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OK. So traditionally, we've um looked at pretty high infection rates with open fractures and previous results of about 40% infection rates um have been published in the past. This is now much better with type one. Gusti fractures almost almost the same as a closed fracture, maybe 1 to 2% higher. Uh Obviously type threes are still carrying a significantly higher rate. Um And I think this is all due to the fact that we've recognized that they need special treatment and I think everyone knows about the boast four guidelines introduced in 2017. I'm not going to particularly go through the entire dose because I'm assuming everyone is, is with it. Um And then the introduction of the trauma network where um open fractures are sort of streamlined into centers which are used to dealing with these types of injuries has improved outcomes for patients and each trauma network has a slightly different pathway, but they all pretty much mirror boast for and I've just put a screenshot up of our one which covers quite a large population of Northeast London and Essex. Um There is a still um an a, a risk of amputation with open fractures. Um But now, um quite a large study fairly recently and it's about 2 to 3% which is pretty low. Ok. Next slide. Yup. When I think of open fractures, I generally think of high energy ones and low energy ones to try and keep this simple. Um So this is um so the X rays I've put up here are of real patients um that I've treated at the Royal London. Um So with low energy fractures and we see them from time to time. So most of our geriatric fractures go to a different hospital, but if they're open, uh they come to the Royal London. Um So there are special considerations with these patients. Obviously, they've got other comorbidities. Their bone quality is not as good because they've got or they tend to have a background of osteoporosis and their skin tends to be of poor quality. So that makes your soft tissue reconstruction options a little bit more challenging. So, with these geriatric open fractures, you tend to see a typical pattern um often of the distal tibia. Um And I don't know if you guys have seen this in your own hospitals. Um You tend to have sort of a, a transverse intramedial wound where the, the, the medial, so it's a valgus deforming force and the, and the distal tibia has, has popped out immediately uh creating a tear in the skin. So it's a in out type injury um, so there's different ways of treating these and I don't know if anyone wants to hazard a guess as to what we've done here with the x rays that I've put up. So if you debride and you've docked the proximal segment into the and looks like you've flattened the distal. Yeah, exactly. So, with some of these, again, you have to tailor this to the patient you can treat these with and, you know, depends on their comorbidities and their mobility before, but you can shorten them. Er so you can shave off some of the bone ends. And if you shorten um to allow er soft tissue coverage, then they don't often need er significant soft tissue reconstructions which may, they may not be fit for. Um you know, that's not always possible, but that's something that, that you can consider. And when you shorten them, er there are different ways of holding that fixation. So here I've used a frame. Um so shaved off the bone ends allowed the medial wound to close and then held it in a frame and then that and you know, you leave the frame on until those bone ends heal, which can be up to sort of six months. Or sometimes we use hi foot nails, um dedicated hind foot nails or sometimes we use a retrograde femoral nail. Uh The problem with that is it um violates the subtalar joint. Uh So patients don't really like it. They, you know, they are in pain post o but in some patients that, that's the only way. Um So next slide, yeah, and then you've got your obvious where you, you know, sort of what you tend to think of open fractures is um, road traffic accidents. Um We get a lot of probably the most, most of our patients are RTC S or cyclists, motorbikes. Um We get quite a few construction site um, injuries. Um So that's a different type of injury where you've got significant um soft tissue injury, um affecting um a a lot of the limb. You can get segmental bone loss, um and you can get associated injuries with that, which you will go through. Um Next one, I think there has to be a special consideration for um contaminated injuries and a lawn mower injury is one but it could be anything really. So we have patients sometimes who have fallen in the Thames. Um And that's obviously a contaminant and, and had an open fracture, which is obviously a contaminated wound. There's a picture there of an open ankle fracture dislocation with um mud. Those are not ones that you can traditionally just hold onto to the next day. So just put a little um screenshot of part of the boast. So you have to kind of decide is this high energy is as low energy and if it's um contaminated or not, cos if they're grossly contaminated, ideally, that patient should go to theater on the same day. Um, if they're high energy, 12 hours, if they're low energy 24 hours, now, this is all well and good, but I don't know how it is and, you know, II worked in various trauma centers as part of fellowship and as a consultant. Um, there are limitations as to what your service can offer. So sometimes here at the Royal London, even high energy open fractures will wait 23 days, er because we physically don't have theater space to get some of these done, which is not ideal and I'm sure that's the same at Adam