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Good evening, everybody. Welcome back to our second session of basic orthopedic emergencies. Today, we have Doctor Aiden who will walk us through open fractures. Um So I will let Doctor Aiden take over now. Thank you. Thank you, Doctor Tti Jane. Hi. Um As my colleague just said, my name is Doctor Aiden Az Adn. People call me Abdi whatever you guys like, I'm a trauma orthopedic senior House officer and I've been working here um in orthopedic for 2.5 years. I'll be presenting a topic uh regarding open fractures. Um I would say from my experience uh II used to think that the open fraction management is straightforward five minute conversation that I would have with you guys. Um But I did a bit of a digging and it turned out that it needed further reading and um there are a lot of material that you need to read from. And uh there is a specific guideline with approximately 250 pages. So what I try to do is to concise most of the information in that guideline. Uh I try to deliver it to you guys, not in a boring way, but in a concise yet kind of interactive way. So this is something that would need my explanation, but at the same time, you guys interactions. Um So what I want to do is in the middle of uh doing the presentation. Um You guys can ask me a question in the chat at the same time. Uh My colleague, Doctor T is uh going to tell me about the questions in case I don't see in the chat if somebody wants to open their mind and ask a few questions in the middle of the teaching, you guys are more welcome. But the teaching itself is an interactive process between me and you guys. So um we'll crack on and um if there is anything you guys need, let us know the chart. So the guideline that I've taken all the presentation slides and the questions and the details was this book that you guys just see. Um it's basically called the Standard for Management of open fractures. And the history behind the story is um previously, and I'm talking about late nineties um open fractures because it's a fracture and because we're dealing with the bone, it used to be dealt with uh dealt by the orthopedic team. But because when, when we talk about open fractures, it's very different from the management of a close fractures based on the fact that it's an extensive soft tissue involvement and there is a skin breach as well. We're going to talk about the definition of uh open fracture. But the what I mean by it is when we treating the closed fracture is a straightforward process where you're dealing with a broken bone, they're going to um immobilize. But we talk about open fracture. The fact that you're dealing with a skin breach and soft tissue injury would not only require the orthopedic team but require other team to be involved specifically the plastic surgery team. And in the late eighties and nineties, these two teams came together and they tried to create a preliminary kind of guidelines, the plans on how to treat open fractures. Um These guidelines were acted on and they were used. However, as anything in the NHS, when something is being acted on done, it's been audited in the same time. So a lot of audits are were done on it. And basically these audits were trying to add few comments and recommendations, things that need to be tweaked here and there to try to maximize the best outcome that we can get for the patients that had fractures. And the latest guideline that had the most audited processes was the guideline that was established in 2017. And that's the outer cover of the book of the guideline. Um So you can see organizations down in debate that um involved Oxford University Press and different um organizations. But the main two ones is the BA which is a um British orthopedic Association and the B which is the British Association for Plastic, aesthetic, plastic reconstructive and aesthetic surgery. Um Because as I said, these two components, these two teams are the teams that uh are going to establish a guideline, going to help with the management. Because fracture wise and soft tissue wise, we need these two teams to work together. Um So if you're going to give um contributes to the people that did these recommendations and guidelines, I'm going to jump to their names and come back to these slides. These are the lead authors and um um thought of mentioning them for the fact that they created, they helped created these guidelines and these are the guidelines are actually acted on a work all throughout the NHS. So basically, this slide is telling you the same as I was said, is that these guidelines were um created audited and updated by these two teams along with the nice guideline team to help create them. Um These are the two of the three names. So the National Institute of Health and uh Care and Excellence. The boh is the British Orthopedic Association and the British Plastic Reconstruction and, and aesthetic surgeons. So, with these three teams, these measurements need to be audited. And the last team that you see down, which is t trauma audit and research network is the team responsible to modify, update and audit these uh these uh measurements uh in order to make sure that we're up to standard and updated to get the best outcome that we can for our patients. No. The first thing is what are we dealing with? What are we talking about? What is open fracture definition wise? Actually, I was thinking about leaving it to the comments and see what do you guys think the best definition of uh open fracture would be. But later on, I thought about it and I said, let's put the definition there because this definition is going to help us later on know exactly why these guidelines were put in. Why the measurements of the prehospital emergency care steps inside the hospital and the final um kind of steps to that these uh fractures happen. It's all because of this defi definition and it says a compound fracture or a fracture in which there is an open wound or bridge in the skin with the bone protruding to this definition require these two teams to come together for the importance of an immediate and effective management to prevent one infection because of the skin breach and the soft tissue breach two for the proper to ensure proper healing wise, proper healing will not be ensured if these measurements are not being taken. That's something that we're going to find out in the next few slides. So um let's pay a bit of attention on it because I'm going to ask few questions about it in the end slides. OK? We know what open fracture is breach in the skin and soft tissue with a fracture inside that's protruding outside. Um As always with every fracture, we would have a classification and with open fracture, we have Guilla under a classification. It's a straightforward classification even though I'm going to put it in one liner for every type in the guideline that I would show you. Now, it's, I would say almost a page