Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246

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Journal of Clinical Orthopaedics and Trauma

journal homepage: www.elsevier.com/locate/jcot

Management of open fractures: A narrative review*

Jayaramaraju Dheenadhayalan*, Vasudeva Nagashree, Agraharam Devendra,
Purnaganapathi Sundaram Velmurugesan, Shanmuganathan Rajasekaran
Department of Orthopaedics and Trauma, Ganga Medical Centre and Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India

a r t i c l e i n f o a b s t r a c t

Article history: Open fractures are an emergency where the principal aim of the treatment is to maximise the restoration
Received 27 February 2023 of limb function while preventing the dreaded consequences of infection and non-union. The decision-
Received in revised form making process for open injuries is influenced by a variety of criteria, such as patient age, injury features,
22 July 2023
systemic response, activity level, comorbidities, and functional requirements. A collaborative orthoplastic
Accepted 31 August 2023
Available online 1 September 2023
approach to treating these injuries is essential for minimizing complications and need to be considered
as a single specialty in early and long-term management. It has been shown that early prophylactic
systemic antibiotics, wound irrigation, aggressive debridement of contaminated and devitalized tissue,
Keywords:
Open fractures
and appropriate fracture fixation decreases the complications in all grades of open fractures. The ad-
Ganga hospital open injury severity score vantages of Gram-negative antibiotics, the use of local antibiotics, intraoperative wound cultures, the "fix
Orthoplastic approach and flap" approach, and Negative Pressure Wound Therapy are few of the treatment options that are still
Debridement controversial. The aim of this review is to provide a comprehensive review and practice guidelines
Wound irrigation regarding the management of open fractures.
© 2023

1. Introduction 2. Initial evaluation

An open fracture is an injury where the fractured bone and/or
hematoma are exposed to the external environment through a
traumatic violation of the soft tissue and skin1. The spectrum of
open fractures can vary from cases that achieve primary closure
after debridement to more complex patterns requiring advanced
reconstructive techniques. The main objectives of the treatment are
to maximise limb function restoration while preventing the drea-
ded consequences of infection and non-union. which can pose
significant challenges to both patients and healthcare systems. In
the article, we aim to provide a comprehensive review and practice
guidelines regarding the management of open fractures.
abbreviations: ATLS, Advanced Trauma Life Support; BOAST, British Orthopedic
Association for Trauma and Orthopaedics; EAST, Eastern Association for the Surgery
of Trauma; ED, Emergency Department; HPPL, High Pressure Pulsatile Lavage; ICM,
International Consensus Meeting; LRS, Limb Reconstruction System; MRSA, Meth-
icillin-Resistant Staphylococcus Aureus; NPWT, Negative Pressure Wound Therapy;
OTA/OFSG, Orthopaedic Trauma Association and the Open Fracture Study Group;
GHOISS, Ganga Hospital Open Injury Severity Score.
*
Institution at which the work was performed: Ganga Medical Centre and
Hospitals Pvt. Ltd, 313, Mettupalayam Road, Coimbatore, India.
* Corresponding author. No.3, Gandhinagar, Behind Cheran Nagar, G N Mills Post,
Coimbatore, 641029, India.
E-mail addresses: dheenu.dhayalan@gmail.com (J. Dheenadhayalan),
agraharamdevendra@gmail.com (A. Devendra).
Open injuries are often due to high-velocity impact and present a
dramatic picture that may draw one's attention away from life-
threatening injuries. Therefore, it is pertinent to assess the patient
in accordance with the Advanced Trauma Life Support (ATLS) pro-
tocol to find any potentially fatal injuries. The primary survey of the
patient takes priority should be evaluated first, and any necessary
resuscitation techniques should be carried out.1 Early and adequate
resuscitation is now considered a crucial factor to reduce mortality,
future chances of infection, and delayed wound healing.
After patient stabilizes, open fractures need to be assessed and
treated emergently. Plain radiographs are usually adequate to
assess the extent of the fracture. CT scan may be done if the patient
is hemodymically stable, when necessary. In the absence of pulses,
a CT angiogram can be used to identify vascular injury. It is essential
to photograph the wound and document neurovascular injuries as
a routine in these injuries.2 Several factors, including patient age,
injury characteristics, systemic response, activity level, comorbid-
ities, and functional demands play a role in the decision-making of
open injuries.
3. Occlusive dressings in the emergency department
Although the National Institute for Health and Care Excellence
(NICE) advises against using wound irrigation in the emergency

