Management of

Open Fractures

Source: Bucholz, R; Heckman, J.; Court-Brown, C.

Rockwood & Green's Fractures in Adults
Volume 1, Section One - General Principles
Chapter 12 - Olson, S.; Willis, M.

INTRODUCTION
Fractures
that are
exposed to
the
environment
through
breaks in the
skin

 Occur in wide
spectrum of
conditions with
specific
consequences
Bacteria may
contaminate area of
injury
Force magnitude
required to produce
the fracture is
variable

 Mechanism of Injury
-result from the application of a
violent force
-applied kinetic energy(KE)=0.5 mV2

 Outcome depends on the extent of

soft tissue injury
Better to emphasize
Degree of soft tissue injury
Degree of contamination

 In certain cases, diagnosis may be

difficult as the wound may appear
remote to the site of fracture.
Missed open injuries
osteomyelitis, infected nonunion
*Fracture must be considered open
until proven otherwise - directed by
surgical staging

History
Hippocrates (460-370 BC) - War as
most appropriate training ground for
surgeons. They can facilitate healing
and cannot impose it. Advocated I&D
for wounds that did not progress.
Galen (2nd) - also recognized
purulence, considered essential to
the repair process

History
Brunschwig and Botello (15th and 16th) removal of necrotic tissue from wounds
that did not progress
Ambroise Pare (17th) - Hot oil as cautery.
Used turpentine over wound, enlarged
wounds; largely unrecognized during his
day
Desault (18th) reestablished exploration
of wound, adopted the term debridement

History
Larrey Desaults pupil added timing
- sooner the better
Mathysen POP, occlusive dressings
were reintroduced, only to lapse
again because of untoward effects
from misapplication, time when
debridement was abandoned
Lister - Carbolic acid dressings

History
Sir Robert Jones (WWI 13-18)
Debridement in missile injuries
Trueta (Spanish Civil War 36-39) Combination of debridement and an
occlusive dressing that also served
as a splint. Only 6 deaths in 1,073
patients
WWII 39-45 - Sulfa agents replaced
antiseptic solutions

History
Korean War 50-53 Antibiotic use.
Policy of rapid evacuation, wound
debridement, and delayed closure.
Still the standard today
Advances shifted the focus
Preservation of life and limb
preservation of function and prevention
of complications

History
Operation Enduring Freedom/OTA
CPG mirror the military model: ABCs,
splint and dress wound, IV
antibiotics, urgent operative
debridement and irrigation, leave the
wound open, and stabilize unstable
skeletal injuries, repeated
debridements prn

DIAGNOSIS
Straightforward in most
History
PE wound dimension, visible bone,
NV, compare to normal side

Assessment of the Patient

Advanced trauma life support
Airway
Breathing
Circulation
Disability
Exposure
Save the patient, then the limb!!

Assessment of the patient

Look for :
Life/Limb threatening injuries
Other associated injuries
Check distal circulation, neurology
Check compartment pressure

The Soft Tissues

Fracture appears non complex on
radiographs

The real
injury

Patient Variables

Age
Gender
Diabetes
Infection
Smoking
Medications
Underlying
physiology

Injury Variables
Severity
Energy of Injury
Morphology of the
fracture
Bone loss
Blood supply
Location
Other injuries

Assessment of the wound

What is the nature of the wound?
What is the state of the skin around the
wound?
Is the circulation satisfactory?
Are the nerves intact?

Open Fracture Classification

Open fracture classification

Allows comparison of results
Provides guidelines on prognosis and
treatment
Fracture healing, infection and
amputation rate correlate with the
degree of soft tissue injury

Gustilo upgraded to Gustilo and

Anderson
AO open fracture classification

CLASSIFICATION
Gustilo and Anderson
Most quoted and widely accepted
Degree of soft-tissue injury and
contamination predict outcome
Wide variation, too much emphasis on
wound size
Devastating crush injury of the leg
necessitating amputation may be associated
with only a small skin wound; very large
wound caused by a sharp object, such as a
knife, may have minimal associated softtissue crush

Type 1 Open Fractures

Inside-out injury
Clean wound
Minimal soft tissue
damage
No significant
periosteal stripping

