which involve fractures of the distal tibial articular surface. Key points include:
1) The term "tibial pilon" was first used in 1911 to describe the distal tibia resembling a pestle. Pilon fractures account for 7-10% of tibial fractures and usually result from high-energy mechanisms.
2) Classification systems include the Rüedi-Allgöwer system (based on articular displacement/comminution) and the AO/OTA system (which further subdivides based on extra-articular involvement and comminution).
3) Treatment involves restoring tibial alignment, stabilizing the fracture to facilitate union,
This document discusses the principles of operative fracture management for open fractures. It defines open fracture classifications according to the Gustilo system and outlines approaches for emergency assessment, wound excision and debridement, antibiotic therapy, wound management, soft tissue coverage, fracture stabilization, and rehabilitation. The key goals are to prevent infection, promote soft tissue and bone healing without complications, and restore function of the injured extremity.
1) Damage control orthopedics (DCO) is a strategy that focuses on temporarily stabilizing major orthopedic injuries in polytrauma patients who are physiologically unstable through techniques like external fixation to minimize surgical insult.
2) DCO follows a three stage approach - early temporary external fixation, ICU resuscitation, and delayed definitive fracture management.
3) Injuries suitable for DCO include those associated with hypothermia, coagulopathy, shock, soft tissue injury, or expected major blood loss from complex and prolonged reconstruction.
This document discusses tendon anatomy, injury, and repair. It describes the composition and vascular supply of tendons. Common tendon injuries include open wounds requiring surgical repair and closed injuries causing deformities. The goals of repair are to reestablish tendon continuity and gliding function. Various suture techniques are discussed for end-to-end, end-to-side, and tendon-to-bone repairs. Post-operative rehabilitation aims to promote intrinsic healing while minimizing scarring through early controlled motion to optimize tendon gliding and range of motion recovery.
This document provides an overview of ankle injuries, including:
1. The anatomy of the ankle joint and surrounding ligaments that provide stability.
2. Common types of ankle injuries like sprains and fractures, which are often caused by inversion or eversion forces on the ankle.
3. Guidelines for evaluating and diagnosing ankle injuries through history, physical exam, and imaging like x-rays. Classification systems for fractures like Lauge-Hansen and Weber are discussed.
3. Approaches for treating different types of ankle injuries non-operatively or operatively depending on factors like the injury pattern and degree of displacement. Surgical techniques like plate fixation are outlined.
The document discusses physeal (growth plate) injuries in children. It notes that physeal injuries represent 15-20% of injuries in children and can cause growth arrest and deformities. The most common sites are the distal radius, distal tibia, and phalanges. It describes the anatomy and blood supply of the physis. It discusses the Salter-Harris classification system for physeal fractures and treatment approaches including casting, splinting, and surgery. Complications of physeal injuries like growth arrest, angular deformity, and limb length discrepancy are also summarized. Long term follow up is needed to monitor bone healing and growth.
The document discusses the decision between limb salvage and amputation for severely injured extremities. It outlines factors to consider like injury classification, soft tissue damage, vascular and nerve injury. Scoring systems like MESS, LSI and PSI are mentioned but have limitations. With advances in wound care, fixation and reconstruction, more limbs can now be salvaged that would have previously required amputation. The optimal decision involves a multidisciplinary team at an experienced trauma center tailored to each patient's injuries and prognosis.
Calcaneal fractures typically result from high-energy injuries and can lead to long-term morbidity if not treated properly. While non-operative treatment is indicated for non-displaced fractures, open reduction internal fixation (ORIF) may be required for displaced or intra-articular fractures to restore anatomy and function. Careful surgical technique and postoperative management are needed to avoid complications and achieve good outcomes with ORIF. Treatment must be individualized based on fracture pattern and soft tissue status.
This document discusses open fractures, including their definition, classification, epidemiology, microbiology, treatment principles, and management. Some key points:
- Open fractures involve a break in the skin and soft tissue leading directly to the fracture site. They were historically associated with high infection and mortality rates.
- The Gustilo-Anderson classification system grades open fractures based on the degree of soft tissue injury from I to III (A, B, C). Higher grades correlate with increased risk of infection and impaired fracture healing.
- Most open fracture infections are caused by bacteria acquired in the hospital rather than the initial trauma. Appropriate antibiotic treatment is crucial.
- Goals of management include preserving life and limb,
Open tibia fractures can range from minor soft tissue wounds to severe injuries with extensive soft tissue damage and bone loss. The goals of treatment are to prevent infection, achieve bone union, and restore function. Management involves thorough debridement and irrigation, temporary stabilization, soft tissue coverage within 7-10 days if possible, and definitive stabilization once the soft tissues have healed sufficiently. Complications include infection, malunion, nonunion, and compartment syndrome, which require additional treatment such as antibiotics, bone grafting, or surgery.
1) The initial management of open fractures, including the timing of debridement, choice of antibiotic regimen, and wound coverage, remains controversial with debate around several key issues and a lack of strong evidence to guide certain practices.
2) While early debridement and antibiotics are generally recommended, the literature does not provide clear guidance on the optimal timing of debridement or whether adding gram-negative coverage improves outcomes for Type III fractures.
3) Antibiotic regimens of short-course cephalosporins begun promptly are supported, but prolonged courses lack evidence. Routine wound cultures also do not predict infection.
1) The initial management of open fractures, including timing of debridement, choice of antibiotics, and timing of wound coverage, involves several controversies with little consensus in the literature.
2) While early antibiotic administration and debridement are agreed upon, there is no evidence that debridement must occur within 6 hours as was once believed; many surgeons now find urgent rather than emergency debridement acceptable.
3) Timing of wound coverage is also debated, but most evidence suggests covering Type III wounds within 7 days is appropriate once tissues have stabilized and debridement is complete.
Open fractures of the tibial diaphysis are common injuries that require urgent treatment to prevent infection and achieve bone union. The treatment priorities include addressing life threats, administering antibiotics and tetanus prophylaxis, debriding wounds, stabilizing fractures, and covering soft tissue defects. Surgical management often involves external or internal fixation along with soft tissue reconstruction using flaps or grafts. Despite treatment, complications like infection, nonunion, and malunion are common, especially with higher grade open fractures and bone/soft tissue loss. The goals of treatment are to prevent sepsis, achieve bone union, and restore function.
Open fractures are unique, complex, and emergently presenting injuries that expose sterile bone to the contaminated environment.
Because a fracture disrupts the intramedullary blood supply, the additionally stripped soft tissue envelope further devitalizes the bone.
The more severe the soft tissue injury or open wound, the more severe the osseous injury.
Historically, open fractures were associated with infection, delayed union, nonunion, amputation, or death.
