•

UNIVERSIDAD AUTÓNOMA DE CHIAPAS

• FACULTAD DE MEDICINA HUMANA CAMPUS II
“DR. MANUEL VELASCO SUÁREZ”

CLINICAL CASE
Dr. Shadi Soltani-Darani Cuesy

Grade: 7 Group: D
CLINICAL CASE

KEVIN VELAZQUEZ MARTINEZ

YEUDIEL A. URBINA MORALES
MARIO A. RUIZ MAYORGA
DANIEL A. ZAVALETA RUIZ
HERMAN J. TOLEDO SANTOS
 13.APRIL.18

IDENTIFICATION FILE
• Name: Roselio Hernández Gómez.
• Date of birth: 11/02/88
• Age: 29
• Gender: Male
• Religion: Catholic
• Studies: Elementary school
• Ocupation: builder
• Addres: Ocosingo, Chiapas
• Civil status: free union
• Language: Spanish
• Grup 0 Rh+
ANTECEDENTS HEREDO-FAMILIARES

• Asked and denied

NOT PATHOLOGICAL PERSONAL HISTORY .

• House of durable materials with all the services of urbanization.

• Diet varied in food beef 2/7, chicken meat 4/7, pork 1/7, fruits and
vegetables 4/7 and 4 liters of water per day.
• Does not know if the inmunizations are complete
• Occasional drinker, denies smoking and use of other drugs.
PATHOLOGICAL PERSONAL HISTORY

• Presented typical diseases of childhood without complications.

• Denies sexually transmitted infections
• Denies transfutsions.
• Denies hospitalizations.
• Denies previous fractures.
• Denies poisoning
• Current illnesses: denies diabetes and hypertension, as well as other conditions (bone,
heart, mental, respiratory, metabolic, etc).
CURRENT CONDITION

• He began his illness on 12.04.18 at 22:00 hours after being hit by car
directly in the left knee, while he was driving his motorcycle. Starting with
intense pain, bone exposure, deformity and functional disability, is helped by
paramedics where he is taken to a health center where he is refered to the
hospital in San Cristobal where he is not accepted and they send him to the
Comitan hospital where he is not received and is transferred to the Dr.
Gilberto Gómez Maza hospital where it is accepted at 9:00 pm on the next
day (13.04.18)
 PHYSICAL EXAMINATION
• Patient conscious and oriented, with adequate coloring of skin and tissues,
normocephalus skull, healthy neurological state, isochoric and normoreflexic pupils,
hydrated oral mucosa, cylindrical neck without adenopathies, presence of a rigid
cervical collar, cardiopulmonary state without compromise, globose abdomen at the
expense of adipose panniculus, soft, depressable, peristalsis present, without pain on
palpation, without data of peritoneal irritation, symmetrical thoracic extremities, no
apparent lesions, present movement arcs, no neurosensory compromise, pulses present.
• LEFT PELVIC EXTREMITY with presence of wound of approximately 5 cm in length, with
bone exposure at the level of the distal third of the thigh, non-pulsatile bleeding,
contaminated, non-assessable movement arcs, without neurosensory compromise,
present pulses, capillary refill less than 2 seconds , without data of distal edema.
DIAGNOSIS

• Fracture of distal femur AO 33 A 3.2 exposed Grade IIIA of Gustillo and

Anderson contaminated by time exposure longer than 24 hrs
PLAN
• 13/04/18 22 hrs He is admitted to the operating room where debridement
and administration of antibiotics are performed.
• (14/04/18) (12/16/18) Surgical debridement is performed, not having
adequate evolution.
• (17/04/18) A globular package is transfused.
• Debridement and placement of external fixators to the femur and left tibia
(22/04/18)
• (25/04/18) (29/04/18) Surgical debridement is performed, not having
adequate evolution. And relocation of external fasteners to the femur and left
tibia.
 (05/05/18)
PHISYCAL EXAMINATION
Male with left pelvic extremity with oblique wound
presence with respect to the perpendicular thigh line of
approximately 15 cm length in the distal third, closed, with • VITAL SIGNS:
the presence of external fixators to the femur and left tibia
with the presence of exudate in the second Schanz with
• AT: 115/70 mmHg
serohematic exudate in moderate amount, not fetid without • HR: 69xmin
purulent discharge, without erythema, with pain to • RR: 21xmin
palpation and volume increase in the left thigh, without
• Temp.: 36.5 ªC
neurosensory compromise, present pulses, flexion ankle
extension without alterations, capillary filling less than 2
seconds without data of distal edema.
PLAN (05/05/18)

• Surgical debridement plus left femur diaphisectomy and relocation

of external fixators.
• Prognosis: High risk of infection, osteonecrosis.
EVOLUTION NOTE 06/05/18

