Open Fractures - Background, Etiology An... Ogy, Indications and Contraindications

5/2/2018 Open Fractures: Background, Etiology and Pathophysiology, Indications and Contraindications
Open Fractures
Updated: Feb 10, 2016
Author: Thomas M Schaller, MD; Chief Editor: Jason H Calhoun, MD, FACS more...
Background
The procedure for evaluation and management of open fractures is best described as a set of
principles that has evolved over time, often in relation to advances in wartime care of military
personnel. These principles involve both initial management and subsequent surgical intervention. [1,
2, 3]
The first step is accurate diagnosis and documentation of the mechanism of injury. Appropriate
coverage of the wound and splinting of the fracture are performed in conjunction with initiation of
appropriate antibiotic therapy and tetanus prophylaxis. Urgent surgical intervention typically follows
and involves both soft tissue and bone management. Adjuncts to the care of open fractures have
evolved and often involve delivery of antibiotics or metabolically important substances to the local
fracture environment.
These principles are generally well established and accepted across the orthopedic community, but in
some respects, controversy still exists regarding the details.
Open fractures pose some unique risks beyond those encountered with similar closed fractures that
may occur with similar amounts of force. The greatest problem is the risk of infection. Diaphyseal bone
loss in excess of 3 cm presents a complex set of problems as well. If the open fracture was caused by
penetrating trauma, direct injury to major neurovascular structures may be more likely, thereby
affecting the prognosis for limb function.
The risk of a fracture being open is related to the amount of softtissue coverage in that region of the
body and to the amount of energy imparted to that region. For example, the tibia has a long medial
aspect that is subcutaneous, and therefore, it is “easier” for trauma to the lower leg to expose the bone
and fracture site. Conversely, the femur is surrounded by thick muscle layers circumferentially and,
therefore, is less likely to be exposed after a similar amount of force to the thigh.
For more information, see the following topics:
Open Tibia Fractures
Tibia and Fibular Fractures
Diaphyseal Femur Fractures
Supracondylar Femur Fractures
Etiology and Pathophysiology
Open fractures occur in many ways, and the location and severity of the injury are directly related to
the location and magnitude of the force applied to the body. Clearly, this involves a broad spectrum of
clinical scenarios.
https://emedicine.medscape.com/article/1269242-overview#a2 1/26
In the most benign form, an open fracture may involve a very small wound caused by a sharp bone
spike, creating a small, minimally contaminated hole in the overlying skin. The opposite end of the
spectrum may involve highvelocity gunshot wounds, vehicular trauma, or industrial accidents with
associated tissue crushing and devitalization.
Direct inoculation of the tissue is a basic issue in the pathophysiology of open fracture management.
Furthermore, bacteria can colonize wounds at later stages of care, being introduced into the wound at
subsequent dressing changes or repeat debridements prior to definitive wound closure. Gustilo and
Anderson reported that 50.7% of their 158 patients had a positive wound culture upon initial
evaluation. [4] Another 31 patients that were initially culture negative had a subsequent positive culture
at the time of their definitive closure.
Because of the identification and sensitivity of the invading organisms, a firstgeneration cephalosporin
and aminoglycosides have become the most common choices for initiation of antibiotic therapy after
open fracture.
Devitalized tissue results from the energy imparted to the body. A crushing injury can impair the local
immune response, with local ischemia playing a large role in this process. Ischemia may also occur by
direct trauma to the large vessels and/or microcirculation. Important indirect causes of ischemia
include increased myofascial compartment pressures, increased vascular permeability, and the use of
vasoconstrictive medications during resuscitation.
Indications and Contraindications
Virtually all open fractures must be considered for operative intervention. The introduction of bacteria
and softtissue compromise associated with even “minor” open fractures mandate appropriate
presurgical and surgical management to minimize the risk of clinically important complications. [5, 6]
Perhaps the only absolute contraindication for operative management of an open fracture arises if the
patient is in such critical condition that any operative intervention could lead to further deterioration;
however, there is no evidence from randomized controlled trials to support this concept. Even the
patient in extremis may benefit from wound irrigation and sterile application of traction or external
fixation in the trauma bay or trauma care unit until a formal irrigation and debridement can be
undertaken in the operating room.