Brooks and, and elsewhere. Um next load. Um We don't tend to see um that many gunshot wounds in the UK um at the Royal on, we see them every now and again and they tend to be low energy. Um So you have to differentiate whether there's a low energy gunshot wound or high energy. Uh This is a patient I had a few months ago. Um low velocity gunshot wound um with these, they get treated differently to the high energy one. So if it's low energy, it is acceptable uh not to do anything. So local wound irrigation, um tetanus, you can give them a a, you know, a course of antibiotics if you want to. However, this one, it was uh low velocity. However, um there's a femoral shaft fracture which you can see on the CT scan sort of distal third. So this is an open fracture. So this patient was taken to theater. And also this patient, the bullet had actually skimmed through um the the sciatic nerve where it sort of branched into the comp peroneal nerve. And so the patient had a foot drop. So we took the patient to theater, explored the nerve, uh took that bullet fragment out, washed the knee out and, and treated the patient with a retrograde. Now, if it was just in the soft tissues, then you don't necessarily have to um fish the boat, the the bullet out um high velocity gunshot wounds which I've not seen here need thorough wound, irrigation, debridement and stabilization if needed. Next slide. Um We're talking about open fractures, but I think open fractures, we need to think about the um uh entire spectrum of injuries that you can get. So the X ray that I've put up, it's a lateral view um of a patient um that was here at the London a couple of weeks ago. So that was a closed injury. But you can see the proximal shaft is tending the skin anteriorly. So that's an impending open fracture and should be treated uh emergently. So it's not something that can wait because unless, until you offload that skin that that fracture will become an an open fracture very quickly. And I think you also have to be um this has caught me out a few times is the closed complex fracture. So high energy um, significant comminution. I know it's a small picture but you've got lots of fracture, blister, um, blisters, Conus skin, er, that skin can very quickly become non viable and convert that into an open fracture. Um, so you have to be aware of these types of injuries that are not, you know, your standard open fractures that you've seen in A&E but can, can become or should be treated as such. And then there's a little sort of slide here. Um A little box about whether it's an inside out, which is most fractures or out or outside in where, which is more of a penetrating injury. Next slide, um epidemiology of open fractures, there's lots published about it. Um I've, I've actually when I was working with Matthew Kkow Adams, we looked at, you know, um all the open fractures over a period of four or five years and they tend to be from a similar type of patient. So the majority are males in their thirties or forties, high energy from road traffic accidents or building sites and that kind of thing. So they tend to be a typical patient. Um especially in the UK, obviously, this will differ if you're in um Asia or North America. Uh next patient, next slide. Um I think you all probably know the Gillo Anderson classification for open fractures. It's probably the most reliable classification we have. There are others um such as the um O ta classification for open fractures. Um This is the one we use most commonly and it has its faults. But I think it's useful in communicating, you know, to colleagues and getting a sort of a quick understanding of the type of injury that you're dealing with. I won't go specifically into all of them. I think you, you probably will know. Um but it's important to, to just highlight that this is meant to be applied after the initial depriment, er which we don't often do next load. So what are the problems with the classification? Well, inter observer reliability has been reported as low as 60% again, as I said before, it's not always used after the debridement. It's for tibias, that was its initial conception. Um There are things that it misses out such as bone loss um which is very important to consider when dealing with these types of fractures. Um So this is a picture of a patient of mine from I think about three weeks ago. I don't know how clear that picture is, but you know, what would you classify that injury as just just looking at it and the x, the X rays of that actual patient there where you can see the wound and that wound is postmedial anyone. It's sort of like a two, I think just based off the wound itself. Yeah, that's what you know, it looks, it looks like that but looking at the X ray there's a young patient in his twenties, uh came off a motorbike. What are the clues on that X ray that you know, this is something significant? The degree of commun extends all the way down to the media well into the Yeah. Yeah. Yeah. So this is essentially a, this is an open peel on. Um and that, that wound is postural medial and we tend to see with PLOS when the wound is postural medial, they are known to be um probably some of the worst prognostic open injuries for a pelon because the twisting injury to get your wound, postural medial uh takes a lot of um sort of results in a lot of damage to soft tissues and bone. Um if you go to the next slide, so this patient was taken to theater uh joined orthoplastic list the next day and this was the tissue that was debrided. So that picture on the left is on day one. So the next morning, joint orthoplastic list. So that entire skin around