This document discusses open fractures of the tibial diaphysis (shaft). It notes that open tibia fractures account for about 1/4 of all tibial fractures and occur more commonly in the tibia than any other long bone. Treatment involves thorough debridement and irrigation of the soft tissue wound, antibiotics, and stabilization of the bone fracture, which may be via internal or external fixation depending on the fracture pattern and soft tissue injury severity. Complications include infection, nonunion, malunion, and compartment syndrome. Outcomes depend highly on the severity of soft tissue and neurovascular damage based on the Gustilo-Anderson classification.
The document discusses ventral hernias, including:
- Incidence and risk factors for ventral hernias
- Options for mesh placement during hernia repair surgery
- Types of prosthetic meshes used, including benefits and disadvantages of polypropylene, ePTFE, polyester, and absorbable barrier-coated meshes
- Studies comparing surgical outcomes and complications between different mesh types
This document discusses the impact of infection on fracture fixation. It notes that trauma and surgery disrupt the body's natural barriers against infection. Recent studies found infection rates of 2.5-25% in open fractures, and 17.6-23.6% in bicondylar tibial plateau fractures. Factors that affect infection risk include surgical technique, time, antibiotic timing, host characteristics, and implant colonization by antibiotic-resistant bacterial biofilms. Proper diagnosis and treatment of surgical site infections aims to eliminate infection while healing the fracture and maintaining patient function, though infections increase 30-day and 1-year mortality rates.
The document discusses open fractures, providing details on epidemiology, classification, management principles, antibiotic treatment, wound irrigation and debridement. Open fractures commonly involve the fingers, tibia and distal radius, and result from high-energy trauma like vehicle accidents or falls. Immediate evaluation and treatment is needed, including antibiotics, wound cleaning, and splinting or stabilization to prevent infection while facilitating healing.
The document discusses surgical meshes and methods of fixation for hernia repair. It covers biologic and synthetic meshes and factors that influence hernia occurrence. Direct closure of hernias has a high recurrence rate of around 50%, which is reduced to around 5-18% when meshes are used. Long stitch lengths during closure are associated with higher rates of surgical site infection and hernia recurrence compared to short stitch lengths. Polypropylene meshes allow for tissue ingrowth but can cause complications like chronic infection, fistulas and erosion over time. Other synthetic mesh options discussed include ePTFE meshes.
This document describes a two-stage technique for treating chronic osteomyelitis of long bones. In stage one, all infected and compromised bone and soft tissue is radically debrided. Healthy soft tissue coverage is then provided, either directly or with a muscle flap. Stage two occurs 3-6 weeks later, where any remaining bone defects are grafted with cancellous bone grafts. This technique was used to treat 37 patients with chronic osteomyelitis of the tibia, femur, radius or humerus. Infection was eradicated in 34 patients, with no patients requiring amputation.
1. Open fractures require urgent evaluation, debridement within 6 hours, and antibiotic therapy.
2. Initial debridement removes contaminated tissue, copious irrigation is used, and repeat debridement occurs within 24-72 hours.
3. Fracture stabilization is determined initially while leaving the wound open. Early bone grafting and aggressive rehabilitation of the extremity are also recommended.
This document provides information on the assessment and treatment of compound fractures where the bone is exposed to the external environment. It defines compound fractures and discusses their pathophysiology, risk factors, initial assessment including examination of the wound and injured limb, antibiotic treatment, classification systems, treatment options including debridement, stabilization, and wound management. Treatment is aimed at achieving a stable skeletal fixation and environment conducive to fracture and soft tissue healing.
This document provides information on fractures of the tibia. It begins with definitions of fractures and their various classifications. The causes of tibial fractures include direct forces, indirect forces, twisting, bending, and pathological fractures. Fracture patterns include transverse, oblique, spiral, impacted, comminuted, and compression fractures. Treatment options for tibial fractures depend on the fracture type and include casting, intramedullary nailing, plating, and external fixation. Complications can include nonunion, malunion, infection, and hardware failure. Open fractures require urgent debridement and antibiotics to prevent infection.
This document discusses the evaluation and management of infected nonunions. It begins by defining infected nonunion and describing the associated patient presentation. Evaluation involves investigating potential contributing factors, imaging to identify the extent of infection, and assessing patient goals. Management includes thorough debridement, stabilization with external fixation, culture-directed antibiotics, and dead space management. Once infection clears, methods to achieve bony union include internal fixation, bone grafting, bone transport, or free flaps. The document outlines various surgical strategies and complications to consider in treating these challenging cases.
This document summarizes a critical review on contemporary views of dry socket (alveolar osteitis). It discusses standardization of definitions, etiology, pathogenesis, and management. Dry socket is defined as postoperative pain in the extraction site 1-3 days after extraction accompanied by a partially or totally disintegrated blood clot. It occurs most frequently after mandibular third molar extraction. Etiology is multifactorial and may include oral microorganisms, surgical trauma, root/bone fragments, excessive irrigation, clot dislodgement, local anesthesia, oral contraceptives, and smoking. Management includes identification and elimination of risk factors as well as preventive and symptomatic treatments.
- Periapical wound healing is the host's programmed immunoinflammatory defense mechanism in response to infection or injury. It involves complex overlapping stages including inflammation, proliferation, and remodeling.
- The primary difference between healing after surgery and nonsurgical root canal treatment is that surgery requires blood clot formation and may result in faster healing dynamics. After successful nonsurgical root canal treatment, periapical inflammatory tissues will be eliminated mainly by phagocytic debridement.
- Healing involves osseous healing of trabecular and cortical bone as well as dentoalveolar healing resulting in repair or regeneration of the apical attachment apparatus. Various factors like age, tooth position, and root canal filling material can
A 13-year-old boy presented with 4 months of right knee pain. Radiographs, bone scan, CT scan, and biopsy were performed. The most likely diagnosis based on the imaging and biopsy is Ewing's sarcoma. Ewing's sarcoma commonly presents in long bones of adolescents with pain and is an aggressive round cell tumor that typically affects the metaphysis of long bones. The imaging and biopsy are consistent with this diagnosis.
Osteoporosis is a disease characterized by low bone density and deterioration of bone tissue, leading to fragile bones and increased fracture risk. It is diagnosed through bone mineral density tests and can be caused by many factors including older age, female sex, family history, and lifestyle factors. Management focuses on lifestyle modifications like calcium and vitamin D supplementation, exercise, and fall prevention, as well as pharmacological therapies to slow bone loss and increase bone density. Complications include fractures which can lead to disability, loss of independence, and even death in severe cases.
Osteoarthritis is the most common form of arthritis that affects the joints, especially in those over 45 years old. It involves the breakdown of cartilage in the joints which leads to pain, stiffness, and reduced mobility. Risk factors include age, genetics, joint injuries, and obesity. Symptoms may include joint pain, stiffness, swelling, and grinding sensations. Diagnosis involves physical exams, x-rays showing cartilage loss and bone spurs, and ruling out other causes. Treatment focuses on reducing pain and inflammation with medications and physical therapy, as well as weight loss and joint protection. For severe cases, surgical options like joint replacement may be considered.
