1 Introduction

Open fractures imply a communication between the external environment and the fracture. Four components characterize the injury:

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  Fracture

  
  
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  Soft-tissue damage

  
  
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  Neurovascular compromise

  
  
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  Contamination

The extent of each component must be assessed individually to achieve a comprehensive understanding of the injury, upon which a treatment plan can be based.

Improved understanding of open fracture pathology, techniques of fracture fixation, soft-tissue care, and antimicrobial treatment has resulted in a significant reduction of morbidity and mortality associated with open fractures. Yet, the most severe open fracture types, even with experienced trauma surgeons, are still fraught with complications and poor outcome.

Complex injuries, regardless of the location and extent, are managed by early aggressive debridement. Early definitive reconstruction can be initiated once the deliberation over whether to salvage or amputate has been resolved. This requires experience and special skills, cooperation of plastic, vascular, and orthopedic surgeons, support staff and services, and specialized equipment in modern trauma centers [1].

2 Historical perspective

The concept of open fracture care has evolved from the experience of war surgeons, dating back many centuries. Only a century ago, the high mortality rate of patients with open fractures in major long bones frequently led to early amputation to try and prevent death. At the onset of World War I, the mortality rate from open femoral fractures was still more than 70%. The nature of the wounds sustained on the battlefield prompted Trueta to recommend “closed treatment of war fractures” in 1939. This included open wound treatment and subsequent enclosure of the extremity in a cast. Trueta was revolutionary in his approach to handling soft-tissue injuries associated with open fractures. Contrary to the general opinion at the time, he believed that the greatest danger of infection lay in the muscle and not in the bone. He recommended wound debridement with excision of necrotic tissue. His method of leaving wounds open persisted as further experience was accumulated during World War II. In 1943, the use of penicillin on the battlefield quickly reduced the rate of wound sepsis. However, overreliance on the efficiency of antibiotics resulted in less emphasis on debridement. Prompted by the complications of inadequately debrided wounds, the concept of delayed closure was adopted. Hampton recommended closure between the fourth and seventh day after injury depending upon the wound being clinically clean. Larger defects continued to be left open to heal by second intention.

Major advances over the last century have moved the focus of management of such injuries beyond the preservation of life and limb to the restoration of function and prevention of complications. Nevertheless, there is no place for complacency. In the most severe open tibial fractures associated with vascular injury, the documented amputation rates still exceed 50% [2].

3 Etiology and mechanism of injury

Open fractures tend to be caused by more severe trauma than closed fractures. However, fractures due to low-energy indirect torsional trauma can penetrate the skin from within, particularly where the bone lies close to the skin and is not protected by a muscular envelope. Severe open fractures usually occur as a result of direct high-energy trauma, either in road traffic collisions or falls from height. The degree of trauma induced is related to the energy imparted by the sudden deceleration at the time of impact. A prime example is the open fracture of the lower extremity in a motorcyclist ( Fig 4.2-1 ). High-energy incidents frequently cause multiple, severe injuries to other parts of the body (head, chest, and abdomen) and the management of these may take precedence over the open fracture(s) (see chapter 4.1).

Despite progress in the management of fractures and in surgical reconstruction of soft-tissue injuries, patients with severe traumatic soft-tissue defects still represent a major surgical challenge, requiring an interdisciplinary approach. Due to the etiology of trauma, the soft-tissue damage is often more extensive than apparent at first. This zone of injury must be defined and inexperienced surgeons tend to underestimate the extent of soft-tissue injury. This may result in the patient entering the wrong therapeutic pathway. The multidisciplinary treatment strategy including timing for complex injuries of the extremities is guided by the injury pattern, ischemic time, and the general condition of the patient.

Crush injury occurs when a force is applied to an immobilized portion of the body. Localized ischemia may occur as vessels are occluded by the external pressure. Crush injury of muscles is often associated with systemic effects of the ischemia and may result in severe electrolyte disturbance and myoglobinuria. The systemic effects are directly related to the severity and duration of tissue damage. They are manifested as an ischemic phase followed by reperfusion of the damaged area once the pressure is relieved (ischemia-reperfusion injury). Products of cellular death are then circulated, causing direct toxicity to organs, such as the brain, lungs, or kidneys.