Type 2 Open Fractures

Moderate soft
tissue damage
Outside-in
Higher energy
Some necrotic
muscle
Some periosteal
stripping

Type 3a Open Fractures

High energy
Outside-in
Extensive muscle
devitalization
Bone coverage
with existing soft
tissue

Type 3b Open Fractures

High energy
Outside in
Extensive muscle
devitalization

Requires a flap
for bone
coverage and
soft tissue
closure
Periosteal
stripping

Type 3c Open Fractures

High energy
Increased risk of
amputation and
infection
Any grade 3 with
major vascular
injury requiring
repair

 A type IIIC open fracture is one in

which there is a major vascular
injury requiring repair for salvage of
the extremity.
A tibia fracture with disruption of the
anterior tibial artery but preservation of
the posterior tibial artery is not a type
IIIC injury.
An open fracture of the forearm with an
intact ulnar or radial artery and wellperfused hand is not a type IIIC injury.

Why use this

classification?
Grades of soft tissue injury correlates with
infection and fracture healing
Grade

3A

3B

3C

Infection
Rates

0-2%

2-7%

10-25%

1050%

25-50%

Fracture
Healing
(weeks)

21-28

28-28

30-35

30-35

Amputati
on Rate

50%

AO classification (adapted
from Tscherne)
The
AO classification of fracture wound severity
provides a grading system for injuries of
each of the skin (I), muscles and tendons
(MT), and neurovascular (NV), each of which
is divided into five degrees of severity.
It is designed to provide a unique,
unequivocal definition of any injury and,
thereby, allows accurate comparison of
cases.

Treatment
Current Treatment at the ER:
Obvious debris that can be easily
removed should be taken with sterile
forceps.
If the patient will be at OR in 1-2 hours
from injury, cover wound with a sterile
bandage
If not, irrigate the wound with 1-2L
PNSS before placing the sterile dressing

 Once the sterile dressing is placed, no further

wound inspection should be done until the
patient is in the OR
4.3% infection rate in open wounds that were
covered immediately with a sterile dressing,
compared with an 18% infection rate in open
wounds left exposed until surgery.
To prevent subsequent physicians removing the
dressings to view the wound, a photograph can
be taken and placed in the chart for later
review.

 After initial trauma survey and

resuscitation for life threatening
injuries:
1. Perform a careful clinical and
radiographic evaluation.
2. Wound hemorrhage should be
addressed with direct pressure rather
than tourniquets or blind clamping
3. Initiate parenteral antibiotics

Antibiotics
Therapeutic, not
prophylactic
Kill residual
organisms and at
least inhibit their
growth to the point
where host
protective
mechanisms can
eradicate them

 4. Assess skin and soft tissue

damage; Place a moist dressing on
the wound
5. Perform provisional reduction of
fracture and place in a splint, brace
or traction
6. Operative Intervention

Operative Treatment
Primary surgery
Objectives of initial
surgical management

Preservation of life and

limb
Wound debridement
Definitive injury
Stages of open fracture management in the
assessment
Fracture stabilization

 Clean open I II fractures where

primary internal fixation is carried
out, immediate cancellous bone
grafting may be indicated
Remove ER splint and dressing
Maintain traction
Possible tourniquet
Two-phase surgical preparation

 Tourniquet should not be inflated unless it is

necessary because anoxia produced
interferes with evaluation of the viability of
muscle and may add to preexisting
ischemic tissue injury.
Transient inflation of the tourniquet for 10
to 20 minutes, followed by release, results
in capillary flush. This may be a helpful
indicator of soft-tissue viability. A tourniquet
should never be inflated while IM reaming.

 Systematic: skin, fat, muscle,

Gregory 4Cs, bone. Scully: (Histo)
consistency and capacity to bleed.
Olson: contractility and consistency
Wound should be equal in length to
the diameter of the limb at that level
Even if 10% of a muscle belly and its
attached tendon is preserved,
significant function is retained

Without a major blood vesel, excise

Meticulous hemostasis
Avoid distal flaps
It is better to deal with the reconstruction
of a large segmental defect than to allow
chronic infection to result in chronic
osteomyelitis, which may lead to even
more bone loss so debride bone. Paprika bone edge bleeding is the most reliable
technique available.

