Stable
skeleton
The
principles of skeletal fixation discussed above also apply in open wounds.
In addition, optimum management of open fractures includes immediate intravenous
broad-spectrum antibiotics and definitive fracture cleansing within four
hours of injury. The extent of soft tissue injury in open phalangeal fractures
has profound influence on expected outcome. Duncan (Duncan) evaluated open
phalangeal fractures along the lines of the Gustilo classification as follows:
-
I
Tidy laceration less than 1 cm in length, no soiling, no soft tissue loss
or crush. Basically a puncture wound from within or without.
-
II
Tidy laceration less than 2 cm in length, from outside in, no soiling,
no soft tissue crush or loss. Partial muscle laceration.
-
IIIA
Laceration greater than 2 cm, penetrating or puncturing projectile wound.
Any frankly soiled wound.
-
IIIB
Same as III A + any periosteal elevation or stripping - either by injury
or surgeon.
-
IIIC
Same as III B + neurovascular injury.
Using
the criteria of total active motion for evaluation of outcome, Duncan found
that three fourths of patients with a grade I injury and half of patients
with a grade II injury had a good or excellent result. In contrast, almost
all patients with a grade IIIB or IIIC injury had a poor result with less
than 50 percent normal range of motion. For phalangeal fractures, periosteal
stripping, either by injury or by the treating surgeon contribute strongly
to a poor result.