The document provides information on the management of open fractures. It defines open fractures as fractures where there is a breach in the soft tissue envelope exposing the fracture site. Key aspects of management include thorough initial assessment, adequate irrigation and debridement within 6 hours, appropriate antibiotic therapy, and stabilization of the fracture either through external or internal fixation. Complications of open fractures discussed include infection, hypovolemic shock, compartment syndrome, fat embolism, acute respiratory distress syndrome, and neurovascular injuries.
Low back pain is a common condition affecting the lumbar region of the back. It has many potential causes, including muscle strains, injuries to bones or discs, and underlying medical conditions. Diagnosis involves taking a history and conducting a physical exam. Common tests used to evaluate low back pain include x-rays, MRI, and CT scans. Treatment focuses on pain relief through medications, physical therapy, exercise, and in severe cases, surgery. Proper posture and lifting techniques can help prevent low back pain.
Knee arthrodesis is a surgical fusion of the knee joint that is used as a salvage procedure for a damaged or diseased knee that cannot be reconstructed or replaced. The document discusses indications for knee arthrodesis including failed total knee arthroplasty, post-traumatic arthritis, and loss of the knee extensor mechanism. It also covers surgical techniques for knee arthrodesis such as external fixation, internal fixation with plates, and intramedullary nailing. Complications associated with knee arthrodesis include nonunion, infection, and degenerative changes in adjacent joints from altered gait biomechanics.
Surgical site infections: Latest Approach on management.drsp46
Surgical site infections (SSIs) are among the most common and preventable hospital-acquired infections. SSIs can prolong hospital stays by a week on average, increase costs, and in some cases lead to poor patient outcomes or even death. Proper prevention techniques include preoperative showering or cleansing with antiseptics, careful handling of surgical attire and equipment, strict hand hygiene protocols for surgical staff, judicious use of antibiotic prophylaxis timed appropriately before incision, and maintaining sterile technique in the operating room. A multidisciplinary approach is important to reduce risks and prevent SSIs.
CASE PRESENTATION ON ACUTE GASTROENTERITIS.Bhavana
This is a case presentation of a 72 year old female patient who was admitted in the hospital with the chief complaints of loose stools since 6 Days and generalised weakness and history of one episode of vomiting (one day back).
As a leading rheumatologist in Chandigarh, Dr. Aseem specializes in the diagnosis and management of a wide range of rheumatic conditions, including but not limited to:
Rheumatoid Arthritis: An autoimmune disorder that causes chronic inflammation of the joints.
Osteoarthritis: A degenerative joint disease characterized by the breakdown of cartilage.
Lupus: A systemic autoimmune disease that can affect the skin, joints, kidneys, and other organs.
Ankylosing Spondylitis: A type of arthritis that primarily affects the spine, causing pain and stiffness.
Gout: A form of arthritis characterized by sudden, severe attacks of pain, redness, and tenderness in the joints.
Psoriatic Arthritis: A type of arthritis that affects some people with psoriasis.
Vasculitis: An inflammation of the blood vessels that can cause a variety of symptoms.
Sjogren’s Syndrome: An autoimmune disorder characterized by dry eyes and mouth.
Accurate diagnosis is crucial for effective treatment. Dr. Aseem Goyal utilizes advanced diagnostic techniques to identify the underlying causes of rheumatic conditions. Our state-of-the-art facility is equipped with the latest technology to provide comprehensive diagnostic services, including:
Blood Tests: To check for markers of inflammation and autoimmune activity.
Imaging Studies: Such as X-rays, MRI, and ultrasound to assess joint and soft tissue damage.
Joint Fluid Analysis: To examine the fluid in the joints for signs of inflammation or infection.
Biopsy: In certain cases, a small tissue sample may be taken for further examination.
Treatment Approaches
Dr. Aseem Goyal adopts a holistic and patient-centered approach to treatment. Depending on the specific condition and its severity, treatment options may include:
Medications
Nonsteroidal Anti-Inflammatory Drugs (NSAIDs): To reduce inflammation and relieve pain.
Disease-Modifying Antirheumatic Drugs (DMARDs): To slow the progression of rheumatic diseases.
Biologic Agents: Targeted therapies that block specific pathways in the immune system.
Corticosteroids: To control severe inflammation quickly.
STRATEGIES FOR RATIONALISING/REDUCING CAESAREAN SECTION RATE BY USE OF "SION ...Niranjan Chavan
The journey to reduce/rationalise the C-section rate started in June 2023 and it’s an ongoing study been carried out at #SionHospital #LTMMC Mumbai.
It’s going to revolutionise the journey of motherhood for safer, predictable maternal and fetal outcome.
The SION model is a structured and networked approach to promoting vaginal deliveries.
By integrating education, support, policy implementation, and continuous improvement, it aims to enhance maternity care and reduce unnecessary C-sections through collaborative efforts among healthcare providers and patients.
Encouraging trials of labor after previous C-sections (TOLAC) and fostering a multidisciplinary team approach in maternity care are crucial.
Regular training for healthcare providers and establishing supportive hospital policies further promote vaginal births.
Staphysagria is often indicated for individuals who have a tendency to suppress emotions and suffer from the effects of suppressed anger, grief or indignation. They may exhibit a tendency to have a fragile or sensitive disposition. Staphysagria individuals often have a craving for solitude and a desire for sympathy.
Report Back from ASCO 2024: Latest Updates on Metastatic Breast Cancer (MBC)....bkling
Join Dr. Kevin Kalinsky, breast oncologist and researcher from Emory Winship Cancer Institute, to learn about the latest updates from The American Society of Clinical Oncology (ASCO) annual meeting 2024.
Introduction to Dental Implant for undergraduate studentShamsuddin Mahmud
Introduction to Dental Implant
Dr Shamsuddin Mahmud
Assistant Professor, Department of Prosthodontics
Nortth East Medical College (Dental Unit)
Definition of Dental Implant
A prosthetic device
made of alloplastic material(s)
implanted into the oral tissues beneath the mucosal and/or periosteal layer and
on or within the bone
to provide retention and support for a fixed or removable dental prosthesis.