and a half or two pages just to explain these two, these three types. And the reason for that is every type would have three specifications and they're going to put an emphasis on these three specifications in order to classify them. What I mean by that is on type one. It's a straightforward less than one centimeter bridge in the skin. So there's a fracture, there, there is a wound that's a clean wound and the opening of the skin and the breach in the skin is less than one centimeter. And the fact that we said clean wound uh uh that we said it is less than one centimeter is pro uh is very important because not, not type two, but in type three, it's divided to A B and C and I'm gonna tell you why later on. So type one is a small, less than one centimeter bridge that has a clean wound. Type two is more than one centimeter. So it's more than type one. There is an extensive soft tissue damage because the, if you talk about one centimeter. That means it, it could be three centimeter four centimeters. Some, some suggestions in the book would say it's all the way up to nine or 10 centimeters of type two. Um So that's type two, but we jump to type three. That is very extensive damage to the level that it's more than 10 centimeters and even more. So there is no number that is a limit for type three if we talk about size wise. But the reason that they divided type three itself to an A B and C is um we're not talking about size anymore because we've surpassed the number 10. We've surpassed how the size of the wound is. There are other elements that will help classify them and that's based on um something that I'm going to show you in the next slide, which is type three A happened from an high energy trauma there. It's irrespective to the size, but there is an ade adequate soft tissue coverage that will help cover the fracture later on or have help um cover the laceration that happened because of the fracture itself. So there, there's a wound, there is a laceration there. It's very severe, it's more than 10 centimeters, but it's, there's a flap that actually can be protracted back to both sides of the skin. And that's what type A is. But we talk about type three B. There is an associated more extensive soft tissue injury. There is preosteo stripping. So the pre ostium on the bone itself has been stripped, the bone exposure is there, but the bone exposure and the soft tissue injury reached the level that there is a quite separation between the both sides of the skin that you would need to put something else in order to cover that gap, that wound. And that's when the plastic surgery team would come in. Uh this is usually associated with massive contamination. So the third component that I'm talking about these ABC are not only talking about size, but they're talking about how extensive the soft tissue injury is. And if it's actually a flap that can be put back in its place or would need some flap from outside, it's talking about how contaminated the wound is. If you can remember in type one, it's a clean wound, but from type three, type two and type three to a level, we start talking about an extensive stuff, tissue injury and an exposure to the level that you would definitely say that this one is actually contaminated and the element of a pre stripping that is not in type a, a type one that's not in type two, but it actually starts with type three. So type A is a flap that can be put back type two. It's very severe to the level that you would need skin flaps. And we're going to talk about the flaps later on. Type three C is when you have what you have in type three B plus an arterial injury. And we talk about soft tissue injury in the side of soft tissue injury. You're talking about muscles, you're talking about fat, you're talking about nerves and obviously women, all of these things, you will see arteries and arteries will be damaged. Arteries are damaged can cause a different SCLE limb because basically, you're not getting any blood supply in the same time, it could cause some other complication that we're going to talk about later on, you can have a think about it, but we're going to reach it later on. It's important to know this classification because the classification itself will help guide your management plan. OK? Um The book itself talks about different stages of managing open fractures. It goes back to a stage where we're not talking only about the hospital. So we're talking about what are the ambulance team or ambulance crew will actually do when they go to the accident scene and what, what, what they, what are they going to do with the patient? Um So it starts from that stage and it goes all the way to the indefinite management. Um I think it's a good approach um because as we know we're doctors, so we're going to only see the patients one once they come to A&E once they are already being managed um initially by the ambulance crew. So it's good to know exactly what it or to know to have an idea about what the ambulance team would do when the patient is in the accident scene. And later on, we can carry on with the, the things that we're going to do once the patient come to us. So prehospital, the ambulance crew would do the same primary survey that we do in A&E which is C ABCD E approach. Um The next slide is going to ask you guys a question about CAD C. So I want you to put it uh for anybody that knows what C AD is. I want you to put in the chat. What do you think? C AD C A PDC E? Sorry. Uh is so C is something A, is B is something, C is something D something E is something whoever knows it before we need to. The next slide, I want you to put it in the chat. Um But the primary survey, the, the ambulance who are going to do is the same as the primary survey that we, that we're going to do in A&E. So they're going to carry out with that approach. That's one second, they're going to give the patient a prophylactic antibiotic. Um giving the patient a prophylactic antibiotic is very crucial to help minimize infection at the same time as one of the cornerstones of the guidelines that we're going to approach. So after Prime Minister, very making sure the patient has antibiotic even before reaching the hospital is one of the cornerstones of the uh 2017 guys that they're going to talk about. So after they stabilize the patient and they make sure that the CAD uh C ABCD E is done and the T is given, they go on to make sure that the patient is splinting and the pain is managed. Once that is done, they will be able to take the patient to the ambulance and actually take the patient to A&E so primary for them and to be able to profile for them then splinting and pain management before bringing the patient to A&E. Ok. I can see King J is saying that C is catastrophic hemorrhage. If I was saying that it's control of catastrophic event, different answers close to each other but different at the same time, um, er, is continuing with the ABCD E I would