Open

Fracture
s
Adeel Husain PGY 3
Loma Linda University
Dept of Orthopaedic
Surgery

Definition
Break in the skin and underlying soft
tissue leading directly into or
communicating with the fracture and
its hematoma

History
Last century, high mortality with open
fractures of long bones
Early amputation in order to prevent death
WWI, mortality of open femur fractures > 70%
1939 Trueta closed treatment of war
fractures
Included open wound treatment and then
enclosure of the extremity in a cast
Greatest danger of infection lay in muscle, not
bone
Trueta J: "Closed" treatment of war fractures, Lacet
1939;1:1452-1455

History
1943 PCN on the battlefield quickly
reduced rate of wound sepsis
Delayed closure of wounds
Hampton: closure btwn 4th and 7th
day
Larger defects continued to be left
open to heal by secondary intention
Hampton OP Jr: Basic principles in management of open fractures; JAMA 1955;
159:417-419

History
Advances shifted the focus
Preservation of life and limb
preservation of function and prevention
of complications

However, amputation rates still

exceed 50% in the most severe open
tibial fractures assoc with vascular
injury*
Lange RH, Bach AW, Hansen ST et al: Open tibial fractures with associated vascular injuries: prognosis for limb
salvage. J Trauma; 25(3):203-208

Epidemiology
3% of all limb fractures
21.3 per 100,000 per year

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
Host classification of open fractures

Gustilo and Anderson

Classification
Model is tibia, however applied to all
types of open fractures
Emphasis on wound size
Crush injury assoc with small wounds
Sharp injury assoc with large wounds

Better to emphasize
Degree of soft tissue injury
Degree of contamination

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

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

Amputatio
n Rate

50%

Gustilo and Anderson

Bowen and Widmaier*
2005 Host classification predicts infection
after open fracture
Gustilo and Anderson classification and the
number of comorbidities predict infection risk
174 patients with open fractures of long bones
Sorted into three classes based on 14
immunocompromising factors
Age>80, current nicotine use, DM, malignancy,
pulmonary insufficiency, systemic
immunodeficiency, etc

Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat
Res. 2005;433:205-11.

What they found

Clas
s

Compromising
factors

Infection rates

4%

1-2

15%

3 or more

31%

Patients with any compromising risk

factor has increased risk of infection
May benefit from additional therapies
that decrease the risk of infection.
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat
Res. 2005;433:205-11.

Gustilo Classification:

a simple and useful tool, but is it

accurate?

1994 Brumback et al.

125 randomized open fractures
245 surgeons of various levels of training
12 cases of open tibia fractures, videos used

Interobserver agreement poor

Range 42-94% for each fracture
Ortho attendings - 59% agreement
Ortho Trauma Fellowship trained attendings - 66%
agreement
Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The
results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone and Joint Am; 76(8):1162
1166.

So.
Fracture type should not be classified
in the ER
Most reliably done in the OR at the
completion of primary wound care
and debridement

Microbiology
Most acute infections are caused by
pathogens acquired in the hospital
1976 Gustilo and Anderson
most infections in their study of 326 open
fxs developed secondarily

When left open for >2wks, wounds were

prone to nocosomial contaminants such
as Pseudomonas and other GN bacteria
Currently most open fracture infections
are caused by GNR and GP staph
Gustilo RB, Anderson JT: Prevention of Infection in the Treatment of One Thousand and Twenty-five Open
Fractures of Long Bones; JBJS, 58(4):453-458, June 1976

Nocosomial infection?!!!!

Cover
the
wounds
quickly

Only 18% of infections were caused

by the same organism initially
isolated in the perioperative
cultures*
Carsenti-Etesse et al. 1999
92% of open fracture infections were
caused by bacteria acquired while the
patient was in the hospital**
*Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the infection rate in open tibial fractures. Clin
Orthop Relat Res. 1983 Sep;(178):36-41.
*Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized,
double-blind study comparing single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy in open
fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-33.
**Carsenti-Etesse H, Doyon F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B, Dellamonica P.
Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis.

Common bacteria
encountered with open
fractures
Blunt Trauma, Low Energy GSW Staph, Strept
Farm Wounds

Clostridia

Fresh Water

Pseudomonas, Aeromonas

Sea Water

Aeromonas, Vibrios

War Wounds, High Energy GSW Gram Negative

What systemic antibiotic?