there was completely degloved. Um He had damaged a lot of his um posterior um muscle compartment, deep muscle compartment, the lateral compartment was degloved. Anterior compartment was intact and all that. So can you see the defect? There is about four centimeters. Um All that, all that bone completely devitalized that one in the bin um His tibial nerve was intact. Um Deep peroneal was intact. His blood vessels were intact, achilles was intact. So he was taking to theater and stabilizing an ex fix. And the X ray on the right is when I took him back to theater. A few days later, this guy's from Brazil and wants to get back to Brazil. There's lots of different ways of managing bone defects in our preferred way is bone transport. Um But he wanted to get back and we don want to leave him the next fix. So he wants to try and get on the next flight back to Rio. So we've stabilized him with an internal plate. He's had a lap do side flap over that medial defect. You can see a cement spacer in there, which is, it's basically dead space management has a bit of structural support, but also it's got antibiotics in it. Vancomycin and Gentamicin, um, and plate of the fibula just because it's easier to gauge length once you plate the fibula. Um So that's about four centimeters and the plates holding his peel on in place, which was minimally displaced. He'll need something else doing at a later stage, uh to, to sort of um replace that missing bone. Next slide. Uh Can, what's that? What was that metal? Um It looks like a wire that's running down the center of that cement on the lizard of Olive wire. Um It just, it just makes it easier to hold that cement block in, in, in the bone. So that is it sort of passing the superior anterior. And so when you make your cement space and you just walk through the wire through before it sets and then the wire bends to allow it to get into the shaft proximately and into the metaphysis distantly. And you make your cement space a little bit bigger than the actual defect just so it's a smudge. Um And then you, you get some so that medial plate is basically an in affix so you can get rid of the X fix. And if the patient wasn't going back to Brazil, then what we'd have done is just leave the patient in an X fix, which it was originally let plastics do their on flap. I would have put the cement space on, let plastics do their flap in a couple of weeks. Once plastics are happy, then I could have converted that X fix into a bone transport frame. Um There's lots of different ways of approaching this type of thing, but that's what we did for him. Uh Next slide. Um So type one and type two fractures. Um Type one is only a slightly higher infection rate than closed fractures. Type two, a bit higher than that. Um It's important to remember that type one and type two that the difference is not just about the size of the wound, but it's also the, the energy that's gone through the soft tissues. So there's a bit more comminution, there's some periostal stripping. Um Next slide type three, obviously a completely different cohort of patients. So this is where you have high energy significant per slipping, stripping soft tissue damage. And with that, the increased risk of all the complications that you would expect. Um Type threes are subdivided at A B and C. Type A doesn't require soft tissue. Um uh extra soft tissue coverage. Type two requires flaps. Type three. You've got arterial injury requiring vascular repair. Um We don't tend to see. So maybe type three CS, we see maybe one or two a month, type two Bs, we see a couple of weeks, sometimes next slide um with three C fractures. I think it's important when, when they come in to Ed, you get the right people involved pretty quickly. If you feel that if this is not salvageable, you want to get your um you tend to have two consultants at least making that decision at the royal on. We get plastics involved, fas involved and the orthopedic team involved. And sometimes actually, it's just better to make the decision that this is an acute amputation rather than trying to do any sort of salvage procedures and delaying the inevitable. But that's sometimes quite a difficult decision to make and we'll talk about that a bit later in our next slide uh with open fractures again. So you're looking at things like bone loss, but also are nerves damaged, are tendons damaged. Um You know, people forget that even if it's an open fracture. You can still get compartment syndrome and we see it from time to time. They're actually an increased risk of compartment syndrome even with an open wound. And um as part of the trauma CT, you get a C TPA because you wanna make sure there's no um vascular compromise. And when the plastic surgeons are planning their free flaps, the plastic surgeons here like to look at the CT PA to see if they've got vessels to, to PLM into next slide. Um Has anyone got any questions at this stage? Everyone's quiet. No, it's grand. Like maybe it's just um, so antibiotics is probably the one of the most important things and there's uh and probably has the strongest evidence of reducing your risk of infection and has been looked into. Um So the most important thing is that, that, that they get a shot of antibiotics early. A lot of the prehospital teams here now will give a shot what, you know, at the roadside. Um I don't know if that happens everywhere, but I'm, I'm, I think most paramedics now will be doing that. Um There is evidence that if they get a, a shot of antibiotics within one hour of their injury that reduces the risk of um infection duration of antibiotics is still controversial, I think, and II