say you're correct with all of them, Kan has corrected the answer and he only wants to answer before we reach the next slide. We're gonna give you 10 seconds guys the disability correct? Can. Ok. Excellent. Um, this is where the question is and the, is the answer. Basically it is, uh, if you go to the first answer, that ear had its control of catastrophic event, most of we, we talk about catastrophic events in open fractures would be the bleeding which goes back to circulation. So it's more or less all of you guys are saying the same answer TT has asked a question about the full form and this is actually the full form of cap CDE. So basically circulation, then the normal ABCDE that all of us know with his airway breathing circulation. Yes, again, is to check if the control of the first bleeding that we controlled and see is maintained or not disability and exposure. If you try to work the uh rationale behind. Um if you're going to ask about the rationale behind doing C ABCD because as we remember, or some of you might remember the uh we used to use ABCD E before, but C was added later on. And the rationale is if you see a patient that would need an ABCD approach as a primary survey, but why are you doing it? You're trying to assess the airway and assess the breathing if they're bleeding and they're bleeding massively. If you think about it, it doesn't make sense because if you try to control the airway and breathing, the air of breathing is happening through a transfer of the oxygen inside your body and taking the um OC two out and that's done through the blood and that won't happen because the patient is actually losing their blood. So whatever you're doing in A and B won't make any difference because you're losing blood anyway. So in order to get the best outcome from AB you have to maintain C first, that's the rationale behind actually making C first, then going through ABCD again. Um So you can control the bleeding, especially when we're talking about open fractures. So control any bleeding that's going, then start assessing the airway, breathing, reassess the circulation, make sure that the patient's BP is maintained. Heart rate is maintained. All the C components, the central and the peripheral cyanosis and whatnot go into the disability, making sure the neurological they're stable, uh GCS wise, uh alertness wise, then go to the exposure. Sometimes we talk about a patient that comes out trauma. Some trauma would distract you from other traumas. A bleeding in the leg might distract you from a bleeding that the patient might have in the back of their head from a deformity that the patient might have in their shoulder. So yes, we're talking about open fracture in this uh lecture at the moment. But in, in order to conduct a fully thorough CAD C here, we need to make sure that you've actually primary surveyed all the injuries. So that's the rationale behind CAD C. We need to keep that in place. No, um uh temporary wound dressing would come would come before one thing I want you to get the scenario in your head because that's how the storyline would go. We visited the patient as an ambulance school members seeing the patient in the accident in place. Did the cap CDE after the, the, the C A PCD? If you go back, if you remember, we said primary survey is done. Prophylactic antibiotic will be ami then splinting the limb that had a fracture. The the splinting itself is one of the measurements that would help reduce the fracture and actually help reduce the hemorrhage that's uh happening. Um And that's something that most of the ambulance crew would do. Um Let's just say, for example, there's a distal tibial fracture that happened for as an open fracture. For a patient, we cannot trans transport the patient to the ambulance itself or transport the patient to the A&E bed with the leg dangling, you need to stabilize something. So it depends on where the fracture is. Sometimes with the fracture that's in the femur, we splint it with something called a thumb splint. If there's a fracture in the distal tibia, uh there are some air costs that are given to the patient that will, will be put below the leg will be inflated and will help align it in a better position and maintain up until the patient comes to us in A&E. So these three things I've done to the patient before they come to us. So when they come to us, what sauce down in A&E there, there will be at least three teams all prepared to see the patient. That will be the orthopedic team, the A&E team, of course, because they come to their place and the last team would be the general surgery team. Um, in different hospitals, there are different approaches. I've seen hospitals where patient, where the trauma team will be led by the A&E doctor. I've seen it being led by the general surgeon and I've seen it being led by a trauma hospital team. I would, I'm, I'm not quite sure what would the difference be, but I would say all of them are the same if they are ATL S trained because they're going to do the same approach anyways. Um But nonetheless, a patient would come, these three teams will be there and one person will be conducting the C A PDC approach. We do this as um we'll reach all the way to the exposure once you finish stabilizing the patient and put them on uh no muscle line. So making sure that their BP is up, you go to the exposure and expose the fracture itself. The main thing that we do or actually what we used to do before is once the fracture is um taken off and we can see the wound that we can see the bone, the bone is protruded from there. What used to happen is that the people used to irrigate the wound itself because they would see some kind of debris, um foreign bodies are there and they would like to just to take them out or wash them with no muscle line so they can cover them. That was an old approach. But based on the new guidelines, avoiding many washouts outside the operating theater is the way to go. And instead of doing this, we leave the debridement and excision and taking all the foreign bodies there to the operating theater team. But what we need to do is after connecting the primary survey and making sure that the limb is splinted is to apply a line soaked gauze on the fracture side itself, on the wood itself. Once you apply this, you put an occlusive dressing on and that's your part. That's where you stop. The rest will be conducted by the operating theater team. That's where the temporary wound dressing uh comes and that takes out the mini washouts that used to happen A&E and leave it to the theater team and leave us with only do a primary survey, making sure that the patient neovascular is intact from the lymph po point of view, then making sure that you put on a saline salt gauze and occlusive dressing and just make the patient go to the next two teams of the orthopedic and the plastic surgery team to conduct their initial management and the definite management. Do