https://doi.org/10.1016/j.jcot.2023.102246
0976-5662/© 2023
J. Dheenadhayalan, V. Nagashree, A. Devendra et al.
department(ED),3 delegates at the International Consensus
Meeting (ICM) on Musculoskeletal Infection supported wound
irrigation in the emergency setting to remove all visible contami-
nants before applying dressings4(Grade D recommendation).
Adequate wound washing and dressing can reduce contamination
and provide time for a quality debridement.5
4. Classification systems
Despite the existence of various classification systems, there is
currently no single system that is sensitivite and classify open
fractures based on their outcomes and accurately reflects their
prognosis.
Gustilo-Anderson classification: It is the most widely used
classification which is based on wound severity, size, periosteal
stripping, contamination, and vascularity, but it has high inter-
observer variability and lacks sensitivity.6 .It has undergone many
modifications since its original description to allow a more accurate
prognosis for more severe injuries (i.e., Type III injuries).7 It is
widely accepted for research, communication, training purposes,
and remains useful as a good, basic approach for managing open
fractures. Additionally, its implementation has played a significant
role in improving surgical protocols, modifying antibiotic guide-
lines, and determining the optimal timing for interventions such as
debridement, internal fixation, and soft tissue coverage. Despite
being often used in practice, it lacks sensitivity and has a number of
drawbacks. The wound descriptors used in the classification system
are highly subjective and have high inter-observer variability.8 Also,
the descriptors are not always mutually exclusive. For example, a
3 cm wound with periosteal stripping has features of both type 2
and type 3 and cannot be classified accurately. Additionally, the
spectrum of injuries that are grouped under type 3 is vast, ranging
from manageable to barely salvageable. The subtypes are
completely varied in terms of management and outcomes, which
makes it difficult to predict the prognosis.
Orthopaedic Trauma Association (OTA) and the Open Frac-
ture Study Group (OFSG) classification: In 2010, OTA/OFSG pub-
lished a classification based on a review of the literature of 34 risk
variables and a consensus from a panel.9 It depends on the condi-
tion of the skin, muscle, bone, and vascular system as well as the
degree of contamination. With moderate to excellent interobserver
reliability, this classification was shown to be better than the
Gustilo-Anderson system.10 This classification also has subjective
descriptors that limit its application.
4.1. Scoring systems
Type III open fractures are the most difficult injuries to classify
and treat due to their diverse injury patterns, higher morbidity
resulting from associated injuries, significant soft tissue damage,
wound contamination, and fracture instability. The decision to
amputate or salvage a severely injured limb can be very challenging
to the trauma surgeon. However, the assessment of the injury's
severity to the limb is often subjective rather than objective. A
misjudgment can lead to either an unnecessary amputation of a
limb that could have been salvaged or, on the other hand, a sec-
ondary amputation after attempted salvage has failed. To aid the
treating surgeon in this difficult decision-making process, several
scoring systems have been proposed such as Mangled Extremity
Severity Score (MESS), Predictive Salvage Index (PSI), Limb Salvage
Index (LSI), Nerve Injury, Ischemia, Soft tissue injury, Skeletal
injury, Shock, and Age of patient (NISSSA) score, Hannover Fracture
Scale-97 (HFS-97).
2
Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246
4.1.1. MESS score11
The Mangled Extremity Severity Score (MESS) was initially
designed as an objective tool to aid surgeons in making decisions
between amputation and salvage in cases of complex lower ex-
tremity trauma involving vascular component. It considers four
factors such as skeletal and soft tissue damage, limb ischemia time,
shock presence, and patient age. A MESS score of 7 or higher is
suggested as highly predictive of amputation. Several studies have
validated its effectiveness in predicting the treatment of major limb
trauma, particularly in identifying limbs suitable for salvage.12e14
However, it may not reliably predict the need for amputation,
especially in type 3B fractures. Poor sensitivity results in higher
rates of failed attempts at salvage and secondary amputations.
These scoring systems, including MESS, were primarily designed
for cases with combined vascular and orthopedic injuries, thus
performing poorly in type IIIB injuries, even when the limb is
severely injured and not salvageable. While the need of amputation
is widely recognized in Grade IIIC injuries, the management of
Grade IIIB injuries often presents challenges, leading to frequent
errors in limb salvage due to the lack of specific guidelines.
Ganga Hospital Open Injury Severity Score (GHOISS)15: It is an
extremely useful predictive tool rather than a true classification,
which aids in decision-making between limb salvage v/s. amputa-
tion.16 This was proposed in 2006, specifically for IIIB open fracture
of the tibia, as this subtype in the Gustilo-Anderson classification
includes a varied spectrum of injuries. GHIOSS uses three compo-
nents to score open injury severity (skin, bone, and muscu-
lotendinous unit) on a scale of 0e5 in increasing severity and seven
co-morbid factors that influence treatment and outcome with two
marks each. The overall score is used to prognosticate the outcomes
and guide the timing and type of reconstruction.17 While global
reconstruction of the bone and soft tissue injuries can be carried
out when the score is < 9, a total of >9 necessitates staged recon-
struction shown in Fig. 1. 15 and 16 constitute the grey zone where
the decision of amputation or salvage has to be made on a case-to-
case basis, taking into consideration the general condition of the
patient, the cost involved, and the time to recovery.13 A score of >17
is predictive of an amputation. Furthermore, the individual
component scores of GHIOSS can be used in decision-making
regarding the type of bony and soft tissue reconstruction
needed.18 Good specificity, sensitivity, and ease of use make it a
very useful tool that can be used routinely in a clinical context.19,20
5. Current treatment recommendations
5.1. Antibiotic prophylaxis: agent of choice
Antibiotics are an essential first-line therapy for open wounds,
