Immediate primary skin closure in type-III A

and B open fractures

RESULTS AFTER A MINIMUM OF FIVE YEARS

S. Rajasekaran,
J. Dheenadhayalan,
J. N. Babu,
S. R. Sundararajan,
H. Venkatramani,
S. R. Sabapathy
From Ganga
Hospital,
Coimbatore, India

S. Rajasekaran, MS, FRCS,

PhD, Director and Head
J. Dheenadhayalan, MS,
Consultant Surgeon
J. N. Babu, MS, FNB, Clinical
Fellow
S. R. Sundararajan, MS,
Consultant Surgeon
Department of Orthopaedics,
Traumatology and Spine
H. Venkatramani, MS, MCh,
Consultant Surgeon
S. R. Sabapathy, MCh, DNB,
FRCS, Director and Head
Department of Plastic, Hand
and Reconstructive Surgery
Ganga Hospital, 313
Mettupalayam Road,
Coimbatore 641043, India.
Correspondence should be sent
to Dr S. Rajasekaran; e-mail:
sr@gangahospital.com
2009 British Editorial Society
of Bone and Joint Surgery
doi:10.1302/0301-620X.91B2.
21228 $2.00
J Bone Joint Surg [Br]
2009;91-B:217-24.
Received 28 April 2008;
Accepted after revision 26
September 2008

217

Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds
of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These
patients were selected from a consecutive group of 557 with type-III injuries presenting
during this time. Strict criteria for inclusion in the study included debridement within
12 hours of injury, no sewage or organic contamination, no skin loss either primarily or
secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a
total score of ten or less, the presence of bleeding skin margins, the ability to approximate
wound edges without tension and the absence of peripheral vascular disease. In addition,
patients with polytrauma were excluded.
At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good
in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients
including superficial infection in 11, deep infection in five and the requirement for a
secondary skin flap in three. Six patients developed nonunion requiring further surgery, one
of whom declined additional measures to treat an established infected nonunion.
Immediate skin closure when performed selectively with the above indications proved to
be a safe procedure.

Debate continues on the timing of closure in

open fractures particularly on the role of
immediate closure in Gustilo and Anderson
type-III injuries.1-7 The common practice of
leaving wounds open after debridement8-12
was based on the experience of war wounds
during a period when antibiotics were less
readily available, the principles of surgical
debridement were not fully developed and the
techniques for proper soft-tissue reconstruction had not been established.13,14 With the
availability of potent antibiotics and refinement in the techniques of surgical debridement, surgeons have slowly advanced towards
early and even immediate closure of the
wound.1-3,15-24
The major concern with immediate closure
is the increased risk of infection on the premise
that the offending organism leading to infection in open injuries is introduced at the site of
the accident. However, there is ample evidence
that infection is generally the result of hospital
acquired colonisation rather than primary contamination at the time of injury.24-28 It has been
shown that there is no correlation between
contaminating organisms and those isolated in
subsequent infection. Pre-operative cultures
rarely grow drug-resistant organisms which

are often found in infected open injuries.27 The

rate of infection may in fact be greater in
wounds which are left open in the hospital
environment for closure at a later date.24 Leaving wounds open may also lead to avoidable
desiccation of the tissues resulting in increased
secondary loss of tissue, an increase in the
number of surgical procedures required, a
lengthened in-patient stay and extra cost.
There is growing interest in the possibility
of primary closure in open injuries.1-3,15-24
However, studies on this subject have
included a wide variation in wound management such as direct skin closure, skin grafting
and early application of skin flaps.28 No study
has evaluated the long-term results of direct
skin suturing performed immediately in typeIII injuries or the appropriate indications for
this approach.
It has been our practice since 1992 to perform immediate skin closure of open injuries,
including type-III injuries, during the initial
reconstruction, if certain criteria were met.
The encouraging results achieved prompted
us to carry out a prospective study on the outcome of the immediate closure of type-III
injuries and to develop safe indications for the
procedure.
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IMMEDIATE PRIMARY SKIN CLOSURE IN TYPE-III A AND B OPEN FRACTURES

