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close this bookWar Wounds with Fractures: A Guide to Surgical Management (ICRC, 1996, 64 p.)
close this folderChapter 1 THE FRACTURE AS PART OF THE WOUND
close this folderWHAT TO DO AT THE SECOND OPERATION (4th to 6th day)
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View the documentAssessing the bone defect

Assessing the bone defect

When inspecting the wound, feel and observe the periosteal tube: some continuity should remain in all but the worst injuries. Bone continuity and an intact periosteum permit fracture healing.

The degree of bone damage may be classified according to the Red Cross Wound Classification; this makes a distinction between two fragments and many fragments as well as indicating the extent of soft-tissue damage. However, it does not apply to the bone defect left after the first operation. The following is a guide to assessing the bone defect.

This tibia is fractured but the bone has no defect. Following excision of the soft-tissue wound accompanying such a fracture, healing will progress smoothly.

A. Small and circumferentially incomplete bone defects

These defects heal well if the wound excision is correctly carried out.

A type A defect in a child's tibia - there is overall continuity of the bone despite the incomplete defect.

B. Small and circumferentially complete bone defect (<3 cm)

These defects may be retained or permitted to shorten. In the lower limb any slight shortening is usually adapted to by the patient.

This bullet wound includes circumferential bone loss but the defect is small. All the periosteum is usually present in such wounds and must be retained during surgery.

C. Large and circumferentially complete bone defect (>3 cm)

With such defects there may be some callus formation from the remaining periosteum. If the progress of callus formation is slow on the radiograph, it may be corrected by a bone graft later.

There is gross comminution and bone loss; this will lead to a type C defect. Many of the fragments will be loose but some will still have good periosteal attachments and should be retained.

D. Large defect associated with circumferential toss of bone and periosteum

The osteogenic potential in such gaps is very small. Even with a subsequent bone graft, healing may take months or years. Management decisions will depend on the site of the fracture and other injuries. There is no easy answer to such problems.

A severe tibial wound with this kind of defect might raise the question of below-knee amputation, depending on locally available prosthetic facilities. However, in severe femoral fractures the greater degree of disability following an above-knee amputation means that a more prolonged and challenging plan of treatment may be justified in order to preserve the limb.

The choice of holding is then made according to which bone is fractured, the wound itself, its position and the bone defect.