Classification of Dental Implant
According to placement within the tissue
Blade/Plate form implant
According to Material Used
A) METALLIC IMPLANTS
Commercially pure Titanium
Cobalt chromium molybdenum
Titanium aluminum vanadium
Stainless steel
B) NON-METALLIC IMPLANT
Zirconium
Ceramic
Carbon
According to the ability of implant to stimulate bone formation
A) Bio active
Hydroxyapatite
Tri Calcium Phosphate
B) Bio inert
Metals
Parts of Dental Implant
Implant fixture
Implant mount
Cover screw
Gingival former/healing screw/healing abutment/permucosal extension
Impression post/impression transfer abutment
Implant analogue
Abutment
Fixation screw
Implant Fixture
Implant Mount
Connected to the fixture
Function: used to carry implant from its vital to the prepared osteotomy site either by hand or with a ratchet/ handpiece adaption
Cover Screw
component that is used to cover the implant connection during the submerged healing of the implant
Function: preserves the patency of the connection by preventing any soft tissue ingrowth in the connection
Gingival former/ Healing Abutment/ Healing screw
Screw/ abutment used to create the soft tissue emergence profile around the implant.
Time of placement:
During 1st surgery – One step surgery
After Osseointegration – Two step/stage surgery
Gingival former/ Healing Abutment/ Healing screw
Placed in the site 2-3 weeks for soft tissue healing
Function:
Create gingival emergence profile
Formation of biological width
Impression post/impression transfer abutment
component that is used to trans- fer the implant Hex position and orientation from the mouth to the working cast.
Types
Closed tray
Open tray
Implant analogue/
component which has a different body but its platform and connection are exactly similar to the implant. The analogue is used to replicate the implant platform and connection in the laboratory mode.
Abutment
Abutments
Advantages of Dental Implant Retained Prosthesis
Maintain bone height and width by preventing bone resorption
Maintain facial esthetics
Improve masticatory performance
Improve stability and retention of prosthesis
More esthetics
Increase survival times of prostheses
There is no need to alter adjacent teeth
Improve psychological health
Disadvantages of Dental Implant Retained Prosthesis
Very expensive.
Cannot be used in medically compromised patients who cannot undergo surgery.
Longer duration of treatment
Requires a lot of patient co-operation because of repeated recall visits are essential
INDICATION OF DENTAL IMPLANT
Dental implants can successfully restore all
Anthelmintics or antihelminthics are a group of antiparasitic drugs that expel parasitic worms and other internal parasites from the body by either stunning or killing them and without causing significant damage to the host. They may also be called vermifuges or vermicides
TEST BANK Physical Examination and Health Assessment 9th Edition by Carolyn J...rightmanforbloodline
TEST BANK Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis, All Chapters 1 - 32 Full Complete.pdf
TEST BANK Physical Examination and Health Assessment 9th Edition by Carolyn Jarvis, All Chapters 1 - 32 Full Complete.pdf
Prakinsons disease and its affect on eye.Riya Bist
Enhance your knowledge about Parkinsons' disease and about basic concept that medical personnel should know regarding this topic.It is very important to know about systemic disease and its impact on the eye so, here you can learn quickly about Parkinson's disease and its ocular manifestation.Download the ppt for visualization of animation.Thank you.
Definition of mental health nursing, terminology, classification of mental disorder, ICD-10, Indian Classification, Personality development, defense mechanism, etiology of bio psychosocial factors,
2024 07 12 Do you share my autistic traits_ - Google Sheets.pdfCarriePoppy
I made this spreadsheet when I was waiting for my autism assessment. It helped me determine that I probably have autism. When I did get tested, they (UCLA) told me I do, indeed, have Type 1 autism. You can use this spreadsheet to compare your experience to mine. I am a white woman, AFAB. My diagnosis is Type 1 autism with a pragmatic language deficit.
कायाकल्प क्लिनिक: पटना के अग्रणी सेक्सोलॉजिस्ट और स्किन केयर विशेषज्ञ
पटना का एक शानदार स्वास्थ्य सेवा प्रदाता, कायाकल्प क्लिनिक, आपके स्वास्थ्य और त्वचा की देखभाल में विशेषज्ञता प्रदान करता है। हमारे नवीनतम तकनीकी समाधानों और अनुभवी विशेषज्ञों के साथ, हम पुरुष और महिलाओं के स्वास्थ्य सम्बंधित मुद्दों को हल करते हैं। यहां पर हम प्रदान करते हैं:
Expert Treatment for Sex Issues at Kaya Kalp Clinic in Patna -best sexologist in patna
Dealing with sex-related problems? Find effective solutions at Kaya Kalp Clinic in Patna. Our experienced sexologist doctors are here to help.
Experienced Doctors
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We offer solutions for all kinds of sex-related issues. Our clinic is equipped with advanced equipment to ensure gentle treatment and positive results.
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We understand the sensitivity of these issues. Our doctors provide confidential and respectful care. We tailor treatments to meet your needs and lifestyle.
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Located in Patna, our clinic is easy to reach. Whether you’re searching “Sexologist Doctor Near Me” or referred by a doctor, we’re here to help.
Start Your Journey to Better Health
Don’t let sex-related issues affect your life. Contact Kaya Kalp Clinic today for expert care and support. Rediscover confidence and happiness in your sexual health.
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Discover the Best Sexologist in Patna: Expert Care at Kayakalp Clinic
Kayakalp Clinic - Best Sexologist in Patna
Kayakalp Clinic - Best Sexologist in Patna
When it comes to sexual health, finding the right expert is essential for effective diagnosis and treatment. At Kayakalp Clinic in Patna, we pride ourselves on providing exceptional care for a wide range of sexual health issues. If you’re searching for the best sexologist in Patna, look no further. Our team of highly skilled professionals is here to help you navigate and resolve your concerns with confidentiality and compassion.
Why Choose Kayakalp Clinic?
1. Experienced Professionals
Our sexologists are highly trained and experienced in dealing with various sexual health issues. They stay updated with the latest advancements in the field to provide the best care possible.
2. Comprehensive Services
At Kayakalp Clinic, we offer a wide range of services, including:
- Treatment for erectile dysfunction
- Solutions for premature ejaculation
- Counseling for low libido
- Infertility treatment
- Management of sexual pain disorders
- STI screening and treatment
- Relationship and intimacy counseling
3. Personalized Treatment Plans
We understand that every individual is unique, and so are their health concerns. Our sexologists take the time to understand your specific needs and create personalized treatment plans to ensure the best outcomes.
These lecture slides, by Dr Sidra Arshad, offer a comprehensive look into cardiac arrhythmias.
Learning objectives:
1. Summarise how an electrocardiogram is read
2. Discuss the electrocardiographic interpretation of:
3. Abnormal voltages of the QRS complex
4. Abnormal sinus rhythms
5. Heart blocks
6. Myocardial ischemia and infarction
7. Electrolytes abnormalities
8. Explain the following terms: reentry, and circus movement
9. Describe the electrical alteration in conduction responsible for fibrillation and flutter
10. Differentiate between fibrillation and flutter based on ECG findings
11. Describe the significance of defibrillation in emergency cardiac situations
Study Resources:
1. Chapter 12, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, https://geekymedics.com/how-to-read-an-ecg/
Osvaldo Bernardo Muchanga- MALE CIRCUMCISION, ITS Vs SOCIOCULTURAL BELIEFS (C...Osvaldo Bernardo Muchanga
MALE CIRCUMCISION consists of the surgical act of removing the foreskin (skin that covers the glans of the penis), leaving the glans more prominent and better cleanable.