personally feel that antibiotics should be um continued until you've got some sort of soft tissue coverage. I think it's a lot of judgment. If it's a grossly contaminated wound, even after debridement and soft tissue coverage, you can continue antibiotics depending on um, what your local microbiology protocol is a little bit longer. And I don't think there's anything wrong with that. Um, local antibiotics. Again, there's no strong evidence, there are some centers that will put local antibiotics in. I don't know if you do. You guys know what I mean by local antibiotics, you mean like stimulant or? Yeah. So those are the brand names, the calcium sulfate and then mix them with different antibodies. You've got stimulant, you've got things like serum. Um You've got cement, whatever brand of cement, you know, most of them have antibiotics in it. You can make cement b pouches, uh just something which acts as dead space management prevents fluid from collecting and, and, and local antibiotic delivery. I don't tend to use local antibiotics in um acute open fractures unless I've got AAA bony defect there that I want to use as dead space management. Um The stimulant. Now, the, the picture that I've put there is a stimulant beads, um which can be quite useful. It's just something to be aware of. Um but they're quite expensive next slide. Um So when you see this patient in A&E, um sometimes it's easy to get carried away, especially if, if they've got a gory open fracture. Um But don't forget the more important things first. So, you know, pneumothoraces usually chest strains, just your usual ABCD and at most trauma centers now, you know, obviously the the patients are treated um as, as part of a wider trauma team. Um I think most of you have probably done ATL S. So I think it's still important just to, to mention that um, so stable up, make sure the patient's stable first before um focusing on their leg or whatever. Next slide. It's the timing of surgery. Um, in the past, it was felt that, you know, you should try and get these patients to the theater within six hours. That's, you know, that's now a very outdated way of thinking. Um, firstly, most places can't get these patients to the theater because there's no theater space and it's better that these cases are done by the right people on the right list and having inexperienced people doing these types of injuries, we tend to see complications with that. Um, ideally you want to get the patient to theater on the next, the next available list the next day. Again, as I said, mentioned earlier, we have so many open fractures here at the Royal London. Sometimes they can wait longer than that, but you try your best and get these done in a timely fashion, I think the quicker the better. But with the right people, there are lots of papers published as to looking at, you know, comparing infection rates with timing of surgery. Um and there's nothing really in you know, strong um to support one over the other. However, the one thing that I mentioned earlier is that if it's highly contaminated, we know that those, those patients tend to have um polymicrobial infections and can get unwell, so they should go to theater on the same day, next slide. Um So when you get this patient to theater, um obviously you'll be doing this um or I hope you'll be doing this with a plastic surgeon present. Um Someone experienced enough to understand um how you um approach these. So general principles are that if you've got an open wound, if it's a puncture wound, you don't necessarily have to open up the entire leg, deliver the bone ends and wash because to do that you're doing, you know, you, you're damaging soft tissues and I don't think it is necessary. Um So it's a, it's a judgment based on the type of fracture, whether it's high energy or low energy and where the open wound is. Um However, so I've put pictures up there that's on the back um website and those are the fasciotomy incisions. So you've got your dual fasciotomy, medial and lateral and they're all go to. So wherever your um so these tend to, these fractures tend to be over the tibia vast majority. Um So wherever it is, you can always cross over into one of your fasciotomy incisions and that's the safe way to do it. Um So whether it's lateral or medial, you can cross the tibia. There's no problem with crossing the tibia to get to the other side if you have to uh obviously being careful and the idea is is to be able to see um the bone ends. Now, if it's a high energies in injury with significant um periosteal stripping, um degloving, then you, then you do want to extend the long fasciotomy incisions to do a a thorough debridement if it's contaminated. Definitely. Um So you will do this with your plastic surgeon uh when um extending into your fasciotomy incisions, what you want to try and avoid is acute angles. So you try and do a gentle s sort of bend um to incorporate your wound and you want to um try and excise your wound. If possible, you don't want to go crazy because then if it's, if you're gonna make um a closable wound into something that's going to require soft tissue um reconstruction, that's not ideal. But if the skin is not viable, then it has to go um next slide uh be mindful um or understand how um sort of the blood supply of bone. So, um we know there are three main ways that we get blood to bone. So, periosteum uterine arteries and your met epiphyseal vessels when you've got a fracture. So normal bone, um blood flows from inside to out. When you've got a fracture, it goes from outside to in because the periosteum tries to push um blood into the bone. But if you've got