Open Fractures
Open fractures are categorized with the Gustilo-Anderson Classification. A Grade I Injury indicated a clean wound, less than one centimeter long with minimal injuries to the soft tissue and minimal bone comminution. A Grade II injury consists of a moderately contaminated wound greater than one centimeter long with moderate tissue injury and moderate bone comminution. A highly contaminated wound, usually greater than ten centimeters, segmental fractures, farm yard injuries, high velocity gunshot wounds and fractures occurring in a highly contaminated environment regardless of the size of the wound.
Grade III injuries are classified further into A, B, and C. Grade III A is a severe soft tissue injury with a crushing comminuted fracture; soft tissue coverage of bone possible. Grade IIIB consists of a very severe loss of soft tissue cover with poor bone coverage and variable—may be moderate to severe bone comminution. Grade IIIB usually requires a soft tissue reconstructive surgery in the form of local or distant flaps. Grade IIIC fractures consists of a vascular injury requiring repair or amputation. There is a very severe loss of soft tissue cover with moderate to severe bone comminution. Injury of the femoral artery from the posteriorly displaced proximal fragment of a Grade III C open supracondylar fracture of the femur. Grade III C has a high rate of amputation, nonunion and infection.
Hip Infection (Septic Arthritis)
An infection in the hip is a serious disease especially in children. The intraarticular structures will be inflamed and the increased intracapsular pressure will decrease the blood supply to the femoral head. Infection is associated with a high risk of avascular necrosis. The position of the limb in the stage of effusion, flexion, abduction, and external rotation. Complications are severe and much more common in children. Complications include: pathological dislocation, avascular necrosis, osteomyelitis, and pelvic abscesses. Urgent aspiration followed by drainage of the hip joint combined with intravenous antibiotics are the typical treatment for hip infections.
Necrotizing Fasciitis
Necrotizing Fasciitis is an insidiously advancing soft tissue infection characterized by widespread tissue necrosis. The most common causative organism—group A beta—hemolytic streptococcus. There is a high mortality rate with sepsis and renal failure. Amputation and the mortality rate is increased due to a delay in diagnosis. Predisposing factors for necrotizing fasciitis include: trauma, surgery, as well we urogenital and anogenital infections. There are three types of necrotizing fasciitis: Type I—which is Polymicrobial, Type II—which is a Group A beta-hemolytic streptococcus, and Type III—which is gas gangrene-clostridial myonecrosis. Treatment consists of an immediate surgical debridement combined with intravenous antibiotics and hyperbaric oxygen if necessary.
Fracture with Soft Tissue Compromise
Soft tissue compromise associated with fracture blisters, ecchymosis, and severe bruising which indicate a greater degree of deep soft tissue damage. Blood filled fracture blisters are associated with high wound complications. Initial management involves application of a spanning external fixator with the fracture dislocation held in reduction with traction. The definitive management involves replacing the spanning external fixation with a hybrid fixator or plate once the soft tissue edema is resolved and the skin is wrinkled, usually in one to three weeks. Spanning external fixation can often be combined with percutaneous fixation of large articular fragments. A soft tissue compromise is more common with tibial plateau fractures and tibial pilon fractures with diaphyseal extension. A calcaneal avulsion fracture is considered an emergency. Urgent reduction and fixation is mandatory to avoid soft tissue complications. Type I—is a “sleeve” type tuberosity fracture. This pressure will create skin necrosis and significant soft tissue complication.
Stay tuned for Orthopaedic Emergencies Part IV!