MALE CIRCUMCISION itself has medical as well as sociocultural implications, as it has been proven to be an act that can minimize SEXUALLY TRANSMITTED INFECTIONS (STIs), especially HIV, but it also represents the SOCIOCULTURAL IDENTITY of some people, respectively.
Now, in a SERO-EPIDEMIOLOGICAL PROFILE like that of Mozambique where the prevalence of HIV is around 12.5% which corresponds to approximately 2 million people living with HIV, where the province of GAZA is the most seroprevalent with a positivity rate of 21% (INSIDA, 2021), it is extremely necessary to THOROUGHLY scrutinize all possibilities for preventing or minimizing the spread of HIV and other STIs.
Introduction of mental health nursing, Perspective of mental health and mental health nursing, Evolution of mental health services, treatment and nursing practices Mental health team, Nature and scope of mental health nursing, Role & function of mental health nurse inn various settings and factors affecting the level of nursing practice, concept of normal and abnormal behavior
1. DR. SUMAN PAUL
Department of
Orthopaedics & Traumatology,
Rajshahi Medical College Hospital
Open
Fractures
2. Definition
• These are the fractures in which there is
breach in the soft tissue envelope over or
near the fracture, such that fracture
haematoma communicates with external
environment.
3. • Egyptians 1st
time recognised he need for
coverage over fracture wounds to minimise
morbidity.
• Hippocrates favoured the debridement of
purulent material.
• Galen considered purulence as necessary
“Laudable pus” & considered it as essential for
healing.
• Ambroise Parè also favoured the debridement
as the mainstay of treatment of open.
History
4. • Desault (coined the term ‘debridement) in 18th
century reiterated this belief by advising
debridement of dead necrotic material.
• Still in the 19th
century, prior to aseptic
technique & antibiotics, emergency
amputation was the life saving measure after
open fracture.
History
5. • Last century, high mortality with open fractures
of long bones
• WWI, mortality of open femur fractures > 70%
• By the WWI the main principle of treatment was
debridement and stabilization & all healing by
secondary intention.
• 1939 Trueta “closed treatment of war fractures”
– Included open wound treatment and then enclosure
of the extremity in a cast
– “Greatest danger of infection lay in muscle, not bone”
History
6. • During the WW-II use of local antibiotics like
sulfonamides was started for wound
treatment.
• Use of PCN on the battlefield quickly reduced
the rate of wound sepsis.
History
7. • Advances shifted the focus
– Preservation of life and limb preservation of
function and prevention of complications
• However, amputation rates still exceed 50% in
the most severe open tibial fractures assoc
with vascular injury.
History
8. • Generally a result of high energy mechanisms which cause
greater soft tissue disruption that leaves the wound more
susceptible to infection by contaminating bacteria.
• The energy is stored in soft and hard tissues until the strength
of respective material is exceeded.
• Comminuted pieces may acquire high velocity after which
they propel into the surrounding soft tissues and cause
additional damage.
• More severe injury, limb absorbs energy releases in
explosion tears the skin momentary vacuum sucks
foreign material into the wound depth.
• Soft tissue damage enormous muscle swelling
compartment syndrome (more in open injuries) of the intact
compartments
Etiology
10. • Fracture pattern
• Local factors
– Amount of foreign debris and contaminant
material
– Extent of soft tissue and bone devitalization.
• Systemic fractures
– Host nutrition
– Medications
– Nicotine abuse
Prognosis
11. Open fracture classification
• Allows comparison of results
• Provides guidelines on prognosis and
treatment
– Fracture healing, infection and amputation rate
correlate with the degree of soft tissue injury
• Gustilo upgraded to Gustilo and Anderson
• AO open fracture classification
• Host classification of open fractures
12. Gustilo and Anderson Classification
• Model is tibia, however applied to all types of
open fractures
• Emphasis on wound size
– Crush injury assoc with small wounds
– Sharp injury assoc with large wounds
• Better to emphasize
– Degree of soft tissue injury
– Degree of contamination
13. Type 1 Open Fractures
• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal
stripping
14. Type 2 Open Fractures
• Moderate soft tissue
damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal
stripping
15. Type 3a Open Fractures
• High energy
• Outside-in
• Extensive muscle
devitalization
• Bone coverage with
existing soft tissue
16. Type 3b Open Fractures
• High energy
• Outside in
• Extensive muscle
devitalization
• Requires a flap for
bone coverage
and soft tissue
closure
• Periosteal stripping
17. Type 3c Open Fractures
• High energy
• Increased risk of
amputation and
infection
• Any grade 3 with
major vascular injury
requiring repair
18. Why use this classification?
• Grades of soft tissue injury correlates with infection
and fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2% 2-7% 10-25% 10-50% 25-50%
Fracture
Healing
(weeks)
21-28 28-28 30-35 30-35
Amputation
Rate
50%
19. Gustilo and Anderson
Bowen and Widmaier*
• 2005 Host classification predicts infection
after open fracture
– Gustilo and Anderson classification and the
number of comorbidities predict infection risk
– 174 patients with open fractures of long bones
– Sorted into three classes based on 14
immunocompromising factors
• Age>80, current nicotine use, DM, malignancy,
pulmonary insufficiency, systemic immunodeficiency,
etc
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205-11.
20. What they found…
• Patients with any compromising risk factor has
increased risk of infection
• May benefit from additional therapies that
decrease the risk of infection.
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205-11.
Class Compromising factors Infection rates
A 0 4%
B 1-2 15%
C 3 or more 31%
21. Gustilo Classification:
a simple and useful tool, but is it accurate?
• 1994 Brumback et al.
• 125 randomized open fractures
• 245 surgeons of various levels of training
• 12 cases of open tibia fractures, videos used
• Interobserver agreement poor
– Range 42-94% for each fracture
• Ortho attendings - 59% agreement
• Ortho Trauma Fellowship trained attendings - 66% agreement
Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two
hundred and forty-five orthopaedic surgeons. J Bone and Joint Am; 76(8):1162–1166.
22. So……….
• Fracture type should not be classified in the
ER
• Most reliably done in the OR at the
completion of primary wound care and
debridement
23. Microbiology
• Most acute infections are caused by pathogens
acquired in the hospital
• 1976 Gustilo and Anderson
– most infections in their study of 326 open fxs
developed secondarily
• When left open for >2wks, wounds were prone
to nocosomial contaminants such as
Pseudomonas and other GN bacteria
• Currently most open fracture infections are
caused by GNR and GP staph
Gustilo RB, Anderson JT: Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones; JBJS,
58(4):453-458, June 1976
24. Nocosomial infection?!!!!
• Only 18% of infections were caused by the
same organism initially isolated in the
perioperative cultures*
• Carsenti-Etesse et al. 1999
– 92% of open fracture infections were caused by
bacteria acquired while the patient was in the
hospital**
*Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res. 1983 Sep;
(178):36-41.
*Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized, double-blind study comparing
single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-33.
**Carsenti-Etesse H, Doyon F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B, Dellamonica P. Epidemiology of bacterial infection
during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:315-23.
Cover the
wounds
quickly
25. Common bacteria encountered with
open fractures
Blunt Trauma, Low Energy GSW Staph, Strept
Farm Wounds Clostridia
Fresh Water Pseudomonas, Aeromonas
Sea Water Aeromonas, Vibrios
War Wounds, High Energy GSW Gram Negative
27. Antibiotic comparisons
• No difference btwn clindamycin and cefazolin*
• Patzakis et al. **
– For type 1&2, cipro = cefamandole+gentamicin
– For type 3, cipro worse (31% vs 7.7% infection)
• Cipro and other fluoroquinolones inhibit
osteoblast activity and fracture healing***
*Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a prospective study. J Trauma.
1983;23:25-30.
**Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P. Prospective, randomized, double-blind study comparing
single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000;14:529-
33.
***Holtom PD, Pavkovic SA, Bravos PD, Patzakis MJ, Shepherd LE, Frenkel B. Inhibitory effects of the quinolone antibiotics trovafloxacin,
ciprofloxacin, and levofloxacin on osteoblastic cells in vitro. J Orthop Res. 2000;18:721-7.
***Huddleston PM, Steckelberg JM, Hanssen AD, Rouse MS, Bolander ME, Patel R. Ciprofloxacin inhibition of experimental fracture
healing. J Bone Joint Surg Am. 2000;82:161-73.
28. When and for how long?
• Start abx as soon as possible*
– Less than 3 hours 4.7 % infection rate
– Greater than 3 hours 7.4%
• No difference btwn 1 and 5 days of post op
abx treatment**
• Mass Gen recommended treatment:***
– Cefazolin Q 8 until 24 hours after wound closed
– Gentamicin or levofloxacin added for type 3
*Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36-40.
**Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou MA. Duration of preventive
antibiotic administration for open extremity fractures. Arch Surg. 1988;123:333-9.
***Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
29. Local antibiotic therapy
• High abx conc within the wound and low
systemic conc
– Reduces risk of systemic side effect
• Vancomycin or aminoglycosides
– Heat stable
– Available in powder form
– Active against suspected pathogens
Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-
impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.
30. Antibiotics - locally
• Prevents secondary contamination by
nocosomial pathogens
• Useful adjunct to systemic abx
• Potential for abx impregnated bone graft,
bone graft substitute, and abx coated IMN
Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases; J Bone Joint
Surg Br. 1995 Jan;77(1):93-7.
Antibiotic Infection Rate
IV Abx 12%
IV Abx + local aminoglycoside
impregnated PMMA beads
3.7%
31. Antibiotic Beads
• Pros
– Very high levels of
antibiotics locally
– Dead space
management
• Cons
– Requires removal
– Limited to heat
stable antibiotics
– Increased drainage
from wound
32. Goals of treatment
• 1. preserve life
• 2. preserve limb
• 3. preserve function
• Also….
– Prevent infection
– Fracture stabilization
– Soft tissue coverage
34. Initial assessment & management
• ABC’s
• Assess entire patient
• Careful PE, neurovasc
• Abx and tetanus
• Local irrigation 1-2 liters
• Sterile compressive dressings
• Realign fracture and splint
• Do not culture wound in the ED*
– 8% of bugs grown caused deep
infection
– cultures were of no value and not to
be done
• Recheck pulse, motor and sensation
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.
35. Can I take pictures with my phone and
send it to my senior?
• Documents characteristics accurately
• Prevents multiple examinations
• Decreases contamination*
• Communication via digital
photography was more useful
than verbal communication**
• 1.3-megapixel camera is comparable
with higher resolution cameras when
viewing color images on computer
desktop***
36. Primary surgery
• Objectives of initial surgical
management
– Preservation of life and limb
– Wound debridement
– Definitive injury assessment
– Fracture stabilization
Stages of open fracture management in the OR
37. Surgical emergency!
• 1898 Friedrich guinea pigs
– Take to the OR within 6-8 hours*
• 1973 Robson:
bacteria multiply in contaminated
wounds **
– 105
organisms/gram of tissue is the
infection threshold
– Reached at 5.17 hours
• 1995 Kindsfater et al:
– 47 G2/3 fxs at 4.8 months out….
• Less than 5 hrs 7% infection
• Greater than 5 hrs 38% infection
– However G3 fxs were treated later
*Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:288-310.
**Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426-30.
38. Or not?....
Calling the “6 hour rule” into question
• 1993 Bednar and Parikh…. No significant difference *
– 3.4% vs 9%; 82 open femoral/tibial fxs
• 2004 Ashford et al…. No significant difference **
– 11% vs 17%; pts from the austrailian outback
• 2004 Spencer et al.... No significant difference ***
– 10.1% vs 10.9%; 142 open long bone fxs from UK
• 2003 Pollack and the LEAP investigators…. No correlation****
– 315 open long bone fxs
• 2005 Skaggs et al….No significant difference *****
– children with all types of open fractures; 554 open fractures
*Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities
caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5.
**Ashford RU, Mehta JA, Cripps R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures. Injury. 2004;35:411-6.
***Spencer J, Smith A, Woods D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Ann R
Coll Surg Engl. 2004;86:108-12.
****Pollack AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive treatment significantly influences incidence of infection
after open high-energy lower-extremity trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake City, UT.
*****Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open
Fractures in Children.” JBJS-A 2005. 87:8-12
No significant
difference
before or after 6
hours!!!
39. Do we even need to do operative
debridement?
• Orcutt et al... No significant difference, BUT…*
– 50 type 1 &2 open fractures
– less infection in nonoperative group (3% vs 6%)
– Less delayed union in nonop group (10% vs 16%)
• Yang et al….0% infections **
– 91 type 1 open fractures treated without I&D
*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of
the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.
**Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat
Res 2003. 410: 289-294.
Do we even
need to debride
low grade open
fractures?
40. However, after review of all literature….….
• Okike et al. states….
• “Thorough operative debridement is the
standard of care for all open fractures.”
• “Even if the benefits of formal I&D were
insignificant for low grade fractures, operative
debridement is still required for proper wound
classification.”
• “Open fractures graded on the basis of superficial
characteristics are often misclassified.”
• Huge risk not to explore and debride!
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006 Dec;88(12):2739-48.
