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I think so. Hello. Can you hear me? Hello? Can you hear me? I can hear you. Yeah. Yeah. The other, the mod is telling me I have some problems with the link. So I told him to send me the link which I used and it's joined seamlessly and you can hear me and everything is all right. So I'll I'll let him know and I'll hand that back to him. All right. Can you hear me? You can you hear me? Yes, I can hear you. I can hear you. I can see your screen, see your learning objectives, see everything. So what about other people? Other um parts of the audience? I don't know. Yeah. Um James, can anyone hear the speaker that's G for oe MC screen? If you can please let us know in the charts? I know. Oh, perfect. So yes, they can see you now. So I will be leaving now and Ando to thank you everyone. I will be leaving and thank you and to be moderate. All right, thank you. Hi, everyone. Can we still hear me? Hello, please? If you can hear me just indicate. So um I can just begin. All right, thank you. Uh So firstly, um let me start by apologizing for the technicalities we had. Um I think there were some issues with the link sent by the Moor. But uh I think that has been rectified now. So I'll just go ahead and start. Um We are supposed to introduce ourselves so that we can get to know each other before we start. I think the time is fast friends. So, um my name is dude and I'm a general CF in trauma orthopedics. If we can do so well, to just drop our names and rules in the chat box, I think that will be all right, while I just go ahead and um try to cover as much as I can within the time frame I have. So, um can you still hear me? OK, I'll try to make this as interactive as I can. Um If you have any questions, please just drop it in the comment section or in the um chat section, then I'll pick it up at the end of the um presentation. Thank you. Um So basically today we will be handling acute management of open fractures. Um Open fractures are um very common, especially in trauma and orthopedics and in the emergency um setting. So if, if, if we pay attention to this um brief lecture, I think we'll have a better understanding of how to manage um open fractures, especially in the acute setting. Um Before the more definitive um processes get involved. So our main objectives for today would include um following on the screen. Basically, we have to um get a grasp of what open fractures are. We try to classify them. And um we'll try to take all through the steps of assessments of the of open fractures, the aims of treatments, the initial management and the operative principles. Firstly, what is an open fracture? Um Basically, it's a type of fracture where um the skin bridge communicates with either the fracture hematoma or the bones. Um So there are, there are a couple of um ideologies, whether the the communication is to the external surface or to the um internal environment by internal environment. I mean, um I say, let's say we have a fracture neck of thermal, communicating with some part of the um pelvis or, or intra abdominal region. That's that is also considered as open. But for the sake of this presentation, we're just considering open fractures as its um communicates with the external environments being the outside world and not um any other the intraabdominal or, or internal environments. And just to add um if there is any form of skin bridge, it's safer to, to consider the fracture as open unless proven otherwise. Then um in terms of classification, there are two broad classifications um namely the Golo Anderson classification and the Chinese classification. Um For the first one, many recent literatures have tried to sideline. Um the second contributor, um which is Andersson. So you might see go to classification and you might also see Golo Anderson classification. The reason for the for removal of Anderson, I wouldn't know. But personally, I've decided to keep him in because he actually contributed to the um facet of works in the classification. Um The first one which is go tries to classify um open fractures according to the size of injury and whether or not there, there's enough skin coverage for performing a primary or secondary closure. The second one basically focuses on the level of contamination and the fracture pattern. So for GARDA, we have the type one which is basically an open fracture with an open wound less than one centimeter. The type two goes from 1 to 10 centimeter with moderate soft tissue injury. Then the type three are all greater than 10 centimeter and this is sub classified into A B and C type three A um would be greater than 10 centimeter with adequate tissue for flap coverage. Um Type three B would most often require um soft tissue coverage or plastic inputs. Then type C would um involve vascular injury and will require an input of the vascular surgeon to um repair the vascular damage. Now, um let me just add on here. That's um this classification is very difficult to, to um make in the acute setting in the sense that if we have a more detailed look, um it's very difficult to, to ascertain the extent of injury, especially in an open fracture because sometimes um after performing a the bride means you realize that the injury is um way bigger than you expected. So um the the most accurate classification, all that goes to it will be done intra op or after the um procedure. So this is a type one injury as you can see with just about less than one cm um skin bridge. And this would also qualify as type two. So if, if we are seeing the screen um in this particular image, it will be very difficult to achieve a full skin closure because there is some, there's some form of um skin EOR. So this will qualify us. Um it those three same here. These are other images of the gas and this one has um vascular compromise. So this will be a cat tray. Now, the Golo classification is way more common and more vastly used