as gram-positive bacteria are present in 78% of open fractures,
while gram-negative bacteria are present in 26% of cases.21 First-
generation cephalosporins are recommended to cover gram-
positive bacteria at initial presentation for all grades of open frac-
ture (Grade A recommendation),22 and an additional high-dose
penicillin for farmyard contamination(Grade A recommendation).
Clindamycin is the preferred antibiotic in individuals allergic to
penicillin, while vancomycin is preferable for penicillin-allergic
patients with an increased prevalence of community-acquired
MRSA infections.23 Although there is limited evidence in litera-
ture regarding the use of third generation cephalosporins, a study
by Johnson et al. showed that there was no statistical difference in
the rate of infection with the use of a first-versus a third-generation
cephalosporin24. However, they noted a decreased infection rate
and severity with the use of a third-generation cephalosporin.
Similarly Suzuki et al. showed no difference in the incidence of
deep infection between first and third generation cephalosporins.25
J. Dheenadhayalan, V. Nagashree, A. Devendra et al.
Fig. 1. (a)- Presenting Xrays clinical pictures with a puncture wound over distal third of the leg. (b): After debridement, it was classified as type IIIb with GHIOSS of 7. ‘Global
reconstruction’ -Local transposition flap and nailing of tibia was done. (c): At 1 year follow-up, flap has healed well and fracture is united. (d): Patient achieved full range of
movements.
Given that gram-negative organisms are a common cause of
infections in grade III fractures, it is recommended to add gram-
negative coverage when treating them22 (Grade A recommenda-
tion). Aminoglycosides have traditionally been used extensively for
prophylaxis against most aerobic gram-negative organisms in open
fractures. However, a study by Bankhead-Kendall et al. found no
difference in surgical site infection rates between patients treated
with a first-generation cephalosporin with or without an additional
aminoglycoside, although those receiving aminoglycoside treat-
ment had a statistically significant increase in renal dysfunction.26
Further analysis by Tessier et al. suggested that patients with higher
ISS (Injury Severity Score) and low blood pressure on presentation
are at an increased risk of renal dysfunction.27 The adverse effects
of aminoglycosides are dose-dependent, and a once-daily dose of
5 mg/kg of gentamicin had a lower infection rate compared to
equivalent three divided doses although it was not statistically
significant.28 Hence, a once daily dose of an aminoglycoside is
recommended for an extended gram negative coverage(Grade B
recommendation).22
5.2. Timing of administration
One cannot overstate the importance of administering antibi-
otics as soon as possible as an infection prevention measure, as
contamination is present in all open fractures to some extent.29 The
BOAST (British Orthopedic Association for Trauma and Orthopae-
dics) guidelines recommend administering antibiotics ideally
within 1 h from the time of injury (Grade C recommendation).30 In
type III open tibia fractures, when cephazolin was administered
within 66 min of the injury, there were no deep infections seen for
90 days as opposed to 17% if it was given later.31
5.3. Duration of antibiotics
Studies have shown non-inferiority of 24 h of antibiotic treat-
ment with a second-generation cephalosporin when compared to 5
3
Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246
days in all grades of open fractures.32 According to a review of the
literature on antimicrobial therapy for open fractures by Metse-
makers et al., antibiotics should be given for at least 24 h after
wound closure but not more than 72 h after injury (Grade A
recommendation).33
5.4. Systemic versus local therapy
The use of topical antibiotics is evolving, and while there is
currently no evidence to support the use of topical antibiotics alone
without adjunct systemic antibiotics, preliminary results of topical
vancomycin are promising.34 Compared to intravenous delivery,
the concentration of antibiotics at the fracture site is substantially
higher for 48 h, making it effective in preventing surgical site
infection. In a meta-analysis, Morgenstern et al. found a significant
risk reduction (11.9%) with local antibiotics.35 However, much
research is needed to clearly define the indications and dosing.
5.5. The “orthoplastic approach”
The importance of teamwork cannot be overemphasized, as
open injuries require the combined efforts of orthopedic and plastic
surgeons to collaboratively decide on the treatment plan and sur-
gical interventions, ensuring the most appropriate and effective
care for the patient. To achieve the comprehensive care by both the
specialities, a new type of emergency trauma organization was
establishedinitiated by Marko Godina in 1976 in Ljubljana, bringing
together orthopedic and plastic surgery services to collaborate on
combined treatments 24 h a day, seven days a week.36 This
"Ljubljana" orthoplastic approach emphasizes the management of
acute trauma cases from the very first visit in the emergency
department to the patient's full weight-bearing stage.37 Hospitals
that have implemented orthoplastic services have shown signifi-
cant reductions in deep infection rates, fewer revision surgeries,
shorter hospital stays, reduced overall costs, and improved out-
comes with lower rates of non-union and amputation.
J. Dheenadhayalan, V. Nagashree, A. Devendra et al.
5.6. Debridement
Debridement is an important step in the management of open
fractures. The primary goal of debridement is to remove all non-
viable tissues and decontaminate the wound to prevent infection
and further complications. The soft tissues must be handled with
the utmost care, and the debridement should be performed by an
expert to remove all the devitalized tissue. A coordinated ortho-
plastic approach helps in minimizing complications.38 Using a
tourniquet gives a bloodless field which provides better visualiza-
tion of structures. However, it must be released at the end of the
debridement to assess the viability of the tissues retained.
5.6.1. Timing of debridement
The classic “6-h rule” for initial debridement is no longer fol-
lowed.39 The adequacy of debridement is given much importance
compared to the timing. Delaying the debridement of less infected
open fractures by up to 24 h has not been found to increase the risk
of infection, although having a good debridement has been shown
to be advantageous (Grade D recommendation). The new BOAST