Laboratory Studies
Laboratory tests are typically not directly important for the acute care of an open fracture. However,
many patients with open fractures will have other injuries that require appropriate laboratory
investigation, and Advanced Trauma Life Support (ATLS) guidelines should be followed for workup of
the traumatized patient. [7]
Acute bacterial culture of open fracture wounds, before or shortly after initial debridement, is of little
clinical utility. [8] Organisms isolated in the acute phase of treatment do not correlate well with clinical
infections that result from open fractures. Therefore, the routine use of cultures at this stage of care is
of little benefit to the patient and is not costeffective.
Imaging Studies
Basic orthogonal radiographs (typically, anteroposterior and lateral projections) are taken of the injured
extremity. The images should include the joint proximal and distal to the area of injury. Oblique images
can be used to obtain further information, as needed. Evaluation of skeletally immature patients is
often facilitated by use of comparison views of the contralateral extremity or joint involved. (See the
images below.)
An open midfoot fracture with bone loss at the base of the first metatarsal, including approximately 66% of the
joint surface.
View Media Gallery
The foot was cared for with serial debridement and temporary pinning of the midfoot to preserve alignment with
minimal additional surgical trauma.
View Media Gallery
An antibioticimpregnated cement spacer was placed in the bone void, and 12 weeks later, after the pins had
already been removed, a midfoot fusion was performed.
View Media Gallery
Intraoperative image of the midfoot fusion. The cement spacer has been replaced by autologous bone graft from
the iliac crest.
View Media Gallery
Computed tomography (CT) and magnetic resonance imaging (MRI) provide further detail of bone and
softtissue injury, but they are often not immediately needed for the acute management of an open
fracture. They tend to be most useful in the management of complex periarticular injuries.
The use of ultrasonography to assess tissue perfusion, myofascial compartment pressure monitors,
and perhaps magnetic resonance angiography (MRA) or enhanced CT imaging of the softtissue
elements of the extremity are all current areas of intense research and should provide increased levels
of predictive data when validated.
Classification of Open Fractures
GustiloAnderson classification
Internationally, for adults and pediatric patients, the modified GustiloAnderson classification is widely
used. [4] Their initial description was published in 1976, as follows:
Type I Open fracture with a wound less than 1 cm in length, and clean
Type II Open fracture with a laceration more than 1 cm in length, without extensive softtissue
damage, flaps, or avulsions
Type III Either an open segmental fracture, an open fracture with extensive softtissue damage,
or a traumatic amputation
The description of type III fractures was subsequently further refined and described by Gustilo et al in
1984, [9] as follows:
Type IIIa Severe comminution or segmental fractures, but with adequate coverage of bone and
a wound that is closeable by simple means
Type IIIb Extensive softtissue damage in association with the open fracture, with significant
bone exposure and periosteal stripping, typically requiring tissue rotation or free tissue transfer
for closure
Type IIIc Any open fracture with an arterial injury that requires repair
It is important to note that the severity of the injury may not be fully appreciated at the time of initial
evaluation, and therefore, classification should be based on the intraoperative findings.
Orthopaedic Trauma Association classification
The Orthopaedic Trauma Association (OTA) published a fracture and dislocation classification
compendium, according to which open fractures are categorized on the basis of five main variables,
as follows. [10]
Skin injury:
1. Laceration with edges that approximate
2. Laceration with edges that do not approximate
3. Laceration associated with extensive degloving
Muscle injury:
1. No appreciable muscle necrosis, some muscle injury with intact muscle function
2. Loss of muscle but the muscle remains functional, some localized necrosis in the zone of injury
that requires excision, intact muscletendon unit
3. Dead muscle, loss of muscle function, partial or complete compartment excision, complete
disruption of a muscletendon unit, muscle defect does not reapproximate
Arterial injury:
1. No major vessel disruption
2. Vessel injury without distal ischemia
3. Vessel injury with distal ischemia
Contamination:
1. None or minimal contamination
2. Surface contamination (not ground in)
3. Contaminant embedded in bone or deep soft tissues or high risk environmental conditions
(barnyard, fecal, dirty water, etc)
Bone loss:
1. None
2. Bone missing or devascularized bone fragments, but still some contact between proximal and
distal fragments
3. Segmental bone loss
To date, relatively few studies have been done comparing the GustiloAnderson and OTA classification
systems with regard to prediction of treatment outcomes (eg, infection, limb amputation, need for soft
tissue coverage, or limb salvage). In a retrospective study aimed at examining this question, Hao et al
found the OTA system to be better than the GustiloAnderson system at predicting postoperative
complications and treatment outcomes in patients with open longbone fractures. [11]
Parenteral Antibiotic Administration
Patzakis et al described the value of acute systemic antibiotic use for open fractures. [12] In a later
review article, Patzakis and Zalavras pointed out that the administration of antibiotics is best
considered therapeutic, not prophylactic, because of the high risk of infection in the absence of
antibiotics. [13]
Although debate still surrounds some aspects of antibiotic administration for open fractures, the
following generalizations can be made:
All patients with open fractures should receive cefazolin or equivalent grampositive coverage;
this may be sufficient for type I injuries
Type II or type III injuries likely benefit from the addition of adequate gramnegative coverage,
typically with an aminoglycoside
Injuries at risk for anaerobic infections (eg, farm injuries, severe tissue necrosis) probably benefit
from the addition of penicillin or clindamycin
The emergence of various antibioticresistant organisms and the development of alternative regimens
of antibiotics for use in open fractures have not yet been sufficiently well studied.