1st Gen
Ceph

Gent

PCN

Grade 1

Grade 2

+/-

Grade 3

+/-

Farm/War
Wounds

(Gustilo, et al; JBJS 72A 1990)

Antibiotic comparisons
No difference btwn clindamycin and cefazolin*
Patzakis et al. **
For type 1&2, cipro = cefamandole+gentamicin
For type 3, cipro worse (31% vs 7.7% infection)

Cipro and other fluoroquinolones inhibit

osteoblast activity and fracture healing***

*Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a
prospective study. J Trauma. 1983;23:25-30.
**Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P. Prospective, randomized,
double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in

When and for how long?

Start abx as soon as possible*
Less than 3 hours 4.7 % infection rate
Greater than 3 hours 7.4%

No difference btwn 1 and 5 days of post

op abx treatment**
Mass Gen recommended treatment:***
Cefazolin Q 8 until 24 hours after wound
closed
Gentamicin or levofloxacin added for type 3
*Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res.
1989;243:36-40.
**Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou

Local antibiotic therapy

High abx conc within the wound and
low systemic conc
Reduces risk of systemic side effect

Vancomycin or aminoglycosides
Heat stable
Available in powder form
Active against suspected pathogens
Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic
use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res.
1988; 237:213-5.

Antibiotics - locally
Antibiotic

Infection Rate

IV Abx

12%

IV Abx + local
aminoglycoside impregnated
PMMA beads

3.7%

Prevents secondary contamination by

nocosomial pathogens
Useful adjunct to systemic abx
Potential for abx impregnated bone
graft, bone graft substitute, and abx
coated IMN
Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures. A review of 1085
consecutive cases; J Bone Joint Surg Br. 1995 Jan;77(1):93-7.

Antibiotic Beads
Pros
Very high
levels of
antibiotics
locally
Dead space
management

Cons

Requires removal
Limited to heat
stable antibiotics
Increased
drainage from
wound

Goals of treatment
1. preserve life
2. preserve limb
3. preserve function
Also.
Prevent infection
Fracture stabilization
Soft tissue coverage

Stages of care for open

fractures

Initial assessment &

management

ABCs
Assess entire patient
Careful PE, neurovasc
Abx and tetanus
Local irrigation 1-2 liters
Sterile compressive dressings
Realign fracture and splint
Do not culture wound in the ED*
8% of bugs grown caused deep
infection
cultures were of no value and not
to be done

Recheck pulse, motor and

sensation
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.

Can I take pictures with my

phone and send it to my
senior?
Documents characteristics

accurately
Prevents multiple examinations
Decreases contamination*

Communication via digital

photography was more useful
than verbal communication**
1.3-megapixel camera is
comparable with higher resolution
cameras when viewing color
images on computer desktop***

*Tscherne H, Gotzen L, editors Fractures with soft tissue injuries. New York: Springer; 1984
**Tipmongkol V, Thepkamnoet H, Tangtrakulwanich B: Using Digital Wound Photography to Improve
Communication among Orthopaedic Health Care Professionals in Orthopeadic Patients. The Thai Journal of
Orthopaedic Surgery: 33 No.2: S16-20 AAOS 2010 Podium Present

Primary surgery
Objectives of initial
surgical management
Preservation of life and
limb
Wound debridement
Definitive injury
assessment
Fracture stabilization

Stages of open fracture management in

Surgical emergency!
1898 Friedrich guinea pigs
Take to the OR within 6-8 hours*

1973 Robson:
bacteria multiply in
contaminated wounds **
105 organisms/gram of tissue is
the infection threshold
Reached at 5.17 hours

1995 Kindsfater et al:

47 G2/3 fxs at 4.8 months out.
Less than 5 hrs 7% infection
Greater than 5 hrs 38% infection
However G3 fxs were treated later

*Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:288-310.
**Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res.