we have? And do you have any questions so far? If there is any questions throughout what we said until now, please put in the comments or raise your hand and let our coordinator know doctor T. So they can um give you a chance to open the mic. We have Kel asking why avoid irrigation. Um That's a good question and that's actually a question that was uh modified or asset by the guideline in the book that I showed you that I will give you the link later on. But the rationale behind it is when you open the wound inside the wound itself and around the wound would be foreign bodies will be bacterias that came from outside or came from the skin surface because our skin surface will contain a normal flora anyways. So the rationale would be if you come and just pour no muscle line gauze uh no muscle line on it. You're actually taking all the bacteria, all the foreign bodies, all the bugs from the top of your skin, of the top of the skin of the patient and all the foreign bodies that were on the top of the wound itself and making them seep inside the deep layers of the wound and actually creating a deep seeded infection rather than treating the patient. So you're actually causing more harm than good for the patient by thinking you're irrigating and actually taking the bugs out, taking the foreign body out. But you're actually creating deep pockets of um deep seated infections that would create so many complications that we don't wanna hear of neck fash, for example, um a deep seated um infections in the tendons and the muscles and that could reach all the way to the bone itself and cause osteomyelitis before it used to be done. As I told you the guideline was created, all guidelines used to have them, they were audited and in the audit, they found that it's actually cause a more hound than good. That's why in the latest version, all of that was taken out. And the final guideline is if an irrigation and cleaning of the wound needs to be conducted, it needs to be conducted in aseptic environment and that would be in theater. Does um that answer your question, Kel or do you want me to move on? Ok. Is not coming back to us. So I think, OK, perfect. Um We're going to move to the next slide, surgical management of the wound. Now we're still in the same story line. Taking the patient from the AM by the ambulance crew, do whatever we said, bring the patient to A&E do all the primary survey, putting the salt gauze then preparing the patient to be taken by the orthopedic and the plastic surgery team four management that will be on two pages where we talk and um uh open fractures. Most of the time we treat it in two stages. The first stage and the first thing that needs to be done is before any procedure to help fix the fracture happens, we need to clean the wound and that's what we avoid in A&E and that's what we need to do. So, cleaning the wound used to be called wound debridement before, but now it's called wound excision. And the reason for changing the name is the difference in definitions. So the definition of deprivement, as you see in the slider refers to cleaning the wound only while excision uh says that we not only clean but take all the contaminated tissue and also the dead tissue out. And the reason behind that is uh we want to clean the wound itself or win to create an environment that's clean and good enough. In order for us to give a final definitive management, whether we want to model metal work in there internally as an internal fixation or whether we want to create um an external fixation. And all of that needs to be conducted in a clean environment. That's why the first stage of actually taking the patient for theater to clean the wound comes. And that's why the two things of the and exciting excision of the wound needs to be done because you need to take all the foreign bodies, all the debris, all the asphalts, the sand, all the things that got into the wound out. But at the same time, you would see some dead tissue, some dead muscles on the skin around the skin. That will actually if say if they stays there and you just keep them there, they are actually dead tissue that will not help you in healing, that will still be dead there and the dead tissue stays somewhere. It's the best environment for any bug to grow. You're basically creating a house for the bugs to say here is the um prima elements that you need the glucose, the proteins, the things that you can break down from that tissue in order for you to survive. So you actually created more harm than good by leaving the dead tissue. And that's why both debriding and excision needs to be done. And that is done as a primary initial surgery. After taking the patient from A&E this operation needs to be conducted by the orthoplastic surgery team because it needs the combined expertise of both teams. As I told you before, we'll come back to the rationale behind combining both of them in this first stage surgery in the next slides. But we're going to tell talk about the next operation. So there are two operations that are done. The first operation is cleaning and with the briding and excising the wound. The second is skeletal stabilization. Actually, the skeletal stabilization stabilization itself happens in the first operation and in second operation as well. But then what happens in the first operation is an initial fixation in its place. So you have a fracture there from a patient that came from A&E you've taken the patient to theater, you have a plastic surgery team that comes to theater with you to help the bride and excise the wound, create a good bed. Then you as an orthopedic team need to stabilize the patient initially because you haven't thought yet about a final management because the final management would be whether to internal fix it or external fix it. But before you take that decision, you need to think about it and formulate a pound with the plastic team. But there is a time limit for you to wait in order for the patient to come from A&E and come to you. There is a guideline that says the patient needs to be operated on the primary operation, which is the wound excite uh excision and depriment needs to happen within the 1st 24 hours. That doesn't give you a lot of time to clean the wound and think about a management plan. So what happens is the management happens in pages. The first stage would require the excision and depriment and an initial fixation of the wound in order to make sure the bone healing starts to give you a a window in order for you to do the final stabilization. So there is an initial and there is a final in the initial, you do the wound excision at the bride and you do an initial fixation. Then the second fixation and the second final soft tissue uh uh soft tissue management will happen. So we talked about the first stage of wound department incision. We're talking about the first stage bone fixation and that mostly happens by introducing an extent of