Excluded

218

738 open injuries

(from 1999-2003)
Excluded
Salvaged: 707

Primary amputation: 31

Type I: 70
Type II: 65
Type IIIC: 15

Type IIIA or B: 557

Inclusion criteria
not fulfilled: 309
Injury severity score
of > 25 and/or
Ganga Hospital Total
Score of > 10 and/or
Ganga Hospital Skin
Score of 3 and above

Excluded
Excluded

Exclusion criteria: (63)

Hand and foot injuries:15
Shock: 13
Sewage contamination/
farmyard injuries: 20
Peripheral vascular diseases: 5
Drug dependent diabetes mellitus: 7
Connective tissue disorders and
peripheral vasculitis: 3

Immediate closure: 185

Lost to follow-up: 8
Died: 4
Study population: 173
Fig. 1
Flow chart summarising the study population.

Patients and Methods

The study was approved by the institutional review board
and all patients included in it were counselled regarding the
implications and outcome of our protocol.
Between June 1999 and May 2003, we treated 738 open
injuries. Of the salvaged 707 injuries, 557 were type-III A
or B injuries. Of this group, 185 patients satisfied the criteria and had immediate closure (Fig. 1). Eight of these were
lost to follow-up and four died during the study period,
leaving 173 available for evaluation. There were 151 men
and 22 women with a mean age of 36.6 years (3 to 75).
Motor-vehicle accidents accounted for 133 injuries, domestic accidents for 15, work-place injuries for 19 and industrial accidents for six. The lower limb was involved in 134
and the upper limb in 39 (Fig. 2). The wound length was
less than 5 cm in 59 patients, between 6 cm and 10 cm in 81
and more than 11 cm in 33. There were inherent difficulties
in classifying the injuries as type IIIA or type IIIB because
from the time it was originally proposed,28 the definition
has been modified many times with frequent changes and
there is no longer a uniformly accepted definition.29-33
Accordingly, the wounds were also assessed using the
Ganga Hospital open injury score34,35 which analyses the
severity of injury to the skin, bone and musculotendon
units individually and also gives a total score (Table I). All
173 injuries had a skin score of two or less and a total score
of ten or less.
Management protocol. The hospital protocol involved debridement at the first opportunity by a senior member of the
orthopaedic and plastic surgical team who assessed the fulfilment of the criteria for primary closure.35 These
VOL. 91-B, No. 2, FEBRUARY 2009

Fig. 2
Diagram showing the distribution in the upper and lower
limbs of the 173 type-III A and B open injuries managed by
immediate direct skin closure.

comprised debridement within 12 hours of the injury and

no loss of skin either primarily or during debridement.
Additionally, stable skeletal fixation had to be achieved
either by internal or by external fixation during the initial

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S. RAJASEKARAN, J. DHEENADHAYALAN, J. N. BABU, S. R. SUNDARARAJAN, H. VENKATRAMANI, S. R. SABAPATHY

Table I. Details of the Ganga Hospital Open Injury Score34

Score
Covering structures: skin and fascia
Wounds without skin loss
Not over the fracture
Exposing the fracture
Wounds with skin loss
Not over the fracture
Over the fracture
Circumferential wound with skin loss

1
2
3
4
5

Skeletal structures: bone and joints

Transverse/oblique fracture/butterfly fragment < 50% circumference
Large butterfly fragment > 50% circumference
Comminution/segmental fractures without bone loss
Bone loss < 4 cm
Bone loss > 4 cm