Tetanus Immunization and Prophylaxis
Immunization and prophylaxis against tetanus deserve specific consideration. Tetanus is caused by
infection from Clostridium tetani, which is an anaerobic bacterium commonly found in soil, and the
toxins produced by the bacteria lead to severe and potentially lifethreatening muscular spasm.
Immunization of civilians became widespread after successful use of heatinactivated toxin during
World War II. [14]
On the basis of a review of various sources, Rhee et al made the following recommendations
regarding tetanus vaccine in cases of traumatic wounds [14] :
Perform appropriate irrigation and debridement as indicated
Obtain patient’s immunization history
Administer tetanus toxoid if the last booster was given more than 10 years previously or if history
is not reliable or available
Give tetanus immunoglobulin to patients with incomplete primary immunization or to patients for
whom it has been longer than 10 years since their last booster dose
The authors point out that the severity of the wound should not be a factor in determining the need for
tetanus immunization or prophylaxis.
Surgical Therapy
Surgical management of open fractures involves adhering to a series of principles that have evolved
over time and that are largely based on the care of warwounded military personnel by military
surgeons. A leading example is the work by Trueta, which described the successful use of
debridement with splinting of injured extremities. [15] Introduction of invasive skeletal stabilization and
continued focus on wound management led to increasing success. A modern protocol from Operation
Enduring Freedom, by Lin et al, was not associated with any infections in 14 open fractures. [16]
Preoperative details
It is critical to follow Advanced Trauma Life Support (ATLS) and institutional protocols to properly
evaluate a trauma patient. [7] The preoperative evaluation must accurately document neurologic and
vascular status. Digital photos are helpful for documenting the initial appearance of the extremity and
can be a valuable addition to the medical record. Digital imaging allows other members of the
treatment team to see the wound preoperatively without repeated manipulations of the wound.
Open fracture wounds can then be dressed with sterile, moist gauze, and clinical realignment of the
limb can be accomplished with a temporary splint or traction. Patients who are appropriate for
operative management should be urgently brought to the operating room.
Irrigation
Washing the wound with large volumes of fluid will remove macro contamination and clotting that may
obscure the view of deeper levels of contamination or damaged tissue. Once the macro contamination
is eliminated, the irrigation serves to diminish the residual bacterial contamination of the remaining
healthy tissue. Irrigation is often done in conjunction with surgical debridement.
The use of antibiotics and other bactericidal additives to the irrigant continues to be a controversial
treatment topic, but the chemical makeup of many of the additives is similar to that of soap and thus
potentially can cause tissue swelling and the creation of surface layers over the damaged tissue. [17]
Debridement
The debridement of an open fracture must be done in a thorough and systematic manner so as to
avoid leaving devitalized tissue or contamination behind. [18] The skin edges of the traumatic wound
should be trimmed to a healthy bleeding edge. Loose subcutaneous fat is also removed, along with
any severely contused or noncontractile muscle. To ensure adequate debridement, traumatic wounds
must be extended and muscle compartments opened and explored.
The removal of devitalized tissue is not limited to the soft tissues; bone should also be removed if it is
free of softtissue attachment. Major articular fragments may be an exception to this rule; they should
be retained whenever possible to allow for attempts at fixation and restoration of joint stability and
motion. In general, the goal is to remove damaged tissue that would serve as a breeding ground for
bacteria, without creating extensive additional surgical trauma by unnecessary periosteal stripping or
undermining of the skin flaps.