significant periosteal stripping, you lose that. Um So very quickly with open fractures, with significant um soft tissue damage, you can get errors of devitalized bone. Um And that's why you have to, I think, be pretty aggressive with how much bone goes in the bin. So if there's no soft tissue attachments, um then I think there's no point in keeping it and I think that's widely accepted with most people next slide. Um So be systematic when you're doing your debridement. So you're extending your wounds along, um your fasciotomy incisions going from skin. Um You go through fascia, fat muscle and then down to bone documenting exactly what's damaged. Uh We know that when you have significant muscle damage, that tends to be a poor prognostic indicator for patients. Um I think most of you have probably heard of the tug test generally if you can pull a bit of bone out, um then it goes in the bin. It depends how hard you pull. Um It's quite hard to make that decision sometimes. Um I think it is dependent on the experience and seniority of the person doing it from us. We know that if bone goes in the bin, we can recreate that bone. So not scared to just say, look, this patient's going to end up with segmental bone loss because that bone is not viable, but we can manage that. I think that's better than actually trying to keep that bit of bone in. Then the patient gets, you know, it acts as a nine of infection and um then then you're dealing with a different type of situation, document how much bone goes in there been take clinical photographs. We encourage all teams here who, who undertake these types of operations, pre um pre surgery and after the operation to document and upload photographs onto our electronic patient records. Um, try and get something into the canal. You know, you can use whatever you want. Really, you can use curettes, er, bone pigs, but make sure you do a thorough bony debridement. Anything anyone wants to add, I don't know how much experience people have of doing bone degrade these factors. I have just a quick question about that. So quite a few common ones, we get a sort of tibial shaft, it's sort of come out the front. So you've got sort of a 10 centimeter oblique angulated wound. So we deliver the bone ends and then the question is sort of how much do we go about? Obviously, if there's nothing, it's sort of, you know, it's not a commuted fracture. You've got two solid ends. How much do you go back to grinding the ends? Because you sort of go at it with a bone nibble. But then you start questioning how obviously a lot of these patients are young, the bones quite tough and you're deciding how much of it are you actually going to take before you end up shortening the patient? Well, shortening, I don't think you need to go crazy with that. I think if it's a highly comminuted fracture and you've got bone fragments that have been completely stripped that goes in the bin. But if it's, you know, a midshaft fracture, whatever a spiral or whatever it is, you don't have to take off pain. I don't think that's the right thing to do. Some people say if the spike has come out of the skin, nibble off where the spike is, I think that's fine. But what you don't want to do is start taking bits off and then you can't really struggle with your reduction and you lose your portable read or whatever. But I think you have to judge on a case by case basis if it's contaminated and you can see bits of road or mud or right over in it then, and that's slightly different to um you know, a clean w most fractures that we see tend to have no gross contamination at all. Um Next. OK. So um yeah, so as I was saying, uh any non viable tissue, whether it's bone or soft tissue needs to be debrided, we don't leave it in um Because that just acts as an nidus of infection. Um So this is an X ray of a young um guy, I think he was 25 ft and well mechanic um who came to us about more than six months ago. Now, um that was his um fracture, the, the initial fracture um in Ed. Um You can't really tell it's quite a small um picture of the X ray there. But once um he was taken to theater, um there was a significant significant soft tissue defect. It was a three B. Um he had a lot of combination that ended up going in the bin. Um So he was, he ended up with a gap of about six or seven centimeters which you can see in the X ray on the right. So I treated him. Um Initially, he was in an X fix with a spacer plastics, did a free alt flap. Um uh The flap um took well and um about three weeks later, two weeks, three weeks later, we took the X six off and converted into a bone transport frame. I don't know how much um you guys have seen or have experience of circular frames. Um So you can see at the top we did an osteotomy um that line going across low energy osteotomy. Um And then eventually you that bit of bone in the middle, which is your transport segment gets dragged down about one millimeter a day. And through a process called destruction osteogenesis, you get new bone formation, you can see the X ray on the right. You've got new bone regenerate at the top. Um And then that transport fragment has um docked into the distal into the distal fragment. Er this guy um because that didn't heal. So you often get problems with healing at the docking site. Um I took him back to theater for bone grafting. Um And we're still waiting to see whether he's healed or not. Um But he's done well. We've um we've gone er 67 centimeters of bone, the next slide. So in theater, when you're debriding, we use just regular saline. There's been studies quite big studies such as the flow flow study to look at. Is it better