• A 29-year-old male patient who underwent a fenestration / diaphysectomy of the

distal third of the left femur to check vitality (Paprika sign)
• Patient awakes at 6:00 p.m. is oriented in all its senses, with pallor of teguments,
normoencephalon, well-hydrated mucous membranes, cylindrical neck.
• Pulmonary fields without aggregate noise and rhythmic heart sounds, soft and
depreciable abdomen, with no evidence of peritoneal irritation.
• Symmetrical thoracic limbs, right extremity presents a venous seal, without apparent
commitment.
• Left extremity with external fixator with 4 nails, 2 in thigh and 2 in leg. Immediate
capillary filling.
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

OPEN FRACTURE
• The site of fracture and/or hematoma communicate with the
outside due to soft tissue injury.
• (AO-definition: “an open fracture is a soft-tissue injury which also
involves the bone”)
• Fracture communicates through a traumatic wound to
surrounding environment.
• Resulting in contamination & soft tissue disruption.
• Even a small wound communicating with fracture ≡ open
fracture (compound fracture).

• Treatment of soft tissue trauma with contamination Î Primarily

important.
• Treatment of skeletal injury Î Secondary .
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Open fracture
• In either situation, the damage to the soft tissues around the
bone—including muscles, tendons, nerves, veins, and arteries—
can be extensive. For this reason, any acute fracture with an
open wound in the area is considered to be an open fracture.
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Etiology
• Generally a result of high energy mechanisms which cause greater soft
tissue disruption that leaves the wound more susceptible to infection by
contaminating bacteria.
• The energy is stored in soft and hard tissues until the strength of
respective material is exceeded.
• Comminuted pieces may acquire high velocity after which they propel
into the surrounding soft tissues and cause additional damage.
• More severe injury, limb absorbs energy releases in explosion tears
the skin momentary vacuum sucks foreign material into the wound
depth.
• Soft tissue damage enormous muscle swelling compartment
syndrome (more in open injuries) of the intact compartments
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Contamination.

• To some extent, the setting in which an open fracture occurs

will affect the degree of contamination. Objects such as dirt,
broken glass, grass, mud, and even the patient's own clothing
can be driven into an open wound. Knowing the setting where
the injury occurred can help doctors determine the best
course of treatment.
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Infection
• Open fractures pose an immediate risk of infection.
• In general, the greater the damage is to bone and soft tissues, the
greater the risk of infection.
• A bone infection can be difficult to treat. The patient may require long-
term antibiotics and multiple surgical procedures. In extreme cases
where the infection cannot be cured and the patient's life is
threatened, amputation may even be necessary. For this reason,
preventing infection is the focus of early treatment.
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Epidemiology
A predominance was observed in
males with 80% incidence, which is
explained in our environment because
men make more activities outside the
home, including work activities, which
is more exposed to the mechanisms of
injury .

It’s appreciate the incidence of

exposed tibial fractures increases in the
young population, especially within the
male population, particularly in the
group of 20 to 29 years with a male /
female of 8.62: 1, and in the group of
30 to 39 years with a ratio of 6.6: 1.
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

• The risk of a fracture being open is related

… to the amount of soft-tissue coverage in
that region of the body and to the amount
of energy imparted to that region.

• For example, the tibia has a long medial

aspect that is subcutaneous, and
therefore, it is “easier” for trauma to the
lower leg to expose the bone and fracture
site.

• Conversely, the femur is surrounded by

thick muscle layers circumferentially and,
therefore, is less likely to be exposed after
a similar amount of force to the thigh.
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Sign and symptoms

• Pain (up to neurogenic shock)
• Hemorrhage (up to hypovolemic shock)
• Functional impotence
• Deformity
• Decreased mobility
• Soft tissue injury (flaps, tegumentary loss, etc.)
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

It’s very important to note that many times the patient with
an exposed fracture is a patient in severe general condition

Internal hemorrhages Traumatic brain injury or That is why the patient

from the same trauma, Acute Renal Failure with an exposed
or with associated Caused by fracture should be
injuries in other systems, Hypovolemia considered a patient of
secondary to the Secondary to presumed seriousness
original injury. Hemorrhage and reserved prognosis.
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Diagnosis
• The X-ray of the affected region is very useful to be able to see the
extent of the damage, in addition to classifying the degree of the
fracture.

• Classification of Gustilo - Andersson

 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Gustilo-Anderson classification
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Gustilo-Anderson classification
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Gustilo-Anderson classification
FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Objectives of open fracture Mx.

• PREVENT INFECTION

• PROMOTE FRACTURE HEALING

• RESTORE FUCTION
 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Principles of treatment ofopen fractures

Shock treatment and radiological exams

General anesthesia

Washing and brushing the injury

Skin resection qnd debridement

Resect any devitalized tissue

Consider the conditions to reduce the fracture

Covering and closing the wound

 FRACTURAS EXPUESTAS, Lucila Di Nunzio, Facultad de Medicina, USAL

Prognosis

• Clinical results in the management of open fractures are similar

worldwide in regards to days of inthahospital stay, number of surgical
procedures needed to solve the injury, time of consolidation and
incidence of complicatios

• Open fractures take from several weeks to several months to heal,

depending on the extent of the injury