guidelines state that in cases of severe contamination, suspected
compartment syndrome, or vascular injury, urgent debridement
should be performed.30 It is preferable to debride high-energy
solitary injuries within 12 h and low-energy injuries within
24 h20,30 (Grade C recommendation).
5.6.2. Guidelines for debridement
Wounds should be extended longitudinally, regardless of the
direction of the open wound. For wounds near joints, a longer
incision may be necessary for a thorough examination. Non-viable
tissue including avascular fascia, muscles, and soft tissue impreg-
nated with fine contaminants, paint, or organic materials must be
removed. The viability of the muscles is determined by the 4 ‘Cs’:
Color, Consistency, Contractility and, Capacity to bleed. It is
important to note that even after the removal of 30% of the mass,
muscle function is not affected. Hence, there shouldn't be any
hesitation in removal of the contaminated and devitalized muscles.
Open injuries create a vacuum effect that draws contaminants
and debris deep into the medullary canal and muscle plane. So, any
protruded fragments must be delivered through the wound, ends
nibbled, and the intramedullary canal must be thoroughly curetted
and washed. All the loose bony fragments should be removed as
they can act as a source of infection and can displace causing sig-
nificant soft tissue and neurovascular injury. The "tug test" can
determine the removal of fragments with less than 50% soft tissue
attachment.40 Large diaphyseal fragments can be temporarily used
to achieve reduction and discarded at the end of the debridement.
However, the key articular fragments must be retained to recon-
struct the joint surface. If grossly contaminated, the fragment must
be thoroughly washed, and cancellous bone nibbled to remove the
contaminants while preserving the cartilage.
It is important to identify the hypovascular zone of injury,
particularly in high-velocity injuries with significant periosteal
stripping and soft tissue damage.41 High velocity injuries result in a
zone of necrosis under the wound that received the direct impact.
The surrounding area, including the uninvolved and normal-
looking tissue, constitutes the zone of injury, characterized by a
precarious vascular supply due to the impact.42 The size of this zone
is determined by the force of impact, and over time, the tissues in
this zone undergo necrosis.
Caution must be exercised, especially in small wounds with
comminuted fractures, as the appearance of the soft tissue may be
misleading. Due to their precarious blood supply, the soft tissues in
the zone of injury may gradually undergo necrosis. Therefore, a
second 'relook' debridement may be necessary after the
4
Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246
development of the line of demarcation. Also, a delayed wound
cover in these situations would be a prudent approach.
At the end of the debridement, it is recommended to evaluate
the loss of tissues and document it with a photograph for future
reference and planning. It is essential to create a definitive plan for
both soft tissue coverage and skeletal stabilization. Financial con-
siderations related to the treatment and the possibility of second-
ary amputation must be discussed with the patient's family at this
stage.
6. Intraoperative wound cultures
A study by Bosse et al. found that only 26.9% of infections were
caused by the organisms identified in the initial wound cultures.43
However, individuals who had positive cultures for any organism
during the first debridement were at a higher risk to acquire an
infection (Odds ratio of 1.92).34 Therefore, there is no need to
perform cultures initially since there is no clinical correlation be-
tween the original organism and the one causing the surgical site
infection (Grade C recommendation).
7. Irrigation
Wound irrigation is an effective method to reduce contamina-
tion and bacterial load, with minimal damage to the surrounding
soft tissues and bone. The risk of infection directly correlates with
the number of bacteria in a wound, which further emphasizes the
importance of thorough irrigation and debridement. Nonetheless,
there are still controversies surrounding their use.
8. Irrigating agent
Several irrigating fluids have been studied for their efficacy and
effects on soft tissue, especially in the “zone of injury”. This tran-
sition zone at the margin of the wound, which is viable but
vulnerable to a secondary insult, is susceptible to necrosis from
chemicals. Normal saline has stood the test of time and remains the
fluid of choice for irrigation for open fractures (Grade A recom-
mendation). The FLOW trial showed that normal saline had
decreased rates of infection and reoperation when compared to the
castile soap solution (11.6% vs. 14.85%).44 The antibacterial action of
surfactants and antiseptics helps to reduce the infection burden of
the wound, but they are caustic to the tissue, affecting the host cell
viability. Hence, they are not routinely recommended in the man-
agement of open wounds. Also, antimicrobials such as bacitracin
had higher wound-healing complications compared to the castile
soap group (9.5% vs. 4%).45
9. Volume
The principle of “the solution to pollution is dilution” remains
the strategy, as the volume of the irrigation directly correlates to
the reduction in the amount of contamination and bacterial load.34
Although there are no specific recommendations regarding the
volume of fluid to be used, the quantity depends upon the extent of
soft tissue damage and the amount of contamination. Conven-
tionally, 3, 6, and 9 L are used for the type I, type II and type III
Gustilo-Anderson fracture types46 (Grade C recommendation).
10. Delivery pressure and pulsatile lavage
High-pressure pulsatile lavage (HPPL) systems were previously
considered more effective in removing bacteria and debris, but
recent studies have shown that they can damage adjacent soft
tissues and impair bone healing. Additionally, high-pressure
J. Dheenadhayalan, V. Nagashree, A. Devendra et al.
systems may push contaminants into deep tissues, leading to
higher infection rates.47 While both the low-pressure and high-
pressure systems equally reduce contamination at 3 h of bacterial
incubation time, the HPPL was effective for longer hours. This im-
plies that high-pressure lavage, which exceeds the adhesion force
of the bacteria, may be helpful in delayed presentations. The FLOW
trial found no differences between irrigation at very low, low, and
high pressure pulsatile irrigation in terms of non-union, wound
complications, or reoperation rates.44 Therefore, non-pulsatile flow
