OPEN FRACTURES

This extends Section 51.3 on caring for a severely injured patient and Section 54.1 on caring for wounds. Open fractures of particular bones such as the tibia (81.12), the radius and ulna (73.6), and the femur (78.6), are discussed elsewhere.

All open fractures need urgent treatment, so don’t leave them until the following day. Take the patient to the theatre and give him a general anaesthetic. Toilet his wound to remove all foreign material (54.1). Syringe out the whole of the inside of his wound with saline under pressure every 10 minutes all through the operation. Remove all dead tissue until you reach a healthy bleeding surface. Then LEAVE THE WOUND OPEN! But make sure you cover any arteries and nerves.

CAUTION! (1) Don’t close the wound by primary suture. (2) if the skin edges gape, don’t try to bring them even partly together with stitches. (3) When you finally close the wound some days later, don’t close it under tension.

If bone fragments have no attachments, remove them. But if they have any attached periosteum, leave them; they may live. if you remove them unnecessarily, you will leave a gap which can only be replaced by grafting.

Try to bring the fragments together end to end. If possible, keep them in place with traction rather than in a cast. If this is difficult, at least try to maintain the alignment of the limb by applying traction. if convenient, you can combine traction with plaster slabs or a plaster gutter.

If you are going to apply a cast, don’t do so until all risk of infection is past. if necessary, graft the patient’s skin wound, and apply a cast on the same day.

Raise the patient’s injured limb.

DIFFICULTIES WITH OPEN FRACTURES

If the SKIN IS BRUISED over the fracture, watch it careful y. It may break down so that a fracture which was closed initially becomes open.

If FRACTURE BLISTERS develop, they do not make the fracture into an open one. Prick them with a sterile needle, and cover them with vaseline gauze.

If a PIECE OF BONE IS MISSING, bringing the fragments into contact with one another is more important than maintaining length.