Penetrating injuries comprise a wide spectrum of soft-tissue injuries, from low-energy stab wounds to the systemic devastation of war-related blast injuries. The effectiveness of any specific weapon relies on its capacity to dissipate kinetic energy to the recipient tissue ( Fig 4.2-2 ). The severity of injury is closely related to the affected structures and their location, the degree of energy dissipation, the behavior of the penetrating object within the tissue, and the degree and type of contamination. These determine the amount of damage, fatality, and long-term disability. It is imperative to understand the mechanisms leading to these injuries and the associated pathology.

Explosive blasts result in high morbidity and mortality. In recent conflicts, injuries to the musculoskeletal system accounted for 54–70% of injuries, and up to 78% of these were related to explosions. Injury to the human body occurs when the rapid expansion of gas surrounding the point of explosion propagates a supersonic shock wave in all directions from the blast. The spectrum of injuries related to blasts is categorized relative to the mechanism ( Fig 4.2-3 ).

Shear forces cause disruption of the skin in most areas of the body. These injuries are due to high energy and are frequently associated with injuries to the deeper tissues, including fractures, disruption of muscle attachments, tearing of nerves, and avulsion of vessels. This multiplanar degloving must be recognized and treated by systematic evaluation and debridement of each tissue layer ( Fig 4.2-4 ).

4 Epidemiology

The frequency of open fractures observed in any area varies according to geographical and socioeconomic factors, population size, and the system of trauma care. The incidence of open fractures in Edinburgh, Scotland has been documented in detail [3]. This unit treats all fractures in a mixed urban and rural population and the frequency of open fractures was 21 per 100,000 population per year ( Table 4.2-1 ). The highest rate of diaphyseal open fractures was seen in the tibia (22%), followed by the femur (12%), radius and ulna (9%), and humerus (6%). In major long bones, open fractures were far more common in the diaphysis than the metaphysis (15% versus 1%).

In a later 15-year study, the same group reviewed 2,386 open fractures [4]. The majority of open fractures were the result of low-energy injuries, with only 22% caused by road traffic accidents or falls from height. High-energy open fractures were more common in younger men and low-energy open fractures were more common in older women. These data are likely to be similar in other developed countries, but will be different in emerging countries that have different demographics and social conditions.

The burden of open fractures in military conflicts is much higher. In a recent epidemiological study [5], a total of 1,281 soldiers sustained 3,575 extremity combat wounds. Fifty-three percent of these were penetrating soft-tissue wounds and 26% were fractures. The 915 fractures were evenly distributed between the upper (461 [50%]) and lower extremities (454 [50%]), and 82% were open fractures. The most common fracture in the upper extremity was in the hand (36%) and in the lower extremity, it was the tibia and fibula (48%). Explosive munitions accounted for 75% of the mechanisms of injury.

5 Microbiology

The immediate effect of a high-velocity injury producing an open fracture is contamination of the soft and hard tissues. In addition, there may be hypovolemic shock, further reducing the blood supply to bone and the muscle. The result is poor tissue oxygenation and devitalization of soft tissue and bone. This produces a perfect medium for bacterial multiplication and infection.

In civilian practice, most acute infections following open fractures are caused by pathogens acquired in the hospital (nosocomial infection). Gustilo and Anderson [6] reported in 1976 that most of infections in their prospective study of 326 open fractures developed secondarily. When left open for an extended period (≥ 2 weeks), wounds were prone to nosocomial contaminants, such as Pseudomonas species and other gram-negative bacteria. Patzakis et al [7] found that only 18% of infections were caused by the same organism isolated in the initial perioperative cultures. This contrasts with a 73% correlation in an earlier study [7]. Therefore, there is no benefit in obtaining preoperative or intraoperative cultures of open tibial fracture wounds. Additionally, postdebridement wound cultures fail to isolate the infecting organism in 58% of cases [8]. Thus, early postfracture wound cultures are also not recommended. In general, multiple wound culture specimens (five or more) should be obtained from deep tissue using sterile techniques when clinical signs of infection are present. This phenomenon of hospital-acquired bacteria and their prominent role in the pathogenesis of infection emphasizes the importance of infection control measures and early wound coverage (5–7 days).

Many factors contribute to the final outcome of an open fracture. Diabetes [9], HIV status [10], and smoking [11] are associated with delayed union and higher rates and increased severity of infections. It is important to consider these factors in the treatment plan and when counseling patients on their prognosis. An appropriate medical or specialist consultation to optimize glycemic control or to initiate HIV treatment, as well as counseling on smoking cessation, may improve the outcome.

6 Classification

An open fracture classification should be comprehensive and based on the mechanism of injury, severity of soft-tissue damage, fracture pattern, and the degree of contamination.