irrigation with copious normal saline is the safest form of wound
irrigation for open fractures (Grade A recommendation).
11. Irrigation timing
With the "6-h" rule for debridement no longer being followed,
timely wound irrigation is crucial since bacterial adhesion starts
within 3 h and biofilm maturation within ten hours48 Wound
irrigation at three, six, and 12 h resulted in bacteria removal of 70%,
52%, and 37%, respectively.49 Hence, an wound irrigation at the
earliest possible opportunity is advisable.
12. Skeletal stabilization
The decision for fracture fixation in open injuries depends on
the patient's condition and the severity of the wound. We routinely
make our treatment decisions based on the GHOISS.
13. Temporary fixation
External fixators are the workhorse of damage control ortho-
paedics and are routinely used in the staged management of open
fractures when GHOISS is > 9.20 External fixators is less invasive,
minimize the further soft tissue damage and provide a stable
skeletal stabilization. It is essential to carefully position the pins to
allow for soft tissue reconstruction, which can be evaluated during
the debridement process. External fixator pins must be placed
appropriately through intact skin, not through the wound, to allow
soft tissue reconstruction. They should also not be placed along the
lines of future surgical incisions as this can interfere with definitive
fixation if pin tracts become infected. It is advisable to reduce the
fracture if the patient's hemodynamic condition permit. If the
wound is located at a distance from the fracture site, skin incisions
to reduce the fracture can be made in coordination with a plastic
surgeon to avoid interference with soft tissue reconstruction.
Otherwise, temporary external fixation can be applied with the
limb in traction to maintain its length, and later this can be con-
verted to internal fixation. Open wounds with articular fractures
present an excellent opportunity for articular reconstruction on day
1. The articular congruity will be maintained even if the definitive
fixation is delayed. External fixators can be used as a definitive
fixation modality in stable fracture patterns (Fig. 2). However, if
there is a secondary loss of reduction, internal fixation is advisable.
14. Primary internal fixation
In the past, internal fixation was often avoided due to concerns
about infection risk, biofilm formation, and potential damage to
blood supply.50 However, with improved debridement techniques
that ensure a clean environment, internal fixation is becoming
more popular and widely accepted. Properly applied internal fixa-
tion can promote better healing and functional recovery in such
situations.
Primary internal fixation can be carried out for open fractures
with a GHIOSS score less than 9, with no gross contamination and
excessive soft tissue involvement, and if the patient is stable. A
5
Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246
good debridement with gentle handling of the fragments to not
devascularize the bony fragments is the key. Definitive fixation of
upper limb fractures can be carried out except in cases of heavy
organic contamination51(Grade C recommendation). An example is
shown in Fig. 3.
In the nailing of the lower limb fractures, although reaming of
the canal was a controversy in the past, many studies, including the
SPRINT trial, have concluded that the reamed nails are better in
terms of union with no difference in the rate of complications.52 In
patients with bone loss, the primary use of the Limb Reconstruction
System (LRS) is a very good alternative. The technique of “tempo-
rary spacer-rod and plate” helps in achieving perfect docking in IIIb
open injuries(Fig. 4).53 (see Fig. 5)
15. Primary closure
Rajasekaran et al. reported excellent outcomes with only a 3%
deep infection rate after immediate primary skin closure in Type III
injuries with strict inclusion and exclusion criteria.54 Primary
closure in type IIIb fractures can be done when the GHOISS skin
score is 1 or 2 i.e., no skin loss after debridement, and the total score
is less than 10, with no sewage or organic contamination and
farmyard injuries. The closure has to be tension free and be carried
out after the skeletal fixation.
16. Interim dressing the open wounds
Negative Pressure Wound Therapy (NPWT) can be used in those
wounds that cannot undergo immediate soft tissue cover, partic-
ularly those with the zone of injury. In the UK WOLLF Collaboration
trial, deep infection rates and quality of life were comparable be-
tween NPWT and occlusive dressings.55 However, a meta-analysis
showed that wounds treated with NPWT had lower rates of
infection, non-union, and flap complications.56
17. Definitive fixation
Conversion to internal fixation is recommended in several sce-
narios during staged reconstruction. This includes where there is
non-anatomic reduction, secondary malalignment, or delayed
union. After acute management, there exists a dilemma about the
timing of conversion to definitive fixation. It can be either ex-fix
removal and internal fixation in a single surgery, or staged with a
"window period" in a cast after ex-fix removal to allow granulation
of the pin sites followed by internal fixation(Grade B recommen-
dation). The choice of staging is frequently made based on the
presence of pin tract infections, and soft tissue condition. When
converting to internal fixation, it is crucial to ensure there are no
signs of pin tract infection or irritation, such as oozing or granu-
lation tissue around the pin sites. Radiographic evaluation should
also reveal no signs of pin loosening or rarefaction around the pin
tract sites. Additionally, biochemical markers like ESR (erythrocyte
sedimentation rate) and CRP (C-reactive protein) should be within
normal limits to indicate a reduced risk of infection. Fram et al.
found that one-stage conversion had comparable or even lower
infection rates than two-stage conversion.57 They also found no
difference in rates of deep infection when conversion to intra-
medullary nailing was done in a single-stage even in the presence
of pin site infection.
Another dilemma exists about the timing of internal fixation
with respect to the soft tissue cover. Definitive internal fixation is
ideally performed before the stage of definitive soft tissue
cover.17,54 After soft tissue cover, definitive internal fixation has to
be postponed until the flap settles, which may take around 6
weeks.
J. Dheenadhayalan, V. Nagashree, A. Devendra et al. Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246