fixation to the patient. Um The reason that we do the initial fixation is early and stable fixation is crucial for the patient ex fixation is often preferred initially in order for us to maintain both sides of the fashion, being close proximity. In order for the healing to start and the same time give give us a a window of thinking and planning together with the plastic team for the final definitive management. So the definite the definite management, the initial management, both of them need to have the initial need to have it first, they definite need to have a second. Both of them have time limits and the time limits for them are the initial management needs to happen within 24 hours. Most of the for the most of the open fractures, there is a specific exception which is if there is a very high, high trauma, high energy trauma patient is preferred more to be done within the 1st 12 hours before all normal open fractures in the initial management of the wound department, excision and the initial fixation needs to happen within the 1st 24 hours. That's the um time limit for the initial management. Then the time limit for the definitive management will come which is within 72 hours. So you have 72 hours to do definitive management from soft tissue point as a plastic surgery team and from bone point as a portability team. And you have only 24 hours to do an initial management as a plastic surgery team from the wound point of view and from an orthopedic team view of stabilizing the fracture, I hope this point is clear. Now, initial and definitive initial is 24 definitive is 72 hours. This logically mention what I just said, which is time for soft tissue exertion. And also you can add to the orthopedic con reconstruction and fixation. The definite needs to happen within the 72 hours and needs to happen in collaboration with the orthopedic and the plastic surgeon's team. All of that, all these guidelines to make sure that this happens in 24 and this happens in 72 are done for the sole purposes and making sure that no delay happens because more delay means more time for bugs to go into the wound and actually cause an infection that would hinder the healing and would make the, the uh uh the implant or the metal work that we're going to insert would deem them mm infected and has to be taken out. One of the main things in metal work introduction, orthopedic is if your metal work is infected, it needs to be taken out. So that's one of the things that we need to avoid. If we avoid delay, we're reducing the risk of infection. Uh We're maximizing our good outcome. Um I'm talking from the orthopedic point of view, but I'm go based because the guideline mentions both orthopedic and plastic point of view. I have to mention what the plastic surgery team actually does as well. So for us, orthopedic, we do the fixation, whether uh an extensive fixation, the start in the initial then in the definitive, do either continue with the external fixation or do internal fixation. But we talk about the plastic surgery team, what, what they do is create a coverage for the wound itself. And that's by doing a flap, flaps are different, there are different types of flaps. Uh the flaps themselves are a very vast topic that we can't cover at the moment. But we, what we can do is mention few of them, there is a local regional flaps, cutting a side that's close to the wound itself and rotating it and covering it with it. It's a whole field that we don't wanna get in deep to. But the whole purpose of it is to help create a ceiling for the empty place for the empty roof of the wound in order to cover it, especially cover tendons muscles. Because by by doing this, you make them less um exposed to the external environment and that will be and that will be basically make them less vulnerable to infections. Um So doing local flaps, re flaps free flaps, actually taking a flap from your thigh area and putting it on the wound that you have in your tee area. And that's basically the the techniques. So the ways that the soft tissue ruction is hap happened by or used by the plastic surgery team one thing that the plastic surgery team always keeps an eye on is the flap that they took, whether it's a free flap that they excised from somewhere in your body and they put it there or it's a flap located that was taken from outside, that's close to the wound and actually rotated and put in there. They need to make sure to monitor the flap and make sure that the flap is still alive. Flaps usually are taken mostly with the because because we're talking about the flaps. So you're talking about the skin, subcutaneous tissue. Some of them might include muscles and they will include the blood vessels that are supplying them because they need all these components for all for the flap to actually survive. And that's what they are trying to achieve. So once you do that, you need to make sure that actually the connections out there, the blood is flowing and the flap is actually alive. Otherwise you would put a flap there and the flap would die. You actually creating more harm to the donor side and actually doing a harm by not creating actually a cover that will help um making the tissue or the wound itself less variable to infections. Now, if we can go back or remember the classification that we talked about, which is the gel classification. We said we have type one, type two and type three. Type one was a small wound that's less than one centimeter. That's a clean wound that's not contaminated. Type 21 to 10 has like social injury, but it's actually maintained as a soft tissue. Can say it's not extensive. That's more than 10 centimeters. Type three used to have ABCD ABC in them. A was a soft tissue that's actually still approximated two soft tissue that would need a flap three was a vascular injury was an arterial injury. And that's something that needs to be identified either by the primary survey that's done by the ambulance team or the primary survey that's actually done by the orthopedic general surgery or the emergency team in A&E. Um The reason for that is if a vascular injury happened, the limb that you're talking about is devascularized. There is it needs to be revascularized again, you need to introduce the blood back to it. Otherwise the tissue would die if they can accumulate lactic acid. Um And if it long time passes since the bad, that part of the limb did not receive blood, that part of that actually might die. Or I if you try to reconnect it again, all the metabolic rubbish that accumulated there from lactic acid. So, necrotic cells would come back with a circulation to your body and actually kill you. So identifying a a limb that has an arterial injury or a vascular injury is important. Usually it's done in primary survey and in primary surveillance, we finish them, we usually tend to send some uh imaging, send the patient for imagings and the instead of mentioning them, I want anybody to tell me in the comments. What imagings do you think we send in the primary survey? And which imaging do you think actually help us find? Um find out if there is a vascular injury that happened, I'll give you guys 30 seconds to write them in the comments but try to be concise and try to be nailing it on spot because it's very accurate question. What kind of imaging do we request on primary survey? Based on the fact that you have a high trauma injury with an open fracture? And what kind of imaging do we do to help identify an arterial injury? 