Or not?....
Calling the 6 hour rule into
question

1993 Bednar and Parikh. No significant difference *

3.4% vs 9%; 82 open femoral/tibial fxs

2004 Ashford et al. No significant difference **

No significant
2004 Spencer et al.... No significant difference ***
10.1% vs 10.9%;difference
142 open long bone fxs from UK
2003 Pollack and the LEAP investigators. No
correlation****
before or after
315 open long bone fxs
2005 Skaggs et al.No
significant difference *****
6 hours!!!
11% vs 17%; pts from the austrailian outback

children with all types of open fractures; 554 open

fractures

*Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures
of the lower extremities caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5.
**Ashford RU, Mehta JA, Cripps R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial
fractures. Injury. 2004;35:411-6.

Do we even need to do
operative debridement?
Orcutt et al... No significant difference,
Do we even
BUT*
50 type 1 &2 open
fractures
need
to
less infection in nonoperative group (3% vs
debride low
6%)
open
Less delayedgrade
union in nonop
group (10% vs
16%)

fractures?

Yang et al.0% infections **

91 type 1 open fractures treated without I&D
*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at
the Annual Meeting of the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.

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.

URGENTLY debride, not

EMERGENTLY
Time to OR is probably less important
than:*

Adequacy of debridement
Time to soft tissue coverage

Timing depends on.**

Within
24
Ortho
trained scrub techs, assistant surgeons,
hours
xray techs, and other OR staff

Is patient stable?
Is the OR prepared?
Is appropriate assistance available?

Within
6
hours

2005 Skaggs et al:***

If after 10pm, keep until the morning! Or at
least within 24 hours.
Unless.
neurovasc compromise
horrible soft tissue contamination
compartment syndrome
*Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg.
2006 Dec;88(12):2739-48.

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
Animal studies show improved
removal of particulate matter
and bacteria but effect
plateaus
Irrigation bags typically
contain 3 L of fluid
Anglen recommends:*
3L (one bag) for type 1
6L (two bags) for type 2
9L (three bags) for type 3

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

How to deliver the irrigation?

(what animal studies show)
Bulb Syringe vs Pulsatile
Lavage
Pulsatile lavage
Detrimental for early bone healing
this is no longer present at 2 wks *

More soft tissue destruction **

More effective in removing
particulate matter and bacteria ***

High or low pressure?

Higher pressure
Better bone cleaning
Worse soft tissue cleaning
Slows bone healing

*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. High Pressure Pulsatile Lavage Irrigation of
Intraarticular Fractures: Effects on Fracture Healing. JOT 1998. 12(7): 460-463.
**Boyd JI, Wongworawat MD. High-Pressure Pulsatile Lavage Causes Soft Tissue Damage. CORR 2004. 427:
13-17

Antibiotics in the irrigation?

Antibiotics (bacitracin and/or
neomycin)
Mixed results, controversial
Costly

No proven
bacitracin alone around $500/washout
?? Causingbenefit!
resistance
Wound healing problems?
Few reported cases of anaphylaxis
Anglen: No proven value in the care of
open fracture woundssome risk, albeit
small.
*Anglen JO. Wound Irrigation in Musculoskeletal Injury. JAAOS 2001. 9: 219-226.

Soaps in the irrigation?

Surfactants (i.e. Soaps)
Less bacteria adhesion
Emulsify and remove
debris
No significant difference
in infection or bone
healing compared to
bacitracin solution, but
more wound healing
problems in bacitracin
group
Anglen JO. Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A
Prospective, Randomized Study. JBJS-A 2005. 87(7):1415-1422.

Level 4 evidence based

recommendations
1st washout, highly
contaminated

Soap solution

Repeat washout of clean

wounds

Saline

Infected wounds

Soap, then antibiotic

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

Wound closure after contaminated

fracture

Timing and technique is

controversial

OPEN WOUND should be left OPEN!

Dubunked!
Prevents anaerobic conditions
in wound: Clostridium
Facilitates drainage
Allows repeat debridement

Zalavras CG, Patzakis MJ:Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 MayJun;11(3):212-9.

To close or not to close?

Recently, renewed
interest in primary
closure

1999 Delong et al: 119 open fxs

Collinge, OTA 2004

Moola, OTA 2005
Russell, OTA 2005
DeLong, J Trauma
2004/
Bosse, JAAOS 2002

Improved abx
management
Better stabilization
Less morbidity
Shorter hospital stay,
lower cost
NO increase in wound
infection

These wounds are at

higher risk of clostridia
perfringens if they do
get infected.