to do post lavage? Is it better just to use low pressure irrigation? Is it better to use soap or just saline by itself? So we just use normal saline. I normally use probably around 6 L. Again, a case by case basis, if it's a dirty wound, you can use more low. Um post lavage has been shown to actually um have uh sub optimal outcomes compared to um low pressure irrigation. So I don't know many centers that use now for irrigating open fractures. Um Unless anyone tells me otherwise. Yeah, next line. So how much do you try and debride and how you know what's the extent of your debridement? Again, that can be quite difficult. If it's degloved, you have to go to the extent of where it's been degloved to thoroughly clean. Again, if it's contaminated, you need to try and get to all those bits of, of contamination. There are some people that say wherever you've got hematoma, you should debride. Some people who say so there's a proximal. So this is an open tibial plateau patient I treated in a frame a few weeks ago. You can see gas in his soft tissues on the CT scan. Um There are some centers who say, well, actually wherever there's gas you need to try and, you know, get to it to debride. I don't do that because you end up stripping the entire leg. So I think it's a difficult call, but I think it just needs to be um tailored to the patient and what you see at the time of the initial debridement. Next slide, if you've got an open wound, um and you are, you know, you know that the wound can be closed following debridement, you can use that wound to do like your nails. So if it's a type one or type two, that can be primarily closed in the tibia and you're going to treat it with an intramedullary nail, um you can keep it open and hold it reduced because it makes everything easier. Put your nail down and then, and then close, primarily be mindful though that sometimes after nailing, you can get some soft tissue swelling, um which can then, so you've got your nail done and then, and then you will struggle to close the wound. Um So you've got to be really careful with that because if you've got a nail done and then you can't close the wound, you're in a bit of trouble. Um, because we, we know that having exposed metalwork increase your risk of infection significantly. Um, if you're gonna close wounds primarily, again, do this with your plastic surgeons, um, it has to be ideally attention free closure. Um because uh wounds under tension, especially over the tibia, bony surfaces, um are susceptible to breakdown next slide. So you got to think um when you've taken the patient to theater, are you going to stabilize this um with external fixation? So, in an X fix or circular frame or you're gonna use internal fixation and that decision has to be made by someone senior and um have plastics present. If you, if you think you can close the wound, then by all means uh fix it with either a nail, if it's dier or meta dice, if it's an intraarticular fracture, you can fix it with plate and screws. Um But you, but you have to get soft tissue courage at the time. If you're worried, then the safest thing to do is just um debride and put in an ex fix. Um we very rarely do acute circular frames. But um because these patients tend to come in and by the time you've got someone who can do a frame, it can be a few days or an available list. So, um all our patients just tend to go into next fix if you can't get the wound closed. Um Next slide, I should, I should probably also mention that actually, um if this is part of, I won't go into damage control and um early appropriate care. But if the patients, um a polytrauma patient, which we tend to see quite a few here at the Royal London, uh you might not be able to do your definitive fixation in the tibia. Er It depends on the patient's physiological parameters and you do what you can. Um So an ex fix sometimes is the only thing you can do. So this is another patient of mine, segmental tibia, um debrided, um temporized the image here. Um I don't know if any of you guys have seen that is um is, is, is um LR S by Ortho fix. So it's essentially a monolateral external fixator. Um But it's, it can be used for definitive fixation, especially if you've got anatomical reduction and the patient can weight, bear on that. And that's designed to stay in for, you know, six months, eight months or whatever it needs. The patient on the left, the whole leg is pretty much degloved. You can see they're in an X fix. Sometimes we do in fixes. So if you, if you can see the entire fracture because everything's been stripped off, you can temporarily put like an LCP plate on just to hold your reduction. Saves the patient being in the next fix. Um And then you know, whatever the vac or whatever goes on or you, you cover the patient in gauze and will enro until they have their definitive surgery. Obviously, that plate can't stay in, but it can be useful sometimes in, in cases where you're, you're looking at the fracture and it's not commun if it's commun, the plates are not gonna do anything, it needs to go in the next fix. Uh Next slide, the next side. Did someone say something? Any, any anyone wanna say anything? No. OK, sir. No. OK. Bank dressings or negative pressure wound dressings, we sometimes use them temporarily. If the patient's got an open wound, we put them in the next week, put a back on and then you can come back to it at a later stage. Next slide it on this side. Um So I won't go too much into um the soft tissue reconstructive side of things because I think you guys have probably had um that talk from um the plastic surgeon. Next slide, the plastic surgeon, next