1
2
3
4
5

Functional tissues: musculotendinous (MT) and nerve units

Partial injury to MT units
1
Complete but repairable injury to MT units
2
Irreparable injury to MT units/partial loss of a compartment/complete injury to posterior tibial nerve 3
Loss of one compartment of MT units
4
Loss of two or more compartments/subtotal amputation
5
Comorbid conditions: add 2 points for each condition present
Injury - debridement interval > 12 hours
Sewage or organic contamination/farmyard injuries
Age > 65 years
Drug-dependent diabetes mellitus/cardiorespiratory diseases leading to increased anaesthetic risk
Polytrauma involving chest or abdomen with injury severity score > 25/fat embolism
Hypotension with systolic blood pressure < 90 mmHg at presentation
Another major injury to the same limb/compartment syndrome

Table II. Inclusion and exclusion criteria used in the study

Inclusion criteria
Type-III A and B open injuries of limbs without vascular deficit
Wounds without skin loss either primarily or secondarily during debridement
Ganga Hospital skin score of 1 or 2 and a total score of 10 or less
Injury to debridement interval less than 12 hours
Presence of bleeding wound margins which could be apposed without tension
Stable fixation achieved either by internal/external fixation
Exclusion criteria
Grade-I, -II and -IIIC injuries
Ganga Hospital skin score of 3 or more and a total score of > 10
Isolated hand and foot injuries
Polytrauma involving chest or abdomen with injury severity score > 25
Hypotension with systolic blood pressure < 90 mmHg at presentation
Sewage or organic contamination/farmyard injuries
Peripheral vascular diseases/Thrombo angitis obliterans
Drug-dependent diabetes mellitus/connective-tissue disorders/peripheral vasculitis

procedure and the skin margins closed by direct apposition

without tension. When there was vascular involvement,
associated hand and foot injuries or a polytrauma with an
injury severity score of > 25,36 other methods of skin cover
were provided and the patients were excluded. Patients
were also excluded from immediate closure if they had

presented with shock, had sewage or organic contamination, had peripheral vascular disease or diseases compromising wound healing such as connective-tissue disorders
and peripheral vasculitis (Table II).
All patients received tetanus prophylaxis and 1.5 g of
cefuroxime intravenously on admission. Whenever the
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IMMEDIATE PRIMARY SKIN CLOSURE IN TYPE-III A AND B OPEN FRACTURES

220

Table III. Details of the assessment of wound healing

Wound assessment

Patients

Type A: primary wound healing

Skin edges well approximated
Epithelialising normally with no signs or symptoms of wound infection
Wound heals by primary intention

143

Type B: marginal wound necrosis not requiring surgical intervention

Skin edges remain approximated but the margins show necrosis
No signs or symptoms of infection
Wound heals by secondary intention
No surgical intervention required

26

Type C: wound necrosis requiring surgical intervention

Necrosis of skin edges with or without infection
Requires redebridement and secondary suturing

Type D: wound dehiscence requiring flap cover

Necrosis of skin edges with or without infection
Requires redebridement and flap cover

Table IV. Details of assessment of final outcome

Grade
Excellent

Type-A or type-B wound healing

No infection
Bony union without intervention

Good

Type-C wound healing or superficial infection

Bony union without intervention

Poor

Type-D wound healing

Deep infection
Nonunion

surgeons were satisfied with the adequacy of debridement,

a decision was taken for primary closure if the inclusion criteria were fulfilled. Wounds were closed with intermittent
skin sutures over a suction drainage.
Collection of data and outcome assessment. The patients
were assessed for wound healing infection, union of the fracture and the need for additional procedures. The outcome
assessment of wound healing, infection and bony union was
done at each follow-up on a data sheet by two of the authors
(JD, JNB). All the wounds were assessed on the second and
fourth post-operative days and at the time of removal sutures.
After discharge, the patients were reviewed at monthly intervals until union and then annually. Wound healing was
assessed according to predefined criteria (Table III). Infection
was classified according to the criteria set by the Centre for
Disease Control (CDC)37 and recommended by Nosocomial
Infection National Surveillance Scheme (NINSS).37
The outcome was defined as excellent when the wound
had type-A or type-B wound healing, with no wound
infection and union without the need for secondary procedures (Table IV). A good outcome was considered to be
VOL. 91-B, No. 2, FEBRUARY 2009