In highenergy cases, it is often necessary to perform multiple debridements so as to adequately
remove tissue that may evolve after the time of the initial operative inspection. In principle, it is best to
avoid infection by removing devitalized bone and muscle and then to deal with later reconstruction by
using bone grafting and softtissue flaps in an aseptic environment.
Stabilization
Fracture stabilization is critical for management of the injured extremity and for the overall benefit of
the patient. The stability imparted to the bone helps minimize ongoing trauma to the soft tissues and
provides a stable scaffold for tissue healing. Furthermore, bone stability allows for early functional
motion of the extremity. Nursing care and mobilizing the patient out of bed are facilitated as well.
The choice of fracturefixation method is based on many factors, including quality of local soft tissues,
location and pattern of the fracture, overall health of the patient, and associated injuries. A detailed
discussion of all the possible fixation methods for the variety of open fractures is beyond the scope of
this article. Generally speaking, the method of fixation must minimize additional surgical trauma to the
zone of injury while providing adequate stability for patient mobilization and soft tissue healing.
Local adjuncts
Some open fractures may benefit from the addition of local antibiotics. Antibiotics placed in the zone of
injury can achieve high local concentration of the drug, typically without systemic side effects. [19] The
technique involves antibioticimpregnated beads sealed into the wound for gradual elution of drug to
the surrounding tissues. The technique is based on the addition of heatstable antibiotic powder to a
batch of polymethylmethacrylate (PMMA) cement, forming beads that are threaded on nonabsorbable
suture or wire.
The use of multiple small beads creates a relatively large overall surface area for antibiotic elution.
Antibiotic cement spacers may also be used to preserve softtissue space in the presence of a
significant bone defect; during a subsequent procedure, the cement spacer can be removed and the
void filled with bone graft. An interesting aspect of this technique is that it has been shown that the
pseudocapsule that forms around the cement has some osteogenic properties beneficial for promoting
successful union after subsequent procedures. [20]
Commercially available preformed antibiotic beads are available and are typically made with a
calciumbased, absorbable bead. These beads need not be removed at a subsequent procedure, and
studies in animal models of contaminated open fractures using these systems appear to demonstrate
promising outcomes. [21]
Initial wound management
Although the practice has come under scrutiny, the prevailing method for dealing with open fracture
wounds has been to perform serial debridements and close wounds in a staged fashion, particularly
with type III injuries. Delayed wound closure became the standard on the basis of the experience of
military surgeons and the severe consequences faced in dealing with primarily or prematurely closed
wounds.
A common practice is to close the surgically created extensions of the traumatic wounds at the time of
fixation and initial debridement, followed by a second look at the wound, with further debridement if
necessary, in 4872 hours. This can be repeated as indicated by the presence of any further evolution
of tissue necrosis.
Vacuumassisted closure (VAC) has become a popular technique for dealing with open fracture
wounds. Some studies have suggested that the use of negativepressure wound therapy (NPWT) may
decrease the need for free tissue transfer or rotational flap coverage in highenergy open fractures. In
many cases, abundant granulation tissue forms and residual softtissue defects can be covered
effectively with basic skin grafts. [22, 23] (See the images below.)
An open tibia fracture with bone loss. A tibial nail was placed and the wound was managed with negative
pressure wound therapy, eventually covered with splitthickness skin graft.
View Media Gallery
Eight weeks later, the defect was approached from a lateral incision to avoid the previous medial open fracture
wound. A central bone grafting technique was performed.
View Media Gallery
The central aspect of the leg was filled with bone graft, and internal fixation of the fibula was performed.
View Media Gallery
The appearance of the mature synostosis 8 months after the patient's original injury.
View Media Gallery
Complications
Infection is the most obvious complication from open fracture. [5, 6] The risk of infection is related to the
severity of the injury (see Classification of Open Fractures above), as follows [13] :
GustiloAnderson type I, 02%
GustiloAnderson type II, 210%
GustiloAnderson type III, 1050%
Failure to heal may result with any fracture. For of a variety of reasons, nonunion risk is greater with
open fractures than with similar closed fractures. Many of the factors are related to the damaged blood
supply at the zone of injury. The impaired circulation can lead to poor formation or loss of the fracture
hematoma. The subsequent poor delivery of inflammatory mediators to facilitate callus formation and
the presence of necrotic bone exacerbates the risk of nonunion.