The classification of open fractures as described by Gustilo and Anderson [6], and later modified by Gustilo et al [12], is the most frequently quoted system in contemporary literature and is used widely. Open fractures are divided into three types in ascending order of severity, based on skin and soft-tissue damage ( Table 4.2-2 ). A later modification subdivided type III injuries based on the degree of contamination, the extent of periosteal stripping, and the presence of arterial injury ( Fig 4.2-5 , Table 4.2-3 ).

This classification is relatively simple and remains a useful tool, although not accurate. It has been validated with regard to time to union, incidence of nonunion, and the need for bone grafting. Its major disadvantage derives from the subjective nature of injury description resulting in high interobserver variability [13].

Bowen and Widmaier [14] studied 174 patients with open fractures of the long bones and found the Gustilo and Anderson classification, age, and the number of comorbidities to be significant predictors of infection. The patients were divided into three classes on the basis of the presence or absence of 14 medical and immunocompromising factors, including an age of 80 years or older, current smoking, diabetes, malignant disease, pulmonary insufficiency, and systemic immunodeficiency. Infection rates were found to be 4% for patients in class A (no compromising factors), 15% for patients in class B (one or two compromising factors), and 31% for patients in class C (three or more compromising factors).

Other classification systems have been proposed. The AO/OTA Fracture and Dislocation Classification is detailed and incorporates the Müller AO/OTA Classification of fractures in long bones. It provides grading systems for injuries of the skin, muscles and tendons, and neurovascular damage, each of which is divided into five degrees of severity (see chapter 1.4). It is designed to provide a comprehensive definition of an injury and allow accurate comparison. When used in a large database this classification permits more accurate comparison of injury types, making it a useful research tool. However, its complexity may make it impractical for everyday clinical practice.

The classification of open fractures is most reliably done in the operating room at the completion of primary wound care and debridement.

7 Goals of treatment

The treatment of high-energy injuries aims at preserving life, limb, and function, in that order of priority. The intermediate objectives are:

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  Prevention of infection

  
  
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  Fracture stabilization

  
  
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  Soft-tissue coverage

As these goals are interdependent, a coordinated treatment plan with early surgical intervention is required. The restoration of normal function is extremely difficult to achieve in the presence of compartment syndrome, ischemia, or nerve and muscle injury. The coordination of the reconstructive procedures with the rehabilitation of the injured limb is mandatory to obtain maximal possible function.

The basic management principles established in the second half of the 20th century remain essentially unchanged:

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  Initial emergency treatment: temporary splinting of the fracture, wound dressing, antibiotic therapy, tetanus immunization

  
  
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  Primary surgical treatment: debridement, irrigation, and fracture stabilization

  
  
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  Delayed surgical treatment: wound closure/cover within an appropriate time scale

  
  
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  Rehabilitation and follow-up

Other adjuvant treatment modalities may be applied where appropriate, for example, local administration of antibiotics, vacuum-assisted therapy or flap coverage. Areas of controversy include the timing of definitive surgery, the type and duration of antibiotic administration, and indications for the use of newer adjuvant treatments.

8 Open fracture care

Achievement of these goals requires a disciplined, logical, and sequential management approach. This commences with good prehospital care and is followed by careful assessment and experienced clinical judgment in the emergency department and operating room. Primary surgical intervention focuses on the prevention of infection by staged wound debridement and fracture stabilization. Secondary surgical procedures address the issues of early skin and soft-tissue reconstruction together with bone reconstruction. Rehabilitation with early movement and mobilization is initiated as soon as possible as an integral part of this staged management protocol ( Table 4.2-4 ).

For the treatment of complex open fractures, a multidisciplinary team, including orthopedic and plastic surgeons, is required [15]. Hospitals that lack a team with the requisite expertise to treat complex open fractures should have arrangements for immediate referral to the nearest specialist center. The primary surgical treatment (wound debridement and skeletal stabilization) of these complex injuries takes place at the specialist center whenever possible. In some advanced countries, specialist centers for the management of severe open fractures are organized on a regional basis as part of a regional trauma system. Usually these centers also provide the regional service for major trauma.