than the channel classification. But um for completion sake, this is the channel classification. Um like I said before, it pays attention to the level of contamination and the fracture pattern. So it is classified into group 123 and four. So um let's just have a trauma scenario. Um Usually it depends on the center where we work. Um trauma calls are usually put out in major trauma centers, but in most light centers, um they might just have a single person in the trauma team. But, but in any way, most open fractures come with other injuries and are almost always um put out as a trauma call. So when the trauma call is put out, um there's usually a where the members of the trauma team gather mostly um in the ed or for any other acute um than the members of this team will involve the anesthetist, the um orthopedic team, the general surgical team, and also the medical team, the medical team, I be maybe a medical registration and consultant. So um usually when this code is put out, there's a period of wait where rules are assigned and that is all the hole. So roles are assigned as to who would lead the trauma team and who would um perform whichever task is involved and um why this is done. Um The the patience is expected, usually the at mis handover is given by the paramedics. Sorry, the um ATMs handover AMIS itself is an acronym for um basically it a type of handover given in trauma set and where the age of the patients does a um the time of injury, does t the mechanism of injury does m then any injuries on signs of does the r then the signs, basically the vital signs and any relevant observations that's for the S and T for treatment, any um treatment is given by the paramedics. So when I, when a trauma call is um put out the first thing you would ask yourself as a junior doctor or. Well, anyone in the trauma team is whether or not this level of trauma can be, can be um properly managed in your center. So, like I said, most um trauma calls are put out in major trauma centers, but let's say you're working in a district hospital or one of the um DGHS. Um according to the both guidelines, there are some types of fractures that should be managed in, in specialist centers because they might require multidisciplinary things like um Orthoplast inputs or vascular inputs. So the first thing during triage is um to make sure that you are in a um proper center that will um manage the open fracture and then also to ensure that you have your trauma team on ground. So um if you were an sho on call and I have a trauma call, I would ensure that my registrar or someone will see you is around to take decisions or possibly take the patient to the theater if needed. Then um let's not forget the A TLS principles because most open fractures, like I said, come with um other injuries. So the open fracture might itself um not be life threatening than other injuries. Let's say we have um a 48 year old male who was brought in about 2 a.m. by the paramedics um involving an RT um car vessels, high velocity um vehicle. So, if this patient has like a chest injury or an intraabdominal injury or an O bleed that should be handled first before any open fractures or before trying to, um split the limb or any other open injuries. The patient has because most time people try to tend to make the take off go for the open injuries first and, and avoiding the patient as a goal. So if we treat the patients as a whole, we try to um go through the A TLS principles where the um catastrophic hemorrhages are first handled before any. Um none of us are going to take care of the open fractures. The object is um we should have would be to preserve life, to preserve limb and to preserve function. So these are the first three things we should um consider when managing any open fracture. So, like I said, the A TLS um principles are the guidelines we use um when doing a primary survey for an open fracture. So that involves attending to the catastrophic hemorrhages. Um by catastrophic, we mean lifethreatening hemorrhages. Um Then after that, we stabilize the airway, make sure there is no um occlusion or blockage. We also stabilize the c spine, then we make sure that patient is breathing very well and that there's no problems with circulation. After that, we assess for disabilities and expose the patients to properly examine. So we see now that the emphasis most times is not on the open fracture, the emphasis is on the um the patients managing the patients accordingly using the um standard protocols. So for catastrophic hemorrhage, of course, we um put pressure tampon out and give a tour care if needed. For example, if this patient has an open femoral fracture that is actively bleeding, we might want to apply a tonic care, then go back to the A TLS principles and ensure that the airway is secured and that the patient is breathing well and that there are no issues with circulation and disability. Um I wouldn't want to go into details of these because I'm strongly aware, aware of it. Um But if there are any questions, please just drop it in the comment section and I'll attend to them accordingly. So if we have um assess the patients using the A TS principles and with taking care of every other thing I would now um have like an isolated lower limb injury. There are a few principles that um the most full in order to make sure that we don't miss anything. Um First of all, there will be the um the antibiotics principles. Um Then after that wound, divide le and um fracture stabilization. But all these are inculcated in um a very important guideline um used for managing open fractures um developed by the Brit, the British Orthopedic Association and standards for trauma. That's the best guidelines. I'm sure most of us are very with this. Um If you don't take anything out of this presentation today. I would like us to um focus on this guideline because I think it's, it's very robust and it's very comprehensive. It contains