a wound which had type-C healing with superficial infection and uneventful bone union. A poor outcome was one
which had a type-D healing requiring flap cover or deep
infection requiring secondary procedures to treat infection
and nonunion.
Skeletal stabilisation. The choice of implant for stabilisation of the fracture was decided by the surgical team and
reflected the fracture pattern with consideration of the site
of injury and the age of the patient. Fractures of the lower
limb were mainly treated by locked intramedullary nails,
while those of the upper limb predominantly had plate fixation. In eight patients definitive internal fixation was performed after temporary external fixation.
Considering tibial fractures separately, since these are
special challenges in management, there were 79 type-III
open tibial injuries. The wound size was less than 5 cm in
35 and more than 6 cm in 44 patients. The injury was in the
upper proximal metaphyseal region in 11, was diaphyseal
in 32 and in the lower metaphysis in 36. Of these, intraarticular extension into the knee was seen in seven fractures
and into the ankle in five. The method of stabilisation used
was a locked intramedullary nail in 56 patients, a limb
reconstruction system in eight, hybrid fixation in five, a
dynamic compression plate in seven and screws alone in
three patients who had fractures of the plateau.

Results
The mean follow-up was for 6.2 years (5 to 7). Of the
173 patients, 150 (86.7%) had an excellent outcome, 11
(6.4%) a good outcome and 12 (6.9%) a poor outcome. All
39 injuries to the upper limb had an excellent outcome. Of
the 134 injuries to the lower limb 111 (82.8%) had an
excellent outcome (Fig. 3). Primary wound healing was
observed irrespective of the size of the wound or the site.
The presence of bleeding from the wound margins which

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S. RAJASEKARAN, J. DHEENADHAYALAN, J. N. BABU, S. R. SUNDARARAJAN, H. VENKATRAMANI, S. R. SABAPATHY

Table V. Details of five patients with deep infection

Time of presentation Secondary
of infection
procedures

Case

Region

Infective organism

Initial management

Tibia, middle third

Staph. aureus

Primary closure,
Immediate
locked intramedullary
nail

Tibia, lower third

Streptococcus viridans

Primary closure,
3 weeks
locked intramedullary
nail

Course of infection
United at 20 weeks
intermittent discharge
from a sinus
Implant removal at 32
weeks

Debridement, antibiot- Union delayed until

ics and walking cast
36 weeks
Implant removal after
one year

Femur, lower third

Staph. aureus

Primary closure,
dynamic condylar
screw

3 weeks

Debridement, antibiotics, implant

removal and sequestrectomy

Femur, lower third

Pseudomonas

Primary closure,
dynamic condylar
screw

Immediate

Debridement, antiPersistent infective

biotics, transposition nonunion
flap, implant removal Mobilised with caliper
and external
fixator

Tibial plateau

Staph. aureus

Primary closure
Buttress plating

4 weeks

Debridement

could be apposed without tension was found to be more

important than the size, nature, site of the wound or the
method of internal fixation. A good outcome was observed
in 11 patients in the whole series because of the presence of
type-C wound healing in one, a superficial infection in eight
and both superficial infection and delayed union in two.
However, these patients did not require any surgical intervention when erythema developed during healing since they
responded to antibiotic treatment and daily dressing. All
these patients also had satisfactory union of the fracture
without the need for further intervention. In the 12 patients
with a poor outcome, this was due to failure of wound healing (type D) alone in one, nonunion alone in five, deep
infection and delayed union in four and infective nonunion
with type-D wound healing in one patient. The other
patient had type-D wound healing with superficial
infection and delayed union.
Complications. At the final follow-up, a total of 33 complications were observed in 23 patients. Of these, eight had
infection alone, two had problems of wound healing alone,
five had delayed union or nonunion, six had infection and
delayed union and two had all three complications of
wound necrosis, infection and nonunion.
Wound healing. Wounds healed without further intervention
in 169 patients (97.7%). Wound healing was assessed as type
A in 143 injuries (82%), type B in 26 (15%), type C in one
(1%) and type D in three (2%) (Table III). Complications in
wound healing requiring surgical intervention were observed
in four patients (2.3%), two in the tibia (2 of 79), one in the