slide. So this is always a hard question. So whether you stage these or I'm getting a bit of an echo. Yes. One of the audience members, Albert, if you're able to mute your microphone, please, because I think Mr Patel's voice coming through your screen would delay that. So what is the Thank you. OK. So um whether to stage or to go ahead and do something like a fixing life is I think quite a difficult decision sometimes and I struggle with it. Um That's why you have an MDT and you have your colleagues and discuss these cases and that's why it's important that these um you have um senior decision makers in theater, it's not easy. So, um why not stage? Well, if you stage operations, you know, the patients tend to have longer length of stays, they have two or more operations, the functional recovery can be a bit longer because they're lying in bed waiting for their next surgeries. That the advantages of staging an operation. And I think it's probably the safer thing to do is it allows you to make a plan with colleagues, plastic surgeons, you know, other, other people in your team um for decision making and especially if there's significant injuries, you're not quite sure what to do. So I think it's safer for patients. Um There are service limitations so we are fix and flat. I don't know if any of you guys have been in theater when that's happening. It requires two scrub staff, a huge team and significant planning because it takes up 67 hours sometimes of a list to organize that. So it's not always possible to do acutely. Um So at the Royal London, we tend to just, you know, debride temporize and, and then, and then plan definitive soft tissue cover at a later stage unless there are type ones or twos and you can close primarily, then you can go ahead and fix it. But I'm talking about the type threes or three BS at least uh next slide. Uh So like this one open fracture temporized in the next fix. Um And then um at a later date, the flap has been put on. You can see so you can leave the patient next fix. There are, there are lots of different ex fix um configurations if you're gonna leave the patient in an X fix and the plastic surgeons are gonna do their soft tissue reconstruction. Um Sometimes it's hard to try and plan your X fix around where they're going to plumb in the, you know, the the flap. Um So sometimes you have to modify your X fix to allow them to do their anastomosis and microsurgery uh allow them to close the wounds and that type of thing. So it requires a bit of playing around sometimes. Um next slide. So there is an open fracture. Um There's a clinical photograph of the wound. So, distal tibia, next slide, uh this patient was treated. So instead of a next fix, we put this patient maybe because we were, you know, it was on one of our lists, we put this patient into a temporary frame. So you can see a ring at the top, a ring at the bottom of foot ring. Er and we've le left the whole medial side, open so that the plastic surgeons can do their, so there's a vac dressing there. Um But then the plastic surgeons can actually. So this is this patients stabilized, the plastic surgeons can then come back er, and do their free flap over that medial defect, soft tissue defect and we don't have to do anything. So that frames in place the flap can take and then we can modify the frame er, once the flap is healthy. Next slide. Um so that patient went on to have a flap and then the frame was er modified. Yeah, next slide. Um So just some important considerations when you're doing a nail. Um So if it's a type one, type two fracture, you've taken the patient to theater. Um you think that wound's closable, you've debrided plastic surgeons there, everyone's happy. Let's close up the wound and you want to fix a fracture. So if there's a tibial fracture in the diaphysis or metadiaphysis, then you can nail it at the role on them. We use um two types of nail. One is the um these are brand names. So this is Cynt E ETM Protect, which is an coated nail. And the other one we're trialing is the Bacter nail which works slightly differently. But the idea is that they aim to reduce your risk of infection. We're still looking at long term outcomes. We've already published a few years ago and 50 cases of using the ETM Protect. So that's just something to be aware of. Not everyone will have these nails, they're a lot more expensive than a regular nail. Um If your patient has been taken to theater and they've been put into an ex fix for whatever reason, so they've had the debridement, but you're worried about the soft tissues. You want the soft tissues to, to declare you feel it's not safe to now straight away, which is reasonable, you put them in an ex fix. Then if the patient goes back to theater timing is important. So obviously having an ex fix with half bins and the tibia, you've got open wounds. Um And there are numerous studies. I put one here from Mo Band Dari. So it's quite a dated study now, but they are saying that actually after 14 days in the next fix, your risk of infection climbs. So, um and actually, now, I think more recently, we think that's actually probably 10 days or less, which is your optimum time period. Um If you're going to convert a patient from an X fix to a nail, which is perfectly reasonable, make sure none of the X fix pin sites are infected because if they are, you can't put a nail done, then what you want to do is, is, is um take the X fix off and you can temporize um give them a Pinar Holiday treat with antibiotics or curette, at least curette. The pin sites out with Saline before putting your nail down next slide. Uh So this is a patient where