everything you need to manage an open factor, especially in the acute setting. Um It's quite extensive because I've just gone through it to highlight the most important things um for, for our discussion. So please do well to go back to the guideline and have a good view of it. So the first things um would be like I said that every open fracture should be managed in the appropriate um setting. So according to the both guidelines, all long bone and hind foot or midfoot fractures should be managed in a center that has plastic change. Basically, this is because most times skin closure is needed. Then if it's a simple hand or wrists or fall foods or digits fracture, this can be managed in the muscle light and ho use, then I would say the most important of these would be the um IV antibiotics because um so these have shown that early administration of antibiotics reduces the rate of infection um significantly. So, but this varies um according to local guidelines. So some hospitals give, give colo most of the hospitals use zam, but please do stick, do stick to your local antibiotic regimen while um giving you antibiotics. And ideally, the first shot of antibiotic should be given within the first hour of um the first hour of injury and this will, this should be continued to any form of definitive treatment and surgery is done. It is also important to document the neurovascular status because um most open fractures tend to disturb the anatomy. So if we document the unas stais before and after any manipulation or any procedure, we do, then um then we have the record of a baseline um by which you can compare the um status of the limb or anything after we've done any maneuver. Then the fourth thing would be to realign and split the limb. Now, this depends on the type of um fracture, but usually we just um split the limb while awaiting any um further definitive management. Then as a rule of thumb, all arterial injuries will manage according to the both guidelines. Um Now, for the purpose of this discussion, we won't go into the um arterial injuries because um that's is uh a bit above the scope of this topic. But, but all of them require um trauma CTT and an angiogram. Then we have to expose the wound and remove any kind of gross contamination. Now, let me just add here that most times um especially when we um work in the Ed. Um some doctors tend to um do something called a mini washout on Ed for most open fractures. I mean, um studies have also shown that there are no advantages or I mean, doing the washouts on the Ed doesn't um make the fracture more clean. Um So it doesn't contribute anything basically to the wound. So, but if there are any obvious contaminants, let's say, like a piece of um a piece of ste or stones or gravel or grass, like any of contaminants can just be um peaked out but no vigorous washing because there's no um advantage that conference the last but not the least would be to take a medical photograph because once we've done any form of um intervention by way of splinting or covering the wound, um no one would like to open the wound again. So the photograph is very helpful. Usually this is done by the medical photographer as well. With verbal consent, you can just take um the pictures um on your phone after getting concern from the questions. Obviously. Um this is also important as junior doctors because um if you have a picture, you can um discuss the case with your seniors and they have a photograph to look at. Then after that, we have to cover the wound with a saline. So it covers and um prepare the patient for the basically. So I just put this image here to remind us that even though in most centers now, um patients have trauma ct when they um when they are done being assessed in Ed, but we should also have it on the back of our mind that most time the trauma CT doesn't cover everything from head to toe. It mostly stops um at the pelvis. So a simple x-ray can confirm the type of fracture and to help in managing these patients. So the objectives um of initial management would be to preserve life um to preserve lym and to preserve function like we stated earlier, then when these have been done, um we move, we move over to the next stage which is to prevent infection, to stabilize the fracture and to perform any um soft tissue. Now, for operative management, um basically, the first thing to do would be to divide the skin. Um development should ideally happen immediately. Um If we suspect any form of vascular compromise. So let's say you've done any vascular check and you feel there's any vascular compromise. Um that person needs to go to theater immediately. So if it's any other high energy um injuries leading to open fractures that can be done within 10 and within 12 hours and any other form of open fracture should ideally um be divided within 24 hours. Basically, requirements um entails removing dead or dying tissue. Now, this is a um very controversial area because sometimes as part of the br man people um do things like amputation because um let's say someone sustained a very nasty um distal tibial fracture which um subluxation and, and um the ho can be mangled. Um If the patient is taken to theater, sometimes as part of the development, you have to do an amputation. No let me just keep, you know though that comes later on. Um when that decision is taken to do an amputation on this as part of the means the amputation don will just be above the level of the injury at that moment because obviously the patient is not aware or is not consulted for a proper amputation. So basically, you don't just go giving someone a bio amputation for for a very distal um open fracture, even though he's very um communi and there is any excessive skin loss. So you just do an amputation just um above the level of the injury and and when the chance wakes up and he is more aware, gives you a consent, then can pro you to do a very definitive um amputation to allow for use