No significant difference
delayed/nonunion and infection rates btwn
immediate and delayed closure

Immediate closure is a viable option

Grad
e

Percent of primary
closures

88%

86%

3a

75%

3b

33%

3c

0%
infection rate

7%

Overall delayed/nonunion
rate

16
%

DeLong WG Jr, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture

Contraindications to primary
closure
Inadequate debridement
Gross contamination
Farm related or freshwater
immersion injuries
Delay in treatment >12 hours
Delay in giving abx
Compromised host or tissue viability

When to cover the wound?

ASAP after wound adequately debrided
Only 18% of infections are caused by the same
organism isolated in initial perioperative
culture*
Suggests hospital acquired etiology of infection

Fix and Flap**

For Type IIIB & IIIC open tibia fractures
Early
flap
coverage
Timingifofnot
flap immediate
Infection
rate
placement
< 72 hours

6%

> 72 hours

30%

Patzakis MJ, Bains RS, Lee J, et al. Prospective, randomized, double-blind study comparing single-agent
antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. JOT 2000. 14:
529-533.

Dressings
Temporary closures rubber bands
Wet to dry dressings
Semi-permeable membranes
Antibiotic bead pouch
VAC

VAC
Vacuum assisted wound closure
Recommended for temporary management
Mechanically induced negative pressure in a closed
system
Removes fluid from extravascular space
Reduced edema
Improves microcirculation
Enhances proliferation of reparative granulation
tissue

Open cell polyurethane foam dressing ensures

an even distribution of negative pressure
-Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg.
2002 Sep-Oct;10(5):303-11.

Types of fracture
stabilization
Splint
Good option if operative
fixation not required

Internal fixation
Wound is clean and soft
tissue coverage
available

External fixation
Dirty wounds or
extensive soft tissue
injury

Fracture stabilization
Gustilo type 1 injury can be treated
the same way as a comparable
closed fracture
Most cases involve surgical fixation
Outcome is similar to closed
counterparts

Fracture stabilization
Gustilo type 2&3 usually displaced and
unstable
dictate surgical fixation

Restore length, alignment, rotation and

provide stability
ideal environment for soft tissue healing and
reduces wound infection
reduces dead space and hematoma volume
Inflammatory response dampened
Exudates and edema is reduced
Tissue revascularization is encouraged

When to use
plates?
Open diaphyseal fractures of arm & forearm
Open diaphyseal fractures lower extremity
NOT recommended
Open tibial shaft plating assoc high infection
rate*

Open periarticular fractures

Treatment of choice in both upper and lower
extremities
Bach AW, Hansen ST Jr.: Plates versus external fixation in severe open tibial shaft fractures. A randomized
trial. Clin Orthop Relat Res. 1989 Apr;(241):89-94.

When to use IM
nails?
Treatment of choice for
most diaphyseal fractures
of the lower extremity
Inserted without
disrupting the already
injured soft tissue
envelope
Preserves the remaining
extra osseous blood
supply to cortical bone
Malunion is uncommon

To ream or not to ream?

Does reaming cause additional damage to the
endosteal blood supply?
Solid IM nails without reaming has a lower risk of
infection that tubular nails with a large dead
space*
However reamed IM nails are biomechanically
stronger and can reliably maintain fracture
reduction if statically locked
2000 Finkemeier et al.
reamed vs unreamed interlocked nails of open tibias
NO statistical difference in outcome and risk of
complication**
*Melcher GA, Claudi B, Schlegel U, Perren SM, Printzen G, Munzinger J.Influence of type of medullary nail on the
development of local infection. An experimental study of solid and slotted nails in rabbits; .J Bone Joint Surg Br.
1994 Nov;76(6):955-9.

When to use external

fixation?
Diaphyseal
fractures not
amenable to IM
nails
Ring fixators for
periarticular
fractures
Temporary joint
spanning ex fix is
popular for knee,
ankle, elbow and
wrist
If temporary, plan
for conversion to
IM nail within 3
weeks

Ex-fix: Weigh the pros and

cons!