United at 22 weeks
with a sinus resolving
after one year

Prolonged antibiotics, united at 20

weeks
Intermittent discharge
from a sinus

femur (1 of 40) and one in the knee (1 of 12). The nature of the
complication was that of marginal necrosis requiring redebridement and secondary suturing in one patient and
wound necrosis requiring debridement and flap cover in three.
While three of these wounds healed subsequently, one patient
with a supracondylar fracture of the femur had persistent deep
infection and osteomyelitis. The patient had a persistent sinus
for three years before it closed and was left with a nonunion.
This patient preferred to be mobilised with a brace and did not
favour any further surgical procedures.
Infection. Infection was observed in 16 of the 173 patients
(9.2%). It was superficial in 11 (6.4%) and resolved after
treatment with intravenous antibiotics. The other five
(2.9%) patients had deep infection (Table V). Debridement
had to be performed within one week in two injuries, at
three weeks in two and at four weeks in one. Two injuries
required only a single debridement, two required debridement twice and one required debridement on three occasions. This final patient also required revision with removal
of the implant and stabilisation using a limb reconstruction
system and a transposition flap. This resulted in an infected
nonunion and a sinus for six months. During this period,
the patient was mobilised using a moulded functional castbrace. The sinus closed, but the patient declined further
treatment for the nonunion. All patients with deep infection
had removal of the implant after consolidation of the fracture. No infection occurred in injuries of the upper limb.
Bony union. In total 160 of the 173 (92.5%) fractures
united uneventfully. Delayed union was observed in
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IMMEDIATE PRIMARY SKIN CLOSURE IN TYPE-III A AND B OPEN FRACTURES

Fig. 3a

Fig. 3b

Fig. 3c

Fig. 3d

Fig. 3e

222

Fig. 3f

Photograph (a) and radiograph (b) showing a type-IIIB open fracture of the tibia with a wound 10 cm 4 cm in size on the anteromedial aspect of
the tibia. The wound was (c) debrided and (d) stabilised with an intramedullary nail with ten hours of injury. At the end of the debridement and
skeletal stabilisation, the skin edges could be approximated without tension and satisfied the inclusion and exclusion criteria of our study (e). The
wound was managed by immediate direct skin closure with an excellent outcome (f).

seven patients (4%) and nonunion in six (3.5%). All seven

patients with delayed union went on to union without any
open interventional procedure. However, two patients with
fractured tibiae required dynamisation, one patient
required injection of bone marrow and others had a period
of functional cast bracing. All the six patients with nonunion required secondary intervention. Bone grafting was
required in five patients and in three of these revision of the
fixation was also needed. As described, the sixth patient
with an infected nonunion refused further treatment.

Discussion
Recently, the traditional concept that wounds in open fractures must be left open at the initial surgery has been challenged.1-3,15-24 In order to determine a realistic protocol the
advantages and disadvantages of both methods of management must be reviewed critically.
Undoubtedly, the major concern of closing a wound
which is contaminated is the fear of severe local infection or
the development of tetanus or gas gangrene.38 Russell et al9
in a study of 90 of 110 consecutive open tibial fractures
reviewed retrospectively, reported a rate of deep infection
of 20.7% (12 of 58) in primary skin closure compared with
3.1% (1 of 32) after delayed closure. In addition, eight of
the nonunions also followed primary closure and they
advised against this.
The suggestion that primary closure may lead to an
increased rate of infection seems, however, to be inappropriate, since there is now growing evidence that most
acute infections after open injuries are the result of pathogens acquired in the hospital rather than from the site of
VOL. 91-B, No. 2, FEBRUARY 2009