 Fasciotomy after vessel repair often is

necessary, surgeon is urged to do it
prophylactically in nearly every case. If
there is any doubt about its indication,
it probably should be done. Moreover,
it is better done too early than too late
10L irrigation. If a little does some
good, a lot will do a great deal more.
The solution to pollution is dilution

 Initial lavage flushes away blood for

inspection, removes debris
Necrotic tissue floats
Lavage restores its normal color and
facilitates determination of viability.
Irrigation reduces the bacterial population.
Irrigation includes pulsatile lavage, water
pic, continuous irrigation, and bulb
syringe. Each has an advocate. Additives

 Irrigation and
Debridement
adequate
irrigation and
debridement are the
most important steps
in open fracture
treatment

However, after review of all

literature..
Okike et al. states.
Thorough operative debridement is the
standard of care for all open fractures.
Even if the benefits of formal I&D were
insignificant for low grade fractures,
operative debridement is still required
for proper wound classification.
Open fractures graded on the basis of
superficial characteristics are often
misclassified.
Huge risk not to explore and debride!
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am.
2006 Dec;88(12):2739-48.

Objectives of Debridement
and Irrigation
Extension of the traumatized wound to allow
identification of the zone of injury
Detection and removal of foreign material,
especially organic foreign material
Detection and removal of nonviable tissues
Reduction of bacterial contamination
Creation of a wound that can tolerate the
residual bacterial contamination and heal
without infection.

I&D in the OR
Trauma scrub

Soap and saline to remove gross

debris

Zone of injury

Skin wound is the window through

which the true wound communicates
with the exterior

Extend the traumatic wound

Excise margins
Resect muscle and skin to healthy
tissue

color, consistency, capacity to bleed and

contractility

Bone ends are exposed and

debrided
Irrigate
Serial debridements?

If needed, 2nd or 3rd debridement after

24-48 hours should be planned

The Irrigation
Amount
No good data, copious is
better
Anglen recommends:*
3L for type 1
6L for type 2
9L for type 3

*Anglen JO. Wound Irrigation in Musculoskeletal Injury. JAAOS 2001. 9: 219-226.

SKELETAL STABILIZATION
If unstable following debridement
Restore length and alignment of long bones
Reduce articular surfaces displaced by
fracture
Allow access to the traumatic wound
Facilitate further reconstruction procedures
Allow early use of the limb
Facilitate fracture union and return of function

 Range from traction to plaster

immobilization to internal fixation.
The more severe the open fracture, the
greater the need for direct skeletal
fixation to allow improved access to the
traumatic wound.
Reestablishment of alignment provides
optimal circulation to the injured
extremity from neurovascular structures.

 Salter, Mitchell and Shepard good

intraarticular reduction have good
outcomes
Contraindications:
Severe osteopenia
Severe comminution; non-reconstructable
Minimal soft tissue injury with a nondisplaced
fracture (i.e., ideal for closed treatment)
Severe ongoing local infection
Severe co-morbidities precluding anesthesia

 Plaster cast use best if univalved

than bivalved
Bubble
External fixation is most often
indicated for Open IIIB IIIC

POSTOPERATIVE ANTIBIOTIC
USE
Oswold: Antibiotics are given for 48 hours
after the initial and any subsequent
debridements, as well as after wound
closure.
This often translates into a patient being
on antibiotics for 2 to 4 days following
initial presentation and debridement. If
signs of infection or drainage occur at any
time, the wound is cultured and treatment
is based on those cultures

 2.4 g Tobramycin or 1g Vancomycin

powder with every 40g of PMMA bone
cement. The mixture is placed into a bead
mold to create a series of 6-mm diameter
beads strung on multiple-strand stainlesssteel wire or nonabsorbable suture
Ostermann et al: bead pouch technique as
a supplement to IV antibiotics. 157 cases,
7.3% VS 39% Osteoblast toxicity, nonunion?

 LOCAL NEGATIVE-PRESSURE
DRESSINGS
1997, Argenta and Morykwas
STSG

 Thank you!