Bone and/or periosteum loss from the fracture site impairs bone healing as well. Operative technique
of debridement and fixation must focus on minimizing further trauma to the bone and surrounding
tissues.
Details regarding outcome and prognosis for open fractures are variable, based on the specifics of the
local and associated injuries.
Postoperative Details and Followup
The duration of postoperative antibiotic use is not clearly supported by the literature, but a common
clinical practice is to continue perioperative antibiotics for 2448 hours after each operative
intervention until complete wound coverage or closure. Some of the literature strongly questions this
practice, and concern has been raised regarding the development of resistant systemic nosocomial
infections in the polytrauma patient because of overuse of perioperative antibiotics. [24] A modern
study in the setting of current trauma care, fixation techniques, and antibioticresistance patterns is
needed to clarify this issue.
In situations involving significant bone loss, the postoperative plan may include the use of autologous
bone graft. In highenergy open fractures, the timing of subsequent grafting procedures should be
based on the presence of a “fully reepithelialized wound with no drainage” and no clinical evidence of
infection. [25]
The frequency of followup is driven by various factors. The wound may need to be monitored closely
in the early phases of healing. The particular fractures and chosen methods of fixation will determine
the need for radiographic and clinical reexamination. (See the images below.)
An open midfoot fracture with bone loss at the base of the first metatarsal, including approximately 66% of the
joint surface.
View Media Gallery
The foot was cared for with serial debridement and temporary pinning of the midfoot to preserve alignment with
minimal additional surgical trauma.
View Media Gallery
An antibioticimpregnated cement spacer was placed in the bone void, and 12 weeks later, after the pins had
already been removed, a midfoot fusion was performed.
View Media Gallery
Intraoperative image of the midfoot fusion. The cement spacer has been replaced by autologous bone graft from
the iliac crest.
View Media Gallery
Open Fracture Care in Children
The principles for preoperative and intraoperative management of open fractures in the pediatric
population are similar to those for adults, but there are a few differences that are largely related to the
overall greater healing potential in this population.
In a review article, Stewart et al summarized each aspect of open fracture care for children. [26] They
noted that initial evaluation and classification of the injury should follow the modified GustiloAnderson
system, as in adults. The primary antibiotic choices are the same as in the adult population, but the
authors cautioned against alternative regimens involving fluoroquinolones because of issues related to
bone healing and chondropathy in children.
The timing of operative debridement has been studied retrospectively, and the results have called into
question the dogma related to emergency management of open fractures in this population. [27] In one
study, no difference in acute infection rate was found to be associated with operative care within 6
hours after injury as compared with operative care more than 7 hours after injury.
Further controversy stems from studies related to nonoperative management of type I open fractures,
but the authors caution strongly against this practice without definitive study. Softtissue care generally
follows that used in adults, and the use of vacuumassisted closure (VAC) has been shown to be safe
and effective in the pediatric population. [28] Fixation choices should account for the greater healing
potential in children and, therefore, often do not require the same degree of stability as in adults. [26]
Future and Controversies
Debridement
The timing of surgical intervention became controversial as a result of reevaluation of the literature
upon which orthopedic dogma was founded—that is, that all open fractures must be operatively
debrided and stabilized within 6 hours after the injury.
In 2006, Pollak authored a review of previous and more recent literature and concluded that "[the
concept of] mandatory debridement within 6 hours of injury is minimally supported by the literature.”
[29] Many studies that have utilized modern fixation strategies and immediate use of antibiotics have
not shown a timerelated difference in infection rate. As Pollak pointed out, a randomized trial in this
area is not feasible, but additional study is needed to further illuminate the role that timing of initial
surgical intervention plays on important outcome variables. [29]
Schenker et al published a systematic review and also concluded that the "6hr rule" is not well
supported by the existing literature. This was based upon the authors' close evaluation of 16 studies
that included over 3500 open fractures. [30]
In clinical practice, it is likely to be in the patient’s interest to use a more practical, less dogmatic
approach—namely, that open fractures should be treated surgically in an urgent (but not necessarily
emergency) fashion, utilizing appropriate timely antibiotic coverage, skilled debridement, and skeletal
stabilization.