Fig. 2. (a)- Presenting Xrays clinical pictures of a IIIb open fracture of tibia and fibula. (b)- After debridement, definitive external fixator was applied and split thickness skin grafting
was done. (c): At 4 months follow-up, the fracture was in good alignment. External fixator was removed and full weight bearing started. (d): Good functional outcome at 6 months.

Fig. 3. (a)- Open IIIb fracture of both bones forearm with comminution and protruding bony fragments. (b)- The wound was included in the incision at the time of debridement.
Primary shortening and plating was done. (c): At 4 months, wounds have healed well and fracture is united. (d): Clinical pictures showing good range of movements and functional
outcome.

Bone loss: Removal of bone fragments or loss at the site of
injury may result in bone loss. The treatment strategy for bone loss
depends on the location and degree of the defect, contamination,
and soft tissue coverage. The treatment plan should be tailored
based on the patient's condition and the experience and expertise
of the treating surgeon. While defects of <4 cm maybe managed
with bone grafting or primary shortening, larger defects are
6
preferably treated with structural allografts or Masquelet technique
or bone transport(Fig. 4).
17.1. Definitive soft tissue cover
The outcome of open fractures after debridement and skeletal
stabilization depends on the timing of wound cover. Prolonged
J. Dheenadhayalan, V. Nagashree, A. Devendra et al. Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246

