Open Fractures
An open fracture refers to an osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma. The term compound fracture refers to the same injury but is archaic.
One-third of patients with open fractures are multiply injured.
Any wound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherwise.
Soft tissue injuries in an open fracture may have three important consequences:
1. Contamination of the wound and fracture by exposure to the external environment.
2. Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection.
3. Destruction or loss of the soft tissue envelope may affect the method of fracture immobilization; compromise the contribution of the overlying soft tissues to fracture healing (e.g., contribution of osteoprogenitor cells); and result in loss of function from muscle, tendon, nerve, vascular, ligament, or skin damage.
MECHANISM OF INJURY
Open fractures result from the application of a violent force. The applied kinetic energy (KE = ½mv2) is dissipated by the soft tissue and osseous structures (Table 3.1).
The amount of bony displacement and comminution is suggestive of the degree of soft tissue injury and is proportional to the applied force.
TABLE 3.1 Energy Transmitted by Injury Mechanism | ||||||||||||
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CLINICAL EVALUATION
1. Patient assessment involves ABCDE: airway, breathing, circulation, disability, and exposure.
2. Initiate resuscitation and address life-threatening injuries.
3. Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
4. Identify all injuries to the extremities.
5. Assess the neurovascular status of injured limb(s).
6. Assess skin and soft tissue damage: Exploration of the wound in the emergency setting is not indicated if operative intervention is planned because it risks further contamination with limited capacity to provide useful information and may precipitate further hemorrhage.
Obvious foreign bodies that are easily accessible may be removed in the emergency room under sterile conditions.
Irrigation of wounds with sterile normal saline may be performed in the emergency room if a significant surgical delay is expected.
Computed tomography (CT) scan has been shown to be an effective method to assess traumatic arthrotomy. Air on CT in the presence of an open wound is diagnostic for traumatic arthrotomy.
7. Identify skeletal injury; obtain necessary radiographs.
COMPARTMENT SYNDROME
An open fracture does not preclude the development of compartment syndrome, particularly with severe blunt trauma or crush injuries.
Severe pain, decreased sensation, pain to passive stretch of fingers or toes, and a tense extremity are all clues to the diagnosis. A strong suspicion or an unconscious patient in the appropriate clinical setting warrants monitoring of compartment pressures.
Compartment pressures >30 mm Hg raise concern and within 30 mm Hg of the diastolic blood pressure (ΔP) indicate compartment syndrome; immediate fasciotomies should be performed.
Distal pulses may remain present long after muscle and nerve ischemia and damage are irreversible.
VASCULAR INJURY
Ankle brachial indices (ABIs) should be obtained if signs of vascular compromise exist.
Obtained by measuring systolic pressure at the ankle and arm.
Normal ratio is >0.9.
A vascular consultation and an angiogram should be obtained if a vascular injury is suspected.
Indications for angiogram include the following:
Knee dislocation with ABI <0.9 following reduction
Cool, pale foot with poor distal capillary refill
High-energy injury in an area of compromise (e.g., trifurcation of the popliteal artery)
Documented ABI <0.9 associated with a lower extremity injury (Note: Preexisting peripheral vascular disease may result in abnormal ABIs; comparison with the contralateral extremity may reveal underlying vascular disease.)
RADIOGRAPHIC EVALUATION
Extremity radiographs are obtained as indicated by clinical setting, injury pattern, and patient complaints. Every attempt should be made to obtain at least two views of the extremity at 90 degrees to one another. It is important to include the joint above and below an apparent limb injury.
Additional studies may include a CT if there is intra-articular involvement.
CLASSIFICATION
Gustilo and Anderson (Open Fractures) (Tables 3.2 and 3.3)
This was originally designed to classify soft tissue injuries associated with open tibial shaft fractures and was later extended to all open fractures. While description includes size of skin wound, the subcutaneous soft tissue injury that is directly related to the energy imparted to the extremity is of more significance. For this reason, final typing of the wound is reserved until after operative debridement.
It is quantitative rather than qualitative and useful for communicative purposes despite variability in interobserver reproducibility.
Type I: Clean skin opening of <1 cm, usually a “poke hole,” usually from inside to outside; minimal muscle contusion; lowenergy simple spiral or short oblique fractures
Type II: Laceration >1 cm long, with more extensive soft tissue damage; minimal-to-moderate crushing component; simple transverse or short oblique fractures with minimal comminution
TABLE 3.2 Classification of Open Fractures | |||||||||||||||
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