injury.24-27 In a prospective study of 326 open fractures,

Gustilo and Anderson29 reported that eight patients developed infection of which five were acquired secondarily in
the hospital. They concluded that during the long intervals when such wounds were open, secondary infection
usually with Gram-negative organisms may be a problem
since these organisms are usually difficult to control by
antibiotics alone.
It is evident that the infection is acquired in hospital since
it is difficult to predict the subsequent infective pathogen on
the basis of the initial wound culture.25-27 In a prospective
study, Patzakis et al27 found that only 18% of infections
were caused by the organism which was initially isolated in
the peri-operative period. The enormity of the problem of
hospital-acquired infection in open injuries is a strong indication for primary closure.24 Since the site of the fracture
and soft-tissue wound are probably most sterile after an
adequate debridement by an experienced surgeon this is an
opportune time to approximate the skin margins.
Reports of good results after early closure are not new.1-3,15-25
The concept was advocated as early as 1948.39 Hope and
Cole40 in a series of tibial fractures in children reported an
infection rate of 7.8% (4 of 51) with primary closure
compared with 14.6% (6 of 41) with secondary closure.
Cullen et al41 reviewed the records of 83 children with open
fractures of the tibial metaphysis and diaphysis in which
57 wounds were closed primarily. Only two children developed superficial infection.
Similar good results have been described in the adult
population. De Long et al21 reported the results of
119 open fractures treated by six forms of wound manage-

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S. RAJASEKARAN, J. DHEENADHAYALAN, J. N. BABU, S. R. SUNDARARAJAN, H. VENKATRAMANI, S. R. SABAPATHY

ment and concluded that immediate primary closure, with

or without a second look was a viable option.
The indications for primary closure which we followed
were very strict and were formed from the experience of
treating a large number of open injuries. The senior surgical
team was able to assess the adequacy of the debridement
and to judge the viability of the tissues.
Extension of the wounds for proper inspection and
debridement was undertaken in a longitudinal fashion to
avoid jeopardising closure in appropriate cases. Care was
taken to avoid creating a dead space using large suction
drains so that no collection which might form a nidus for
infection could accumulate.
Assessment of the skin margins requires good judgement
and experience. The Ganga Hospital score was particularly
useful in assessing the status of the skin and judging the suitability of wounds for immediate closure since the scoring system is weighted towards loss of skin rather than the size of
the wound. Irrespective of the size of the wound we found it
was safe to close wounds with a skin score of 1 or 2.
We acknowledge that the patients in our study were not
randomised, but our previous experience has shown that it
was inappropriate to delay closure of a wound when this was
possible since this increased the chances of complications.
An increase in the rate of complications by adopting a
delayed closure has been noted by others.15-24,40,41 Our primary aim was not only to prove the advantage of selective
closure of open injuries, but also to verify the indications
which were evolved following our previous experience. The
results of this prospective study have shown that these indications are appropriate and can be used as a guideline in
deciding to undertake immediate closure.
Although infection was noted in 16 patients, deep infection occurred in five. This is less than has been previously
reported.15,28,29 Similarly, the requirement of a subsequent
soft-tissue flap due to failure of wound healing only arose
in three patients. We attribute this to immediate closure
which protected the normal internal environment and prevented the additional loss of soft tissue.
However, we emphasise that closure of all wounds without adequate debridement and in the absence of tension will
be disastrous. While advocating immediate closure in certain
open injuries, the criteria for this treatment were met only in
185 of the 557 injuries (33%) which we managed.
We would like to thank Mr K. Ganesh, Physician Assistant, for help in the collection and analysis of the data. This study was supported and funded by Ganga
Orthopaedic Research and Education Foundation.
Although none of the authors has received or will receive benefits for personal or professional use from a commercial party related directly or indirectly
to the subject of this article, benefits have been or will be received but will be
directed solely to a research fund, foundation, educational institution, or other
non-profit organisation with which one or more of the authors are associated.

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