Revista de Actualización Clínica Volumen 34, 2013
Exposed fractures
Ortiz Vasquez Solange Mollericona
1 of limb", are lesions which occur in bone
Laura Yarmila Lisseth2 Chui Rivas
Daniela Miriam Regina3
1
Univ. Fourth year Faculty of dentistry
UMSA 2 Univ. Third year Faculty of
dentistry UMSA 3 Univ. Third year
Faculty of dentistry UMSA
OVERVIEW
It is known as the fracture exposed to
the lesion of bone, that its gravity breaks
injuring the soft tissue, opening up to
the outside with the consequent
pollution of an initially aseptic area.
This alteration may present different
complications, agree a: the degree of
contamination that has had the injury,
the time that has elapsed since its
establishment, the place where he has
been caused and commitment tisularque
possess.
The origin of this type of fracture is
multifactorial in nature, being the most
common, traffic accidents and accidents
at work, but also it should be noted that
they may result from the evolution of
certain diseases as in the case of
the osteomyelitis.
Because of the danger that they
represent, the exposed fractures should
be treated with the urgency required to
get in this way possible to more
favorable prognosis, since otherwise
they can have severe consequences on
the patient, ranging from one infection
in the area of the injury, amputation of
the affected limb, septicemia putting at
risk the life of the patient.Key
words Exposed fracture. Woven
bone. Soft fabric.
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INTRODUCTION
Fractures exposed, also called as "injury
compromising soft tissue, by section or
navigate them, assaulted bone fractured
ends, which are exposed with the
external environment, becoming
contaminated with different micro-
organisms, depending on the place
where contamination, this way, injuries
will get worse the greater the
contamination of the environment with
which it is put contact.
For this reason, are considered medical
emergencies in the area of trauma and
should be answered in the shortest time
possible, since if it does not, the tissue
is contaminated in such a degree that it
may lead to a bone infection and if any
injury vascu LAR, the resultant ischemia
would trigger in the production of tissue
necrosis, gangrene and subsequent
amputation of the same.
Anyway, the exposure to a contaminated
environment would cause the
Hematogenous spread of
microorganisms causing septicemia
which could result in the death of the
patient, without forgetting that the
fracture itself, can release bone marrow-
derived lipid fragments, which enter the
body would cause a fat embolism with
fatal results for the patient. 1-4, 8, 9
ETIOLOGY
There are different causes which
originate the exposed fractures, among
these are those caused by violent
trauma, where are commonly taken to
traffic accidents, work-related accidents
and injuries by firearms. All of them,
come to compromise in any way the
extremity function and trigger the
aforementioned complications. 1.3
However, also can be caused as a result
of different pathologies, as happens in
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the case of metastatic carcinoma or
senile osteoporosis; However, there are
cases in which arises due to a continuous
wear in a given area, often seen in
dancers and athletes, although at one
lower percentage compared to injuries
caused by trauma caused violently .
The most affected group is male and is
presented predominantly in adolescents
and young adults. 1, 6-7
CLASSIFICATION OF
EXPOSED FRACTURES
The classification of these injuries varies
according to:
1. the elapsed time and the place of
origin
a.. method splits, recent or
contaminated: this type of fractures, are
those that have been exposed to the
external environment for a period of
time less than six hours, with a
maximum of twelve hours provided that
the damage is minimal.
They are small traumatic injuries in the
soft tissues as a result of a violent clash
of bone to these, which will produce a
cut in the skin which will originate from
the inside out favoring the degree of
contamination and gravity make minor.
b. method, exposed fractures late or
infected: it is called them, when there is
a high degree of destruction of soft
tissues, whether they are product of an
accident on a plane moving or
fixed. Usually the places where happen
this kind of trauma, are very
contaminated, why it should be
considered that the fracture is already
infected and exposure should not extend
beyond 6 hours then as you increase the
time foci of inf address will also
increase. 2
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2. the degree of commitment of the soft
parts (Gustilo and Anderson
classification)
a) grade I: wound is produced at
cutaneous level, is clean and without
separation of tissues, it is less than a
centimeter, presents a minimal bruising
and damage to the soft tissues,
therefore shows no bone or muscle loss,
trauma is oblique or transverse short
and low-energy is produced in places
with a minimum pollution. 1, 5,8
b) grade II: wound is extensive, since
the size of the contusion is greater than
one centimeter and are considered
serious because the bone exposure is
higher. It is not evidence of bone or
muscle loss, physical damage is
moderate, therefore the trauma is of
medium power, being its mechanism
from the outside inward, which will
produce a fracture transverse, oblique
and long. This type of fractures are also
produced in places where there is a
minimal pollution. 1,5,8
(c) grade III: the wound is broad in
extent and depth, so there is great
damage to bone and vascular levels. The
type of traumatic shock will be greater
and will commit to all the tissues that
surround the site of bruising. It is more
prone to the production of any type of
infection, since it shows commitment to
adjacent tissues. It can also be of type:
a grade III - A, where the muscle and
bone loss is deep and there is also nerve
damage, although it preserves skin;
b. grade III - B, where there are
fractures with a severe compromise of
the soft parts exposed to the bone
tissue, allowing a massive pollution;
c. grade III - C, where occurs the
attrition of the Member concerned and
there is a lesion neurovascular, as well
as destruction of the affected structures
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and also bone loss. The trauma is high
energy and are the most frequent;
d. grade III - D, associated with the
traumatic loss of the affected
extremity. 1,5,8
CLINICAL PICTURE
The exposed fractures have as main
characteristic, the exposure of a deep
and irregular surface presenting
anfractuosas areas, which accommodate
the formed clot, fabrics torn, foreign
bodies and remains of the clothing of the
patient . Is for this reason that the
contaminant material will penetrate
easily in the place in which the exposed
wound occurred and as a result, the
patient will develop subsequent
infectious picture, characterized by fever
that delimits the infection local or
systemic resulting.