Historically was definitive treatment

Now, more commonly as temporary fixation
Can be applied almost always and everywhere
Severe soft tissue damage and contamination

Advantages:

Easy and quick

Relatively stable fixation
No further damage done
Avoids hardware in the
open wound

Disadvantages:

Pin track infections

Malalignment
Delayed union
Poor patient
compliance

Skin cover and soft tissue

reconstruction
Do these early!
1994 Osterman et al.*

Infection
risk
Retrospective 1085 fractures, 115 G2
and
239
G3
increases
if
wound
All treated with appropriate IV Abx and I&D

7 days

No infection if wounds closed at 7.6

days
Yes infection if wounds closed at 17.9
days

open >

*Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures: A review of 1085
consecutive cases. J Bone Joint Surg Br 1995;77:9397.

Reconstructive ladder: options

for wound coverage
Type 1 open fx

Type 2/3A open fx

Type 3B
open fx

Flap coverage for type 3b

Type 3c, a bad injury!

Devastating damage to
bone and soft tissue
Major arterial injuries
that require repair
Poor functional
outcome
Consensus btwn ortho,
vascular and plastics
Salvage is technically
possible in most cases
However it is not
always the correct
choice esp type 3c tibia
fractures

We can do both, salvage &

amputate.

Vascular surgery can

revascularize with bypass graft
Generally before fracture
stabilization

Plastics can provide soft tissue

coverage
However, in the tibia, the
severity to soft tissue
envelope and bone may result
in infected nonunion
If salvage. long course of
repeated surgical procedures
Painful and psychologically
distressing
Functional outcome may be poor
and no better than amputation

How to decide, salvage or

amputate?
Important factors in decision
making:*
General condition of the patient (shock)
Warm ischemia time (>6hours)
Age (>30 years)
Cut to crush ratio (blunt injuries has a
large zone of crush)

Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities
following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg. 1987 Apr;53(4):2058.

Gunshot injuries
Energy dissipated at impact =
damage severity
High velocity rifles and close range
shotguns
Worst, high energy of impact
Huge secondary cavitation
Secondary effects of shattered bone
fragments

Bullets lodged in joints should be

removed
avoid lead arthropathy and systemic
lead poisoning

Low velocity GSW <2000

ft/sec
Low velocity handguns
Less severe, not treated like open
fractures
Cavitation is not significant
Secondary missile effects are minimal
Bone fragments rarely stripped of soft
tissue attachments and blood supply
Soft tissue injuries not severe and skin
wounds are small

Low velocity GSW open

fractures
Geisslar et al. *
Dickey et al.**
No abx vs IV Ancef
If neurovascular
Treat open
x 3d
status normal, do
fractures
from

67 low velocity
local debridement
GSW fxs
low
GSW
NO formal
I&Dvelocity
Not requiring
needed
operative fixation
as closed
IV Abx
No difference in
fractures
without
infection rates
Approach
fx
**Dickey et al, J Ortho Trauma, 3;6-10,1989
fixation as if closedAbx
*Geisslar ett al, J Ortho Trauma, 4;39-41,1990

Pitfalls and complications

Infection delayed union, nonunion,
malunion and loss of function
Plan ahead to avoid delayed union and
nonunion
Predict nonunion in severe injuries with bone
loss
Bone grafting usually delayed 6 weeks when soft
tissues have soundly healed
Autogenous bone grafting is usual strategy
Fibular transfer, free composite graft or distraction
osteogenesis for complex defects
Recombinant human BMP in open tibia fracture
reduces risk of delayed union

Advances
BMPs
40% decreased infection rate with BMP
in type 3 open tibia fractures*

Antibiotic Laden Bone Graft**

Tobramycin-impregnated calcium sulfate
pellets with demineralized bone matrix
Animal study: successful in preventing
infection
*BESTT Study Group, Govender S, Csimma C, Genant H, Valentin-Opran A. Recombinant Human Bone
Morphogenetic Protein-2 for Treatment of Open Tibial Fractures: A prospective, controlled, randomized study
of four hundred and fifty patients. JBJS-A 2002. 84(12): 2123-2134.
**Beardmore AA, Brooks DE, Wenke JC, Thomas DB. Effectiveness of local antibiotic delivery with an

Summary

A = good evidence (level 1 studies)

B = fair evidence (level 2/3 studies)
C = poor quality evidence (level 4/5 s
I = insufficient or conflicting evidence

Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):273
48.

Thank you