Fig. 4. (a): A 22 year old presented 1 week after the injury with external fixator in place. Note the unhealthy wound and dry, dessicated bone. (b)- Removal of the dead bone
resulted in a bone gap of 8 cm. Hence, it was decided to apply primary LRS using the “spacer-rod” technique. (c)- X-rays after application of LRS frame showing good alignment of
the fracture ends. (d)- Clinical image at the time of the soft tissue cover and Xrays showing corticotomy. (e)- 15 months follow up after removal of LRS and plating showing
consolidation of the regenerate. (f)- Clinical pictures showing good functional outcomes.

Fig. 5. (a): Open IIIb fracture of the distal fourth tibia with degloving of the skin. It was decided to follow “fix and flap” approach with primary soft tissue cover and fracture fixation.
(b): Wound image at the end of plating and intra-operative images showing anterolateral plating of tibia and rush nail fixation fibula. (c): Post-operative clinical image showing split
thickness grafting and definitive fracture fixation. (d): At two years follow up, fracture has united and flap has healed well.

delays increase the chances of soft tissue necrosis and hospital practice to achieve soft tissue cover within 7 days59(Grade B
acquired infection. Therefore, it is crucial to plan soft tissue cover at recommendation). The Ganga Hospital Open Injury Score (GHOIS)
the earliest opportunity to avoid complications. In a study by offers guidelines for determining the appropriate soft tissue cover
Godina, the infection rate was lower (1.5%) when soft tissue in open injuries.
reconstruction was done within 72 h compared to those done be-
tween 72 h and 3 months (17.5%).58 Several studies have also found
17.2. Fix and closure
that earlier wound cover results in better outcomes, including
lower rates of deep infection, earlier mobilisation, reduced need for
Injuries with a skin score of 1 or 2 do not have skin loss at the
further unplanned surgery, shorter hospital stay, and less flap
time of injury or during debridement. When contamination is less,
complications. Based on these findings, it has been a common
tension free primary suturing can be done after adequate
7
J. Dheenadhayalan, V. Nagashree, A. Devendra et al.
Fig. 6. Stepwise initial assessment and management of open fractures.
debridement. The total score must be < 9, indicating low-energy
trauma, wherein skeletal stabilization can be carried out as well.
However, injuries with a skin score of 1 or 2 but with either a total
score above 9 or moderate to severe contamination should not be
treated with primary closure. A total score exceeding 9 suggests
high-energy trauma, and reassessment after 48 or 72 h becomes
necessary. A delayed suturing is done if wound characteristics allow
for closure during a second-look debridement.
17.3. Fix and skin grafting
A skin score of 3 indicates the presence of skin loss either at the
time of injury or during debridement. However, the wound does
8
Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246
not expose the fracture site, or there is sufficient soft tissue cover
such as in femur fractures. In such cases, split skin grafting after
skeletal stablisation is.
Fix and flap: A skin score of 4 indicates the presence of skin loss
either at the time of injury or during debridement. If the wound
exposes bone, articular cartilage, tendons, or a vascular anasto-
mosis site, flap becomes necessary. Some centers have adopted a
more radical approach called "fix and flap," which involves per-
forming definitive bony stabilization and soft tissue cover at the
same time to prevent colonization of "naked" implants and sub-
sequent deep infection.60 Patients with a single procedure were less
likely to require amputation or further unplanned surgery when
compared to staged management. An early flap is considered if the
J. Dheenadhayalan, V. Nagashree, A. Devendra et al. Journal of Clinical Orthopaedics and Trauma 44 (2023) 102246