we've done a fix and flap. Um This is uncommon, but um we've done a couple of cases where the patient is not fit for any type of soft tissue reconstruction. The fracture is not amenable to um shortening or the shortening won't help you close your soft tissues. So, what we do is we put into a frame and we intentionally deform the leg so that the soft tissues can close. You wait till your wounds have healed in 234 weeks, sometimes. And then if you've got a Hexapod frame on, you can gradually straighten out the leg. Um And, and make it look not wonky again. And that's a patient we did maybe about a year ago now. Ok, next side. So, um limb salvage. So we tend to get the mangled extremity here every now and again. Um They're quite hard to make that call. Um You need to have lots of people available. Um, as I said earlier, remember that amputation is an option, but you want to discuss with um your vascular colleagues, um your um trauma team, um, whoever else that needs to involve family members. Um Sometimes if the patient is an extremist and you need to cut off the leg for their own safety, then that's something you have to take in, in, in, um, you have to do for their best interest. Um There are studies looking at um, well, acute amputation in um mangled limbs compared to multiple limb salvage operations. Um having, you know, multiple operations to the leg debridements frames, you know, when they've got segmental bone loss, significant soft tissue damage, damage to nerves, um, it can actually have a significant psychological impact on the patient. So, if you've put them through one year, 1.5 years of limb salvage operations, they've already been deconditioned because they're in and out of hospital, they've lost their job, they've, you know, their marriage is falling apart. Um And then you do an amputation, your outcomes are um inferior to whether if you just did an amputation, you know, in the first few days of their, of their initial injury, um there are different um scores that you can use to help you make your decision. Um The ganga score is one. there are lots of different types. I don't use any scoring systems. Um I tend to just um have a, you know, you can't always discuss it with a patient because they're intubated and they're part of polytrauma, but it's the extent of soft tissue damage. So how much bone loss have they got? How much muscle damage have they got? Um Are their nerves working? Have they got an associated vascular injury? What was their morbidity? What was their mobility status, pre and post? Um Have they got any other conditions? Um and then tend to make that decision with other consultant colleagues overnight. Sometimes you ha you have to do a guillotine amputation and um then you do a formal amputation in a, in a, in a few days with plastic surgeons on the once the patient is uh physiologically able to tolerate it, any questions. No. So, complications are throat and fractures. Um Pretty much what you'd expect infection, non unions, posttraumatic arthritis, if it's intraarticular, uh there's a lot of um ah, focus nowadays on the psychosocial impact of open fractures. Again, as I was saying, patients lose their jobs has an impact on their social network and it's something that's often we're not very good at dealing with. There are certainly the role on we're trying to get, we do have a psychology team which helps look after polytrauma patients, but they're so inundated. The patient doesn't get reviewed. Um, so I think there's something that I think we can all do better. Why do these patients get infections? Well, some of them are gonna get infections anyway, by definition. Um, you can't prevent all of them getting infected even though we are better at dealing with these. Um, sometimes it's because of the contamination from the time of the open fracture. Sometimes it's because the soft tissues are so badly damaged. You've got, um, deficient, um, vascular supply to your soft tissue. So, um, they, they're more prone to getting infections. They've got wounds, they might not heal, they're polytrauma patients, they're malnourished cos they're, you know, they got other injuries or they're comorbid and these are all predisposed to having um complications after an open fracture. Next load. Um So we've talked a bit about outcomes. Um type ones tend to have fairly good outcomes, but the higher your severity, as you can imagine, the greater your risk of a poor prognosis. Type three CS have probably the worst um outcome on multiple parts of um your patients lives. Um Next slide. So I think we should try and get so to summarize, I think we should try and get these patients to the theater as quickly as possible. But with the right people and and on the right list. So it doesn't need to go overnight unless they are grossly contaminated. But often these injuries will present to major trauma centers rather than your um district general hospital. There are lots of different ways of uh fixing open fractures, internal, external with amputations if needed. Um Sometimes you have to think out of the box to try and um manage these types of injuries. Work good working relationships with your plastic surgeons is vital. Um We know some of these are going to get complications, but I think you have to be aware of this and mindful of them and actually follow these patients up longer term because it's not just the standard complications like infections and nonunion, but it's a psychosocial dysfunction that can have the biggest impact and, and the the type of injury and the patient will influence the outcome of your open injury. That's it. Awesome. Thank you very much.