Wound closure
The timing of wound closure is another area where the traditional dogma has been challenged. Again,
the standard treatment is based on literature published before current standards related to antibiotics,
surgical implants, and surgical technique. In short, it seems that, in many cases, primary wound
closure at the time of operative debridement and fixation can be done safely without additional risk to
the patient. As described by WeitzMarshall and Bosse, “Surgical judgment, typically gained with
experience, is required to successfully use an immediate woundclosure protocol." [31]
WeitzMarshall and Bosse made the following additional suggestions [31] :
Gross contamination, stagnant water contamination, and farm injuries or freshwater boating
injuries should not necessitate immediate wound closure
Delay of 12 hours after injury for delivery of antibiotics, confounding comorbidities, and doubt
about the adequacy of the initial debridement are all contraindications for acute closure
Pending definitive research, the “best clinical practice may be the adoption of a treatment plan
that allows for the earliest possible softtissue coverage over a clean, stable, viable zone of
injury”
Very similar recommendations were made in a review paper published by Crowley et al [32] and
include consideration of supporting literature published since the review described by WeitzMarshall
and Bosse. [31]
Irrigation
It is clear that irrigation is critical in the surgical management of open fractures, but the method of
irrigation and the choice of irrigant solution are subjects of debate. An international survey of 984
surgeons described some of the differences in practice: 70.5% preferred normal saline, 16.8% added
bacitracin, 6% added iodinebased solution, and 1.3% added a detergent or soap solution. Low
pressure modes of irrigation were preferred by 71%. The differences in practice reflect the variability in
early and more recent studies. [33]
The conclusions of Crowley et al with respect to irrigation may be summarized as follows [32] :
Normal saline should be used routinely
The use of antibiotics and antiseptics should be limited because of the lack of evidence of
efficacy and because of potential risks
Lowpressure methods should be used routinely; pressures above 50 psi likely damage soft
tissue and bone
A multicenter study by the FLOW investigators found that very low pressure (12 psi) was an
acceptable, lowcost alternative for the irrigation of open fractures. [34]
Bone morphogenic protein
Another area of both current controversy and future research pertains to the use of bone morphogenic
protein (BMP). Although BMP may have many applications related to orthopedic fracture care, it has
rarely been studied in relation to open fractures. A multicenter, prospective, randomized trial that
studied the use of recombinant human BMP2 (rhBMP2) in open tibia fractures found that patients
who received BMP at the time of their wound closure had lower infection rates and less frequent
secondary intervention to obtain union. [35]
Certainly, cost is one controversial aspect of BMP therapy, but Jones et al showed that the use of
BMP in open tibia fractures could result in a situation where the cost of the agent is offset, or even
surpassed, by cost savings resulting from decreased secondary procedures and complications. [36]
Further research is needed to define the proper patient and fracture populations in which BMPs are
safe and effective adjuncts to open fracture care.
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Contributor Information and Disclosures
Author
Thomas M Schaller, MD Orthopedic Trauma Surgeon, Steadman Hawkins Clinic of the Carolinas

Thomas M Schaller, MD is a member of the following medical societies: Alpha Omega Alpha,
American Academy of Orthopaedic Surgeons, AO Foundation, Orthopaedic Trauma Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Smith
Nephew<br/>Received income in an amount equal to or greater than $250 from: smith nephew.
Specialty Editor Board
Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical
Center College of Pharmacy; EditorinChief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.
Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery,
Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting
Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for
the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern
Orthopaedic Association

Disclosure: Nothing to disclose.
Chief Editor
Jason H Calhoun, MD, FACS Department Chief, Musculoskeletal Sciences, Spectrum Health
Medical Group

Jason H Calhoun, MD, FACS is a member of the following medical societies: American Academy of
Orthopaedic Surgeons, American College of Surgeons, American Diabetes Association, American
Medical Association, American Orthopaedic Association, American Orthopaedic Foot and Ankle
Society, Michigan State Medical Society, Missouri State Medical Association, Southern Medical
Association, Southern Orthopaedic Association, Texas Medical Association, Texas Orthopaedic
Association, Musculoskeletal Infection Society

Additional Contributors
Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and
Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Orthopedic
Surgery, Podiatry, Rheumatology, Sports Medicine, and Pain Management, Dreyer Medical Clinic;
Chairman, Department of Surgery, Provena Mercy Medical Center

Steven I Rabin, MD is a member of the following medical societies: AO Foundation, American
Academy of Orthopaedic Surgeons, American Fracture Association, Orthopaedic Trauma Association


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