Fig. 7. Flowchart for the management of type IIIb fractures, considering various factors that may influence treatment decisions.

total score is less than 9, whereas delayed flap cover is done when ongoing research to further improve outcomes for open injuries.
the score exceeds 10 depending on the condition of the wound and Identification of infection using bacterial DNA sequencing and
the soft tissue swelling. A skin score of >5 needs staged protein biomarker detection are promising. The development of
reconstruction. hardware coating techniques to prevent biofilm formation and
stimulate the local immune response is ongoing.
18. Types of soft tissue cover
20. Algorithm for the management of open injuries
Type III injuries present with wounds of varying size and
complexity. Traditionally, a reconstructive ladder for managing soft While adhering to a strict algorithm in managing such complex
tissue defects has been described, starting with simple split skin injury patterns may not always be feasible, the provided flowcharts
grafts and advancing to more complex options such as fascio- offer a comprehensive overview of open fracture management.
cutaneous flaps, rotational muscle flaps, and free muscle flaps. Figs. 6 and 7 give a concise outlines for the management of open
The choice of treatment depends on factors such as wound location, injuries based on Ganga Hospital Open Injury Score.63
exposure of bone and implants, and the presence of a healthy
muscle bed. For wounds not directly over the bone and with a
21. Conclusion
healthy muscle bed, split skin grafts are typically sufficient. Small
defects over bone and exposed implants can be effectively covered
Despite the challenges posed by open injuries, following the
with rotational fascio-cutaneous flaps, given that there is no
principles of adequate resuscitation, infection prevention, and a
extensive zone of injury or degloving. Larger defects that expose
combined "orthoplastic" approach during initial and definitive
bone and tendons require coverage with vascularized tissue, such
management can yield good results. The use of the Ganga hospital
as a muscle flap covered with a split skin graft. In cases where a
score for assessment can help with salvage and prognostication.
pedicle flap is not suitable or the wound is too large for a pedicle
Early stable fracture stabilization facilitates quick soft tissue
flap, free microvascular tissue transfer becomes necessary.
reconstruction, while an appropriate secondary intervention with
Recently, a "revised reconstructive ladder" has been advocated,
bone grafting ensures union and early joint mobilization.
incorporating newer developments such as vacuum-assisted
closure (VAC) therapy, acute bone shortening, bone transport, and
other advanced techniques.61 These innovations have significantly Level of clinical care
impacted clinical practice, leading to increased use of delayed pri-
mary closures and reduced reliance on traditional skin flaps for Level I Tertiary trauma centre.
wound management.
Alternatively, in the “reconstructive elevator” model, the sur-
Ethics approval
geon chooses the reconstructive procedure that best suits the pa-
tient's needs and the overall clinical context, rather than solely
Approval was obtained from the Institutional ethics committee.
opting for the simplest technique that achieves wound closure.62
The goal is to achieve the most optimal reconstruction with mini-
mal morbidity for the patient. This approach encourages flexibility Funding
and the freedom to select the most appropriate procedure, similar
to taking an elevator to the desired level, rather than following a No funding was received for conducting this study.
rigid step-by-step ladder approach.
Conflicts of interests
19. Future trends
The authors have no competing interests to declare that are
While modern treatment modalities are effective, there is relevant to the content of this article.
9
J. Dheenadhayalan, V. Nagashree, A. Devendra et al.
Credit author statement
Jayaramaraju Dheenadhayalan: Conceptualization, Methodol-
ogy, Project supervision, Writing - review & editing; Vasudeva
Nagashree: Data curation, Methodology, Writing - original draft;
Agraharam Devendra: Project administration, Supervision, Writing
- review & editing; Purnaganapathi Sundaram Velmurugesan: Data
curation, Project administration, Supervision, Writing - review &
editing; Shanmuganathan Rajasekaran: Project administration,
Supervision, Writing - review & editing.
Declaration of competing interest
The authors declare that they have no known competing
financial interests or personal relationships that could have
appeared to influence the work reported in this paper.
Acknowledgement
Not applicable.
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