41. URGENTLY debride, not EMERGENTLY
• Time to OR is probably less important than:*
– Adequacy of debridement
– Time to soft tissue coverage
• Timing depends on….**
– Is patient stable?
– Is the OR prepared?
– Is appropriate assistance available?
• Ortho trained scrub techs, assistant surgeons, xray
techs, and other OR staff
• 2005 Skaggs et al:***
– If after 10pm, keep until the morning! Or at least
within 24 hours.
– Unless….
• neurovasc compromise
• horrible soft tissue contamination
• compartment syndrome
*Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
**Werner CM, Pierpont Y, Pollak AN: The urgency of surgical débridement in the management of open fractures. J Am Acad Orthop
Surg. 2008 Jul;16(7):369-75.
***Stewart DJ, Kay RM, Skaggs DL: Open Fractures in Children. Principles of Evaluation and Management. JBJS-A. 2005;87:2784-2798.
Within
24
hours
Within
6 hours
42. I&D in the OR
• Trauma scrub
– Soap and saline to remove gross debris
• “Zone of injury”
– Skin wound is the window through which
the true wound communicates with the
exterior
• Extend the traumatic wound
– Excise margins
– Resect muscle and skin to healthy tissue
• color, consistency, capacity to bleed and
contractility
• Bone ends are exposed and debrided
• Irrigate
• Serial debridements?
– If needed, 2nd
or 3rd
debridement after 24-
48 hours should be planned
43. The Irrigation
• Amount
– No good data, copious is better
– Animal studies show improved
removal of particulate matter
and bacteria but effect plateaus
– Irrigation bags typically contain
3 L of fluid
– Anglen recommends:*
• 3L (one bag) for type 1
• 6L (two bags) for type 2
• 9L (three bags) for type 3
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.
44. How to deliver the irrigation?
(what animal studies show)
• Bulb Syringe vs Pulsatile Lavage
– Pulsatile lavage
• Detrimental for early bone healing
– this is no longer present at 2 wks*
• More soft tissue destruction**
• More effective in removing
particulate matter and bacteria***
• High or low pressure?
– Higher pressure
• Better bone cleaning
• Worse soft tissue cleaning
• Slows bone healing
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects
on Fracture Healing.” JOT 1998. 12(7): 460-463.
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial
Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.
45. Antibiotics in the irrigation?
• Antibiotics (bacitracin and/or neomycin)
– Mixed results, controversial
– Costly
• bacitracin alone around $500/washout
– ?? Causing resistance
– Wound healing problems?
– Few reported cases of anaphylaxis
– Anglen: “No proven value in the care of open
fracture wounds…some risk, albeit small.”
No proven
benefit!
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.
46. Soaps in the irrigation?
• Surfactants (i.e. Soaps)
– Less bacteria adhesion
– Emulsify and remove debris
– No significant difference in
infection or bone healing
compared to bacitracin
solution, but more wound
healing problems in
bacitracin group
Anglen JO. “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A Prospective,
Randomized Study.” JBJS-A 2005. 87(7):1415-1422.
47. Level 4 evidence based
recommendations
• 1st
washout, highly contaminated
Soap solution
• Repeat washout of clean wounds
Saline
• Infected wounds
Soap, then antibiotic
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.
48. Wound closure after contaminated fracture
• Timing and technique is
controversial
OPEN WOUND should be left OPEN!
– Prevents anaerobic conditions in
wound: Clostridium
– Facilitates drainage
– Allows repeat debridement
Zalavras CG, Patzakis MJ:Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9.
Dubunked!
49. To close or not to close?
• Recently, renewed interest
in primary closure
• Collinge, OTA 2004
• Moola, OTA 2005
• Russell, OTA 2005
• DeLong, J Trauma 2004/
• Bosse, JAAOS 2002
– Improved abx management
– Better stabilization
– Less morbidity
– Shorter hospital stay, lower
cost
– NO increase in wound
infection
• These wounds are at
higher risk of clostridia
perfringens if they do get
infected.
• 1999 Delong et al: 119 open fxs
– No significant difference
• delayed/nonunion and infection rates btwn
immediate and delayed closure
– Immediate closure is a “viable option”
DeLong WG Jr, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture wounds. J Trauma. 1999
Jun;46(6):1049-54.
infection rate 7%
Overall delayed/nonunion rate 16%
Grade Percent of primary closures
1 88%
2 86%
3a 75%
3b 33%
3c 0%
50. Contraindications to primary closure
• Inadequate debridement
• Gross contamination
• Farm related or freshwater immersion injuries
• Delay in treatment >12 hours
• Delay in giving abx
• Compromised host or tissue viability
51. When to cover the wound?
• ASAP after wound adequately debrided
– Only 18% of infections are caused by the same organism
isolated in initial perioperative culture*
• Suggests hospital acquired etiology of infection
• “Fix and Flap”**
– For Type IIIB & IIIC open tibia fractures
– Early if not immediate flap coverage
•Patzakis MJ, Bains RS, Lee J, et al. “Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin,
to combination antibiotic therapy in open fracture wounds.” JOT 2000. 14: 529-533.
**Gopal S, Majumder S, Batchelor A, Knight S, De Boer P, Smith RM. “Fix and flap: the radical orthopaedic and plastic treatment of severe
open fractures of the tibia.” JBJS-B 2000. 82(7): 959 – 966.
Timing of flap placement Infection rate
< 72 hours 6%
> 72 hours 30%
53. VAC
• Vacuum assisted wound closure
– Recommended for temporary management
– Mechanically induced negative pressure in a closed
system
– Removes fluid from extravascular space
– Reduced edema
– Improves microcirculation
– Enhances proliferation of reparative granulation
tissue
• Open cell polyurethane foam dressing ensures an
even distribution of negative pressure-Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11.
-Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in
the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007
54. Types of fracture stabilization
• Splint
– Good option if operative
fixation not required
• Internal fixation
– Wound is clean and soft tissue
coverage available
• External fixation
– Dirty wounds or extensive soft
tissue injury
55. Fracture stabilization
• Gustilo type 1 injury can be treated the same
way as a comparable closed fracture
• Most cases involve surgical fixation
• Outcome is similar to closed counterparts
56. Fracture stabilization
• Gustilo type 2&3 usually displaced and unstable
– dictate surgical fixation
• Restore length, alignment, rotation and provide
stability
– ideal environment for soft tissue healing and reduces
wound infection
– reduces dead space and hematoma volume
• Inflammatory response dampened
• Exudates and edema is reduced
• Tissue revascularization is encouraged
57. When to use plates?
• Open diaphyseal fractures of arm & forearm
• Open diaphyseal fractures lower extremity
– NOT recommended
– Open tibial shaft plating assoc high infection rate*
• Open periarticular fractures
– Treatment of choice in both upper and lower
extremities
Bach AW, Hansen ST Jr.: Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin Orthop Relat Res.