of prosthesis. Now, I'll just put this picture here to remind us of the anatomy of the lower limb, especially um when the open fractures um affect this region because one of the very important complications would be compartment syndrome. Here we see the different compartments and as part of the operative management, when um the wound is being explored, most of them um go into fix or external fixators. And when that is done, um prophylactic fasciotomies are usually performed to prevent compartment syndrome. And on the image on the left, this shows us the usual um incision sites for that. So now that we've um performed avi the next step would be to stabilize the fracture. Now, usually this is done using an external fix acceptor, like I said, but depending on the s um choice and preference and the findings intra op, if the wound is clean enough after the departments, then a definitive um internal position can be done using plates and screws. But usually um when these patients presents after 12 hours and we have a suspicion of deep, deep um contamination. The primary occlusion is not done. So usually these patients get an external fix at all and the wound is just um covered and sent back to the ward. Then um we plan for possible skin closure um when the wound is clean. So that brings us to the very common ACON spine scan and plan. So when you have an open fracture and um we suspect any form of deep contamination or the time of presentation is more than 10 to so long you spa this patient spanning meaning putting in the um spain external after which you scan, usually a CT scan to to help um surgical planning, then you plan for the type of um surgery to give these patients um usually involving the plastic team too and the vascular team if necessary. So this is a picture of an external and um done in a patients like I previously explained to prevent um compartment syndrome. So, definitive soft tissue coverage or primary occlusion should ideally be achieved within 72 hours if not done. Immediately because like, you know, this can is the most important uh barrier against infection. So, um open fracture, should I be close um skin wise within 72 hours? Um Like I've previously explained, um we don't do a below knee or a proper um amputation for patients that require amputation because of medical legal reasons. And um we also have to have that discussion with the patients and the family and the multi. Let's also remember that most people that have coping fractures, especially when they are associated with high energy injuries. It a life-changing events and um these patients will need a very long time for rehabilitation, which is usually the hardest part. Um Thank you so much. Do we have any questions at this point? Do you have any questions? Ok. It almost said, OK. So I think doctor Adi is asking how is management affected if the patient has peripheral vascular disease related infected? Um OK. Do you have any other questions before I go into that one? Ok. So usually, like I said, um when we suspect vascular compromise, we we tend to involve the vascularity and these patients who have um a CT angiogram to delineate the vessels that are affecting. So, if there's a previous history of um vascular disease, let's say peripheral vascular disease, um definitely this would um involve the plastic thing and it should be done rather sooner than later because um the vascular compromise will lead to ischemia and lymph nodes. So if a patient that has a um vascular compromise as a previous history presents in with an open fracture and you feel for pulses and you don't get a pulse, please invo the vascular team as soon as possible because this, this patient would need to um get to theaters and um the the injury needs to be explored immediately. So for these patients, I wouldn't do a primary closure, like I said, um because of um possible vascular compromise. So I want to get a CT angiogram as soon as possible for these patients and um proceed, proceed with the plan. I don't know whether I did your c to your question. Doctor Adi. OK, I have another question here by Doctor Kate Brown. What's your take on field management in the acute state of hemorrhage? Ok. Thank you for your question. Um Usually um um people that have open fractures, especially when they are, when they involve high energy injuries. They are usually um people of the mid age group, let's say between 20 to 4 to 9 and they're usually fit and well. Um unless otherwise stated, so the um food management uh would be according to the psychiatry compromise because the most likely cause of psychiatric compromise would be blood loss. Um Most times you give blood for blood if there is significant um bleeding. But in the acute setting, when let's say you in the ed in the DGH, you don't have access to blood bank. Please um expand the plus no volume with um si but we don't want to give too much fluid in the acute setting. So as not to dislodge any clots and cause any further hemorrhages, but for sure, during the state of shock, um due to vascular compromise, please give no more. Then if you have drug then um give that as well. Um OK, I have another question here, especially in diabetics and immunocompromised. OK. Yeah. So this photo complicates the issue if, if someone is diabetic has a history of um peripheral vascular disease and is in and, and is immunocompromised, this patient should, should ideally be explored in the sooner than the. So um immediate surgical planning, um immediate ct angiograms, an involvement of the vascularity would be highly indicated in these patients. Uh Do you have any further questions, please? Um Any further questions? OK. All right. In the absence of any other questions. Um Thank you everyone for attending and thank you for those that um participated actively. Um We also apologize once again for the delays in commencing this um teaching service. These are technicalities. We have, you will have a good day.