20 seconds, 10 seconds. Ok. Yes, sure gave us an answer of Act Trauma with the series with CT and we have Ian Cunningham with a Doppler, both are correct, but the more accurate answer and the more guideline based answer would be the first answer of a CT tomogram with CT Angio. The reason that's more close to the guideline is once we do a primary survey for a patient based on the findings that we have on the primary survey, we either sometimes don't request anything. Example, we have patients that come as a primary survey that will literally just fall from the stairs or GCS 15 would not complain anything from ABCD E approach. All the upper limbs and lower limbs, chest up the pelvis, head, neck movement, everything is fine. So we'll discharge them without doing anything. Some of them require specific x-rays pains. In fact, they only have th that is in the ankle. So we do a, an, an X of ankle, but we are talking about most of the open fractures would happen because of a high energy trauma. 99% of the high energy traumas that we see in A&E would have extensive injuries that would require CT trauma. Anyways, uh we talk about C trauma, CT trauma is CT head, neck, chest, Abdel s and that's in other departments. And actually, or other trust I used to see that they do the whole CT from head to toe and that's actually more accurate to the guideline. So if you have an open fracture, that more likely would have an extensive trauma that will more likely have act trauma gram, adding a CT angio to it. So the patient would have uh a contrast and will be able to see the continuity of the vessels or be more accurate imaging protocol to perform and would give us more accurate answer about this vascular injury than having a Doppler. So, yeah, Doppler would show us if there is a flow in blood vessels, correct? But in the setting of a high trauma with a patient that came as a trauma call and would have most likely a CT trauma gram, adding a CT and specifically to the limb that had the injury would be more preferable. So, thank you both and we would go with the CT and due this time, um as I told you, air ation is valid, it's something that we need to make sure that happens. The reason for that is if we see that the the limb is devascularized and we need to vascular it, we need to involve the vascular team in as well. So they can try to use different shuns from other vessels to help make sure that the circulation to the distal side of the limb is maintained. Otherwise, all the effort of for, for us to help cover the wound manage, the facia will be for nothing because the distal sign of the that limb itself will be dead to the level that you would need an amputation. So in order for us to avoid amputation, we need to make sure that there is no vascular damage that happened and that happens through both primer surveys in in the ambulance team at the um emergency team. One thing we need to mention is fasciotomy. And so that's something that needs to happen when there is a possibility of compartment syndrome. Um Does anybody know what Koma syndrome is? Can I get one person to write a definition of their own or what do you think? Compartment center is? Let's give ourselves 30 seconds for compartment ather Ali had answered with a high pressure in the limb aedans with increased pressure in the muscle fascia, we'll get one more answer and we wrap up. Ok? For the time sake, we have to jump on this question because I wanna make sure that you guys see all these slides on time. All of you guys's answers are correct. But I wanna make it in the context of having an open fracture. Ok? You're sure with the pain out of proportion good. That that is one of the symptoms that we see it can be included in the definition. But basically compartment is an increased pressure in a closed compartment. And when we talk about a muscle, we're talking about an increased compartment within the fascia that's in circulating the muscle compartment. Of course, when you have a patient with compartment syndrome, the obvious sign, even though everybody says there are six ps pain pallor paraia pulse and all these symptoms, the main symptoms would be pain out of proportion to the injury that the patient is having. And when the other symptoms would happen, that means we already started through the pathway of having necrosis and dying of the tissue. The reason that we mentioned compartments end and open fracture is it doesn't only happen in close but open fracture would create arterial injuries which would bleed inside the muscle compartment, which would create an elevated compartment pressure going to compartment syndrome. So thinking the fact that we're dealing only with com in closed fracture, when we talk about compartment syndrome that's something that's not valid. And I've seen a lot of people talk about it, but the compartment can happen both in closed and open fractures. So that's something that we need to keep an eye on. Specifically, if there is a vascular injury, the treatment for the compartment syndrome is fasciotomy. And the other reason that we mentioned it is if we go back to the fact that we said orthopedic aplastic both manage open fractures is sometimes we have an open fracture with an impending compartment syndrome. What needs to happen is an immediate fasciotomy that immu fasciotomy mostly happens in the initial stage of the wound department, excision and it's mostly being done by the orthopedic team. But the plastic team would be on theater would look with the uh uh with the orthopedic team on how the incision is done and help plan when the incision is done. Then the initial external fixation is applied to make sure that the wound is a wound that can be later on managed by the plastic team. You're talking about two teams who will be working together, looking at the fact that there is a fracture that will be done by orthopedic and there is an increased wound that will be done as a fasciectomy, you have a wound in the middle, but the compartment that it's pressurized that would need to be fasciitis. So we'll increase the wound from here. And from here, you extend it to the lines that we know about. There are two lines that we do. In order to the compartments, I don't wanna go into t to it. But there, there is an anterior compartment if we talk about um a tibial fracture, for example, there's anterior compartment, there is a lateral compartment