The characteristics of an open injury that should prompt referral to a specialist center are based on:

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  Fracture patterns:

  
  
  
  
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    – Transverse or short oblique tibial fracture with fibular fracture at a similar level

    
    
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    – Multifragmentary tibial fractures with fibular fracture(s) at a similar level

    
    
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    – Segmental tibial fractures

    
    
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    – Fractures with bone loss

  
  
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  Soft-tissue injury patterns:

  
  
  
  
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    – Skin loss of such an extent that a direct tension-free closure is not possible

    
    
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    – Degloving

    
    
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    – Injury to the muscles that requires excision of devitalized muscle

    
    
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    – Injury to one or more of the major arteries of the leg

The specialist center needs to:

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  Provide intensive care and other trauma facilities for the multiple-injured patient

  
  
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  Include orthopedic trauma surgery with special expertise in complex fractures and bone reconstruction

  
  
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  Include plastic and microvascular surgery with expertise in vascular reconstruction

  
  
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  Provide facilities for simultaneous debridement by orthopedic and plastic surgical teams

  
  
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  Ensure orthopedic and plastic surgical planning of a management strategy to ensure efficient and optimal patient care

  
  
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  Provide dedicated operating room sessions for combined orthoplastic management

  
  
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  Include microbiology and infectious disease consultants with expertise in musculoskeletal infection

  
  
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  Include facilities for emergency musculoskeletal imaging with angiography and interventional radiology

  
  
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  Provide a service for, or have access to, artificial limb fitting and rehabilitation for amputees

  
  
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  Have access to physical and psychosocial rehabilitation services

  
  
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  Include an audit of outcome as part of the care pathway

  
  
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  Aim to reach a throughput of 30 such cases per year to maintain appropriate skill and experience levels

  
  
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  Provide multidisciplinary ward rounds and combined orthoplastic clinics

8.1 Initial assessment and management

When evaluating a patient with a high-energy extremity injury, the first priority is to identify and treat life-threatening injuries. The survival of the patient is the ultimate goal and even a severe limb injury must be kept within this “whole patient” perspective. When the immediate life-threatening conditions have been managed, the assessment of the viability of the injured limb comes next.

The assessment of any traumatized extremity must include:

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  History and mechanism of injury

  
  
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  Vascular and neurological status of the extremity

  
  
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  Size of the skin wound

  
  
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  Muscle crush or loss

  
  
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  Periosteal stripping and bone vascularity

  
  
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  Fracture pattern, fragmentation, and/or bone loss

  
  
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  Contamination

  
  
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  Compartment syndrome

Meticulous assessment of these components enables the surgeon to give an accurate description of the injury.

Some of the components of the injury are immediately evident; evaluation of others can only be performed at the time of initial debridement or subsequent debridements.

Assessment is an ongoing process with continuing reevaluation.

Management begins at the trauma scene, where prehospital personnel should splint the limb and protect the wound with a moist sterile dressing. Thereafter, to protect the wound from further bacterial contamination, the dressing should be disturbed as little as possible.

The vascular status may be assessed by evaluation of pulses, capillary refill, limb color, temperature, and the presence of bleeding from wounds. The most important clinical sign is the presence or absence of pulses. There may be sufficient collateral circulation for the skin to remain pink while there is critical ischemia of the underlying muscles. Doppler assessment of the ankle-brachial index can be helpful (> 0.9 is normal). A CT angiography study may also be required but should not lead to delay in treatment.

In the emergency department, only a superficial assessment of soft-tissue injuries can be performed. The history, dimensions, and location of all open wounds should be recorded. A photograph of the open wound helps to document its characteristics ( Fig 4.2-6 ) and prevents multiple examinations that increase the risk of bacterial contamination.

Open fractures may be missed if the examining physician does not elevate the extremity to inspect it circumferentially.

Extensive or contaminated wounds should be lavaged with an adequate quantity of sterile saline solution. Superficial foreign bodies, such as leaves and grass, which are immediately accessible, should be removed from the wound before it is covered. The surgeon must use a sterile technique to minimize the contamination of the wound during the initial inspection phase. A clean moist sterile dressing should be applied to the wound and not be removed until the patient is in the operating room. The reduced limb is then placed in a well-padded splint.

Pulses should be documented before and after alignment. Pulses often improve with realignment; persistently diminished pulses may indicate a vascular injury and mandate further evaluation with a Doppler assessment or arteriogram. Gross motor function and sensation of the foot and leg should be documented whenever possible. Tetanus prophylaxis should be provided in any open fracture.

Related posts:

4.5 Antibiotic prophylaxis 4.9 Imaging and radiation hazards 4.7 Postoperative management: general considerations 4.8 Fragility fractures and orthogeriatric care 4.3 Soft-tissue loss: principles of management Section 4 General topics

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