1989 Apr;(241):89-94.
58. When to use IM nails?
• Treatment of choice for most
diaphyseal fractures of the
lower extremity
• Inserted without disrupting
the already injured soft tissue
envelope
• Preserves the remaining extra
osseous blood supply to
cortical bone
• Malunion is uncommon
59. To ream or not to ream?
• Does reaming cause additional damage to the
endosteal blood supply?
• Solid IM nails without reaming has a lower risk of
infection that tubular nails with a large dead space*
• However reamed IM nails are biomechanically
stronger and can reliably maintain fracture reduction if
statically locked
• 2000 Finkemeier et al.
– reamed vs unreamed interlocked nails of open tibias
– NO statistical difference in outcome and risk of
complication**
*Melcher GA, Claudi B, Schlegel U, Perren SM, Printzen G, Munzinger J.Influence of type of medullary nail on the development of local
infection. An experimental study of solid and slotted nails in rabbits; .J Bone Joint Surg Br. 1994 Nov;76(6):955-9.
**Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM: Locking intramedullary nailing with and without reaming for open
fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997 Mar;79(3):334-41.
**Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF: A prospective, randomized study of intramedullary nails inserted with
and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000 Mar-Apr;14(3):187-93.
60. When to use external fixation?
• Diaphyseal fractures
not amenable to IM
nails
• Ring fixators for
periarticular
fractures
• Temporary joint
spanning ex fix is
popular for knee,
ankle, elbow and
wrist
• If temporary, plan
for conversion to IM
nail within 3 weeks
61. Ex-fix: Weigh the pros and cons!
• Historically was definitive treatment
• Now, more commonly as temporary fixation
• Can be applied almost always and everywhere
• Severe soft tissue damage and contamination
• Advantages:
– Easy and quick
– Relatively stable fixation
– No further damage done
– Avoids hardware in the
open wound
• Disadvantages:
– Pin track infections
– Malalignment
– Delayed union
– Poor patient
compliance
62. Skin cover and soft tissue
reconstruction
• Do these early!
• 1994 Osterman et al.*
– Retrospective 1085 fractures, 115 G2 and 239 G3
• All treated with appropriate IV Abx and I&D
– No infection if wounds closed at 7.6 days
– Yes infection if wounds closed at 17.9 days
*Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures: A review of 1085 consecutive cases. J Bone Joint
Surg Br 1995;77:93–97.
Infection risk
increases if wound
open > 7 days
65. Type 3c, a bad injury!
• Devastating damage to
bone and soft tissue
• Major arterial injuries
that require repair
• Poor functional outcome
• Consensus btwn ortho,
vascular and plastics
• Salvage is technically
possible in most cases
• However it is not always
the correct choice esp
type 3c tibia fractures
66. We can do both, salvage & amputate.
• Vascular surgery can revascularize
with bypass graft
– Generally before fracture stabilization
• Plastics can provide soft tissue
coverage
• However, in the tibia, the severity
to soft tissue envelope and bone
may result in infected nonunion
• If salvage…. long course of
repeated surgical procedures
– Painful and psychologically distressing
– Functional outcome may be poor and
no better than amputation
67. How to decide, salvage or amputate?
• Important factors in decision making:*
– General condition of the patient (shock)
– Warm ischemia time (>6hours)
– Age (>30 years)
– Cut to crush ratio (blunt injuries has a large zone
of crush)
Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities following combined
orthopedic and vascular trauma. A predictive salvage index. Am Surg. 1987 Apr;53(4):205-8.
68. Gunshot injuries
• Energy dissipated at impact = damage
severity
• High velocity rifles and close range
shotguns
– Worst, high energy of impact
– Huge secondary cavitation
– Secondary effects of shattered bone
fragments
• Bullets lodged in joints should be removed
– avoid lead arthropathy and systemic lead
poisoning
69. Low velocity GSW <2000 ft/sec
• Low velocity handguns
– Less severe, not treated like open fractures
– Cavitation is not significant
– Secondary missile effects are minimal
– Bone fragments rarely stripped of soft tissue
attachments and blood supply
– Soft tissue injuries not severe and skin wounds are
small
70. Low velocity GSW open fractures
• Geisslar et al. *
• If neurovascular status
normal, do local
debridement
• NO formal I&D needed
• IV Abx
• Approach fx fixation as
if closed
• Dickey et al.**
– No abx vs IV Ancef x 3d
– 67 low velocity GSW fxs
– Not requiring operative
fixation
– No difference in
infection rates
*Geisslar ett al, J Ortho Trauma, 4;39-41,1990
**Dickey et al, J Ortho Trauma, 3;6-10,1989
Treat open
fractures from low
velocity GSW as
closed fractures
without Abx
71. Pitfalls and complications
• Infection delayed union, nonunion, malunion
and loss of function
• Plan ahead to avoid delayed union and nonunion
• Predict nonunion in severe injuries with bone loss
– Bone grafting usually delayed 6 weeks when soft
tissues have soundly healed
– Autogenous bone grafting is usual strategy
– Fibular transfer, free composite graft or distraction
osteogenesis for complex defects
– Recombinant human BMP in open tibia fracture
reduces risk of delayed union
72. Advances…
• BMPs
– 40% decreased infection rate with BMP in type 3
open tibia fractures*
• Antibiotic Laden Bone Graft**
– Tobramycin-impregnated calcium sulfate pellets
with demineralized bone matrix
– Animal study: successful in preventing infection
*BESTT Study Group, Govender S, Csimma C, Genant H, Valentin-Opran A. “Recombinant Human Bone Morphogenetic Protein-2 for
Treatment of Open Tibial Fractures: A prospective, controlled, randomized study of four hundred and fifty patients.” JBJS-A 2002.
84(12): 2123-2134.
**Beardmore AA, Brooks DE, Wenke JC, Thomas DB. “Effectiveness of local antibiotic delivery with an osteoinductive and
osteoconductive bone-graft substitute.” JBJS-A 2005. 87(1): 107-112.
73. Summary
A = good evidence (level 1 studies)
B = fair evidence (level 2/3 studies)
C = poor quality evidence (level 4/5 studies)
I = insufficient or conflicting evidence
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
1] Review the common bacteria encountered with open fractures.
2] Note the distinction between the primary infections which occur due to inoculation of bacteria (above) at the time of injury and secondary infections acquired after hospitalization.
Give IV antibiotics as early as possible. The two most important factors in reducing infection is early antibiotic use with early surgery (Patzakis, JBJS 1974).
Review recommended prophylactic antibiotic treatment based upon severity of soft tissue injury. Note that there are some variations in clinical practice; limited definitive literature.
Review Pros & Cons of antibiotic bead use:
Requires bead removal.
Requires heat stable powdered antibiotics: tobramycin, vancomycin, cefazolin, oxacillin.
Wound closed over beads drain more.