Open fractures (OF) are one of the most common surgical emergencies. Accurately assessing the severity of the injury and making appropriate treatment decisions are crucial for helping patients recover quickly and preserving the position of the injured bone.
Assessing the Severity of Open Fractures
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When a bone is fractured, sharp edges can pierce through soft tissue from the inside out, causing varying degrees of soft tissue damage and bleeding. However, evaluating the injury and determining the treatment direction is not straightforward; about 30% of open fracture victims suffer from multiple injuries that pose a threat to life and require immediate emergency care. To facilitate memory, the three critical letters A, B, and C are often used in order.
Airway: Is the airway obstructed by any foreign object?
Breathing: Is there any bleeding in the pleura due to fractured rib segments causing difficulty in breathing?
Circulation: Is there vascular injury causing significant blood loss?
Bleeding in open fractures can result from skin, muscle, and bone injuries, or from ruptured arteries and veins, leading to hemorrhagic shock. Attention must be paid to the aforementioned three emergencies. The consequences of open fractures include infections, non-union of the bone, loss of bone segments, loss of function leading to disability, as well as significant economic costs in treatment. The prognosis of open fractures depends not only on the condition of the fracture but also on the extent of soft tissue injury. Globally, medical professionals classify open fractures into the following types:
Type 1: An open fracture with a clean wound, less than 1 cm in length, usually caused by bone protruding from within.
Type 2: An open fracture with a soft tissue tear larger than 1 cm, with the skin being degloved but not crushed.
Type 3: The most severe type, which can be subdivided into three smaller groups.
Severe soft tissue degloving greater than 10 cm due to strong trauma.
Severe contamination, due to friction on the ground, injuries in areas prone to infection such as farms, drainage areas, and requiring emergency care after 8 hours.
Vascular injuries that require emergency vascular repair and reconstruction surgery. Injuries from firearms, explosives, or severe fractures due to traffic accidents are particularly severe injuries.
Management Measures
In these cases, the first priority is to control bleeding effectively, especially in severe cases; fluid resuscitation, wound stabilization, and immediate transfer to a medical facility for emergency care are essential.
Surgery is the primary treatment for open fractures. The goal is to clean the wound thoroughly, potentially addressing multiple injuries in one operation under good anesthesia, depending on the patient’s condition, to avoid multiple anesthetic procedures. Surgery also involves debridement of crushed tissue and wound cleaning, ensuring that exposed nerves, blood vessels, and bones are covered with adjacent skin flaps. However, skin closure should not be done immediately to prevent gas gangrene; wounds need to be treated properly for several days before being closed. If there is doubt about the cleanliness of the wound, it can be cleaned with a less harmful antiseptic solution, and systemic high-dose intravenous antibiotics should be administered, along with tetanus vaccination.
Generally, fixation of fractured bones should not involve intramedullary nails or plates. External fixation methods can stabilize complex fractures, reduce infection risk, and allow joint mobilization, which is recommended by orthopedic specialists. However, overly complex external fixations should not be used in emergencies; rather, simple one-sided supports should be employed to facilitate wound care and soft tissue reconstruction with skin flaps covering vital areas.
Despite many aggressive treatment measures for open fractures, there remains an imperfect outcome rate: limb discrepancies, rotational malalignment, bone segment loss, pseudoarthrosis, and classical infections leading to non-union. Causes may include the patient’s condition upon hospital admission, such as multiple trauma, coma, internal organ rupture, and spinal fractures accompanying open fractures. Patients require multidisciplinary care, nutritional support, and rehabilitation post-surgery, with further complications addressed in subsequent stages.
During wartime, open fractures are a common issue, while in peacetime, this type of injury is mostly caused by traffic accidents. Therefore, the most important preventive measure for open fractures is ensuring safety while participating in traffic. If a person unfortunately suffers an open fracture, they should be quickly transported to medical facilities for timely treatment.
Prof. DUONG DUC BINH