and there are two posterior compartments. In order for us to open these compartments, two incisions needs to be done a posterior medial approach, a posterior medial incision and anterior lateral incision. These two incisions are long incisions that will be done in order for us to release the fascia, release the compartments, reduce the pressure. And this needs to be done in a specific manner that will help the plastic team later on be able to close either close or create a flap for that wound. So even though it's a different topic compartment needs to be discussed in open fractures because it wouldn't require fasciotomy plus and the intervention and if not identified would create a limp uh threatening and a life threating issues. Um Now we talked about the antibiotic and the start, we talked about the antibiotic in the middle. But I wanna know uh if you wanna know exactly what kind of antibiotic it needs to be given, it's divided to two stages. We're talking about antibiotic that'll be given in the next in the, in the 1st 30 minutes when the patient is a fight by the, by the Ambu ambulance team and the antibiotic, they will be given for the patient. When the first operation is done with the initial department, when the decision is done, these two antibiotics are different and there is a reason for them being different. I just want one person to predict why do we have two phases and two different sorry, two different antibiotic regimens for the patient on these two different stages with just one answer but try to make it as precise as you can. Why do we have two different antibiotic regimens for these two vases? The immediate and the definitive give you 20 seconds, 10 seconds. Anybody with a rotation. Why these two antibiotic regimens are done? Ok. The reason behind the difference between the these two phases is once you see a patient in an accident place, most of the time we try to go with as broad spectrum of antibiotic as we can correction, we go with the most broad spectrum anti that we can. But when we talk about the phase two, it's a definitive management that will happen not on the first stage only but in the second stage. And by that time, the patient would be correction is targeted staph aureus, but not only that, we also add the gentamicin because we're talking about coverage of bugs or nosocomial nosocomial drugs and nosocomial bugs actually are more vicious, are more infectious than the bugs that we find on the road. The reason for that is they have more resistance in them than the ones that we see from outside. That's why we start broad spectrum at the start we call Mola. Then once we do the initial and definitive management, we go in the less broad spectrum antibiotic but more focused toward the staphylococcus Methylin resistant and uh nosocomial bugs in order to help minimize the infection rate and be more specific with the antibiotic that we have specifically with the nosocomial bugs that we have in the hospitals. So the whole concept of this of uh open fracture is making a time timing of the soft tissue reconstruction and the definitive orthopedic management done within 72 hours rehabilitation wise, making the patient mobilize and have a physical therapy as soon as possible. Of course, with high energy trauma, we need um of the psychological support as well, which is important for the recovery. It's not something that we are focused on in my previous slides, but it's something that I wanted to mention here in order for us to cover all bases. Now, only we're dealing with the plastic surgeon or orthopedic issues. We're dealing with the physiotherapy rehabilitation and the psychologist as well. So that's something that we need to focus on or actually keep in our heads. So the summary of all the 200 50 something pages of the guideline is the importance of making sure that multidisciplinary approaches done for managing open fractures and the two teams that definitely been in involved are orthopedic and the plastic surgery team. These interventions need to be timely interventions, including the antibiotic excision of the wound reconstruction. And all these things are crucial to have the best outcome. Not only that we need to make sure that we follow up with the patients. Have a look at the wound. See exactly if the wound is actually healing in the way that we want to. Hopefully there are some complications might develop. But that's uh that's why a followup process needs to be put in place. Um We've reached to the end, but before the end, I will put this case study of this stage of um uh this case of a patient that's 35 year old that's sustained an open fracture through a motorbike accident, had his right tibia being fractured in this open fracture case. And if you're driving a motorcycle, you're on the road, you have a lot of soil, dirt, maybe a grass, a lot of things coming in and contaminating the wound initially when the ambulance team saw him, um, the patient had a GSS of 15 stable, uh vital wise has severe pain in his right leg. What they did is it the same as we talked about before, did AC A PCD, they gave the patient a diabetic which is called within 30 minutes, they stabilize the limb by reducing it. Put it in a splint in case of the tibia, it's the air cost and it's the air, um air cost that helps stabilize the fracture. Then they did the covering with the sterile dressing, which is basically the saline salt cause now in this stage, the ambulance crew done their job. I want everybody to write, what do they think would happen from now? As in what would happen, A&E what would happen in the initial, what would happen in definite management? I want to add to the context that you're working in at D uh D JH hospital, a district hospital. Uh That's a key word, not a major trauma hospital. OK. You're working in uh not a major trauma hospital. You receive this patient from the ambulance team and we wanna know what you would be doing from this point forward. This is the end of the teaching. This is the end of the open fracture management class. All I wanna know is the management that you guys would be coming up with. After seeing this case, we'll give you guys two minutes. It's 85 will stop at eight, seven, one more minute to go. We have 12, three for answers. OK. We have answers from Julia that says C ABCD from Ahmed that says A&E deprivement IV, antibiotic, pain control with opioids, then sent orthopedic, then orthopedic, we then do the definitive management with or if LAR with primary survey CT excision change of antibiotics. Daniel C ABC. Full Trauma series considered N TC discussion. ABCD check your vascular damage. CT and angio if indicated for orthopedic. A lot of people would want to refer to orthopedics right away. All the answers are aiming toward the right direction. But I've, I didn't see anybody talking about the plastic team yet, which is the main component of our discussion. Now, is all the answers are