Of course, the breaking of the bone is
characterized by presence of pain and
functional impotence, as well as tissue
deformity, same that will be dependent
on the severity of the injury and the
tolerance of the tissues to internal
aggression produced by the broken
bone. In some cases, the exposure is
very small and apparently systemic and
local commitment does not entail risk. 3
Patients usually present:
( 1) General, symptoms that
are presented after the trauma, and it
starts with primary, shock where the
patient presents a State of partial
unconsciousness, so it cannot be
movements, in addition, not will react to
stimuli, demonstrating, tachycardia and
hypotension both temporarily. A few
hours later, is a secondary shock that
will cause the patient to present
polydipsia, nausea and pallor.
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In more serious cases where there is a
severe hemorrhage the clinical picture
could worsen reaching a hypovolemic,
shock with tachycardia and
hyperventilation so what will finally
trigger a State of coma and finally
death. 2"3 "
2) local, symptoms should be initially
discussed the size and type of wound,
the patient, if this were very small and
with a minimum tear then it is a wound
punctiform. When the lesion present a
clear separation at their edges, as a
result of one greater tissue
deterioration, it will be a torn wound. If
the damage is really severe and the
wound as well as exhibit anfractuosos
places have flaps because of the
loosening of the tissues it could lose
some areas of the injured
member. 2"3 therefore the extent and
severity of the pain will relate with the
descriptions prior to being able to reach
a type neurogenic shock by the severity
of the painful picture."
Epidemiologically it has been confirmed
that the bones involved in this type of
fracture, are those who are away from
the tibia in the lower limb and away from
the forearm in what refers to the upper
limb, since in these regions is
presented scarce tissue soft, therefore
more frequent fractures are in the legs
and hands despite the fact that they
have a high degree of irrigation.
The prognosis of injuries, will depend on
aggression to tissues, fractures with
large losses of tissue environment being
risky. 1
DIAGNOSTICS
While the diagnosis is obvious due to
exposure of bone structures, it is
necessary to make a good anamnesis
the patient, in order to specify
e.g.: how was the wound, to analyze
the magnitude of it. When the injury
occurred, for thus, calculating the time
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that was exposed to the environment
outside and finally, where it was
exposed, to be able to specify the type
of soil that is caused, if it is Earth,
asphalt or other and in this way have at
least an idea of the degree of
contamination.
Si el paciente está siendo tratado con
algún tipo de fármaco, además de
eliminar cualquier sospecha de que el
accidente haya podido producir otro tipo
de lesiones y si es o no pertinente
solicitar un estudio radiográfico del
hueso fracturado, pudiendose llegar en
algunos casos a solicitarse otros
exámenes complementarios como un
hemograma, tomografía y cultivo y
antibiograma. Sin embargo, en caso de
no contar con los medios
correspondientes para la realización de
todos estos estudios el paciente debe ser
atendido de igual forma y con la mayor
urgencia posible.13-
TRATAMIENTO
El tratamiento no necesariamente debe
iniciarse en un centro de salud, tiene que
ser desarrollado de manera inmediata en
el sitio mismo del accidente o en la
ambulancia que trasladará al herido.
Se debe proceder en primera instancia a
contener la hemorragia y cubrir las
heridas con compresas o vendas
estériles, en caso de ser necesario
colocar férulas para evitar cualquier
movimiento brusco del área afectada.1,3
Una vez confirmado el diagnóstico y
conocido el grado de la fractura
expuesta la intervención clínica debe ser
inmediata por considerarse una
emergencia.
El tratamiento tiene como objetivos
principales: cubrir el área expuesta con
los tejidos blandos adyacentes, alinear el
eje del miembro afectado inmovilizando
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la región, evitar y prevenir una infección
aplicando una terapia antibiótica
adecuada.5
La antibioticoterapia para las fracturas
de grado I se realizará con Cefazolina,
iniciando con una dosis de ataque de
2gr. por vía endovenosa, posteriormente
1 gr cada 6 horas por el lapso de 48 a 72
horas.
If the fracture is grade II and III it should
be administered as initial dose Cefazolin
2 gr. plus an aminoglycoside in a dose of
3 to 5 mg/Kg intravenously.
In cases where fractures have been
produced in a contaminated
environment, you will have to administer
penicillin g. sodium 4,000,000 IU every
4 hours.
If the exposed fracture is in the cranial
region and there is evidence of brain
mass exposure or penetrating trauma
administered amoxicillin more
potassium clavulanate, cephalosporins
second generation and metronidazole in
case that the patient is allergic to
the Penicillins. 1, 5-8
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