correct, but don't forget that the plastic team are involved as well. So it's an orthoplastic approach. Ok. Um I will give you the answer. But remember in the context of this case, plus the fact that you work in at district hospital, that's not a major trauma hospital. That's a point that I haven't mentioned throughout my uh slice up until now, but that's worth mentioning because not all of us will be working in major trauma hospitals. A lot of us will be working in the hospitals and we need to know about the next answer. Af after saying the word immediate and conducting the major trauma uh referral to orthoplastic capabilities, all of you guys answers are correct of bringing the patient having AC A P CDE happen. I see the patient from head to toe, making sure that the CT trauma gram is done, making sure that if there is a suspicion of an arterial injury to conduct A CTN G based on it, then once that is done and you make sure that you did the primary things in managing any open fracture. With this several gauze applied to the wound occlusive, uh, dressings in there, splinting the, that's what you need to do. Whether you work in a major trauma hospital or a district hospital. C ABCD E explosion in the wound sterile gauze saline on them, wet them on Saline, put them on the wound, occlusive dressings in there, stabilizing the fracture. Once that is done in any settings that you are, you have two options. Either you actually working in a major trauma center that has both orthopedic and plastic capabilities. Because as everybody said, yes, orthopedic needs to be involved, but it's not only the orthopedic, it's orthoplastic approach that needs to be done based on the guideline we mentioned. But in many situations and situations that I've been in as well, I used to have patients that come to us with open fractures. They will be assist as AC A P CDE have the trauma gram done and have imaging of that limb, making sure that we do the sterile cause and all the primary things that we do as be both guideline. Once that is done, we call a hospital in my situation. I work in Midway Marath Time Hospital and our major trauma center is Kings. We raise the phone, we speak to the Kings orthopedic department and orthoplastic department that would say that we have this patient with this fracture and making sure because every, every trauma center or every, every trauma center you refer to would like imaging from the wound that you have and every emergency uh department would have ipads and things that they would try to take images with these will help evaluate the type of wound that like how the, what's the classification of the wound that you're dealing with in order for the other center to evaluate? So once we conduct all the primary things, you lift the phone, you speak to the man's trauma center, you relay the message to them, You try to make sure that you send the image to them and they will straight away, take the patient so they can conduct the orthoplastic approach of doing the wound exci uh excision and debridement. Then thinking about the definitive of whether they would do do the definitive uh with internal fixation with external fixation, doing a flap or not doing a flap. These are other details that can be discussed between the two teams, but that has to happen in major trauma center. So answers are right, but they stop at C ABCD E city trauma grams and trauma gram of uh city of the limb. There is arterial injury, doing the both guideline approach of saline G so called occlusive dressing, still sprinting the limb. Then if you are working in district, send the patient to a major trauma center. If you are a major trauma center, making sure that you if you work in an A&E speak to the orthoplastic team and make sure that they are aware so they can do their managements within the time limits that we discussed with this wound excision performed within six hours or 12 hours maximum 24 hours and the definitive of skeletal stabilization and soft tissue coverage within 72 hours. Basically, this case study is the cornerstone of everything that we discussed in this teaching. And at the same time, that's a bit of a concise image of what the book of the guideline and the standards of fracture management is relaying to everybody. The key point is what we discussed, which is making ba ba making sure that the C ABCD E both guideline of dressing and occlusive. Uh uh So go and dressing is done timely management of every step that we do include every team that's involved. That's how we created this guideline. That's how the guideline has been audited, updated and how that's how it stands up till now. Um I'm really sorry to take a long time in explaining this. Actually, the book took me a lot of time to try to dissect and put in slides. I would recommend everybody to have a look at the link in the end and actually visit the website of PAS which will show you a PDF of the, of the book that I'm talking about, which has all the details that we talked, but in very specific details that will help you not only think about what you do in A&E or what do you do on orthopedic or a plastic surgeon? But also what are the options that the orthopedic surgeon thinks about? What are the options that plastic surgeons think about when they talk about the definite management in the orthopedic case, whether you're talking about the internal fixation to be done or external fixation? What, what leans you more toward internal or what leans you more toward external? If you talk about the plastic surgery, are you going to do a free flap? Are you going to do a, a local flap? Are you going to do a rotational flap? These are very, very vast details that I didn't wanna go into. Now, as I mentioned in just bulk uh kind of um statements that you can dissect more when you want to go to the book. Um At the end, I would say just thank you to everybody that attended. Um It's been wonderful. Uh I would thank the coordinator uh Doctor Tt Jane. I will thank everybody that attended. Hope everybody had their knowledge increased, had their questions answered. Um And if every and everything is clear, you can tell me the comments if there is questions, let me know. And as always, everybody would require more knowledge, more reading, more researching. And I would say let's let's let's create more events like this. Um Thank you, Doctor Aden for such an insightful session. Uh I'm sure it was really valuable for most of us here. A big thank you for everybody joining this event and I have left the feedback form in the chat box. I hope everybody uh can get some time off and just fill that form for us so that we can make better for the future sessions. Uh That's all and we would like to see you in the future once as well. Thank you everybody. Bye. Have a good evening, take care all. Uh Yeah, someone has asked, uh can we get the slides? I will up uh upload them on meal so you can get the content there. Thank you. Bye.