Management of

OPEN FRACTURE
July 14, 2021
Daizha D. and Aiza G.
 Objectives:
• To discuss important history in the management of
Open Fracture
• To Discuss on the classification of open fracture
• To Review on the management of Open Fracture
• To Review on the literature supporting the
management of open fracture
 DEFINITION
•open fracture

defined as an injury where the

fracture and the fracture hematoma
communicate with the external
environment through a traumatic
defect in the surrounding soft tissues
and overlying skin
• the skin defect may not lie directly over the
fracture site and may lie at a distant site

• are often high-energy injuries and are

frequently associated with life-threatening
polytrauma
 HISTORY

• Tscherne

has grouped the developments into four eras

of life preservation, limb preservation, infection
prevention, and functional restoration
• Ambroise Pare
-16th century
-emphasized the need for cleaning
wounds of all foreign matter and
necrotic tissue and leaving the wound
open
Pierre Desault (1731-1795)
• Promoted deepening incision to explore
wounds, remove nonviable tissue and
allow a path for drainage

• Coined the term “Debridement”

• Stated the sooner debridement

performed, the less likely an infection
would develop
 “Lose a Limb to save a Life”

• was an accepted dictum of management

as gross infection of open injuries often
led to gangrene, septicemia, and death
 World War I
saw the successful beginning of the “Era of
Life Preservation” as mortality was considerably
reduced as a result of the application of the
principles of good resuscitation, thorough
debridement, stabilization, and avoiding closing
the wounds
 1970s

• “Era of Limb Preservation”

• major advances in both orthopedic and

plastic surgery
The availability of antibiotics and the
understanding of the need for aggressive
debridement and early soft tissue cover
helped to control infection bringing in the
“Era of Infection Control.”
• Gustilo and Anderson published their
landmark classification scheme for
open fractures that brought
attention to the importance of the
wound and the need for early soft
tissue cover
• The management of open injuries is now in the
“Era of Functional Restoration”

Functional restoration is aided by aggressive

wound debridement, early definitive fracture

stabilization and early wound closure or cover to achieve
bone and soft tissue healing as soon as possible.
 PATHOPHYSIOLOGY
• Long bone open fractures  frequency of 11.5 per 100,000
persons per year

• Open tibial diaphyseal fractures

 commonest open long bone fracture but open femoral

diaphyseal, distal femoral, and proximal tibial fractures
occur frequently
 Causes
• high-energy event:
• Gunshot
• motor vehicle accident

• lower-energy incident:
• such as a simple fall at home
• injury playing sports
Few facts require
emphasis:
• size and nature of the external wound may
not reflect the damage to the deeper
structures

• small lacerated wounds are associated with

extensive occult degloving with severe soft
tissue damage and bone comminution
 Principle In Managing Open
Fracture
• Antibiotic
• Debridement
• Fixation/Stabilization
• Soft Tissue Cover
 Assessment: Initial Evaluation

• Every open injury is an orthopedic emergency

• patient must be thoroughly assessed for ABC

• 30% of patients with open injuries have more

than one injury
 Examination

• an injured limb that is grossly deformed or

shortened must be gently reduced and
splinted so that vascularity is not
compromised
 Examination
Tenting of the skin by sharp bone
fragments or dislocated joints may lead
to avascularity and further loss of skin
and these fractures must be considered
as impending open fractures even when
no wound is present
• Any wound, no matter how small or distant from the
fracture, must still be considered indicative of an
open fracture

• Persistent oozing from a small laceration, especially if

it carries fat globules indicates a discharging fracture
hematoma
examination of the wound:
size

location of the wound

orientation of the wound (longitudinal, transverse or

irregular)

depth of the wound

whether bone, tendons, and muscle are exposed

• arterial doppler or a CT angiogram  useful as apart
from indicating the location and type of the block,
they reveal the status and adequacy of the collateral
circulation

• touch sensation and pinprick testing can be used to

examine distal dermatomes and motor movements
can also be tested
• open injuries

• presence of air in the subcutaneous tissues

• intramuscular planes, and joint cavities
• visualization of foreign bodies
 Radiographic Imaging and Other
Diagnostic Studies

• anteroposterior

• lateral

• inclusion of the joints above and below

• Radiographic gas shadows in the muscular
planes: infection:
• Clostridium perfringens
• Escherichia coli
Classifications and Scores for Open
Fractures
 Mangled Extremity Severity Score
• is frequently used to predict the likelihood of
amputation in Gustilo IIIb injuries

• A score of >7 has been reported to predict amputation

accurately in both retrospective and prospective
studies
Mangle Extremity: Primary
Amputation
Ganga Hospital Open Injury Score
• all limbs with a score of 14 and below were salvaged
successfully, a score of 17 and above required an
amputation, score of 15 and 16 were categorized to
be in a gray zone
 Principle In Managing Open
Fracture
• Antibiotic
• Debridement
• Fixation/Stabilization
• Soft Tissue Cover
 Role of Cultures in the Emergency Room

• commonly isolated organisms:

Staphylococcus aureus

Pseudomonas

Escherichia coli
 RECOMMENDATION
(2009)
• First or Second generation Cephalosporins
• absence of organic or sewage contamination

• Aminoglycosides

• Penicillin
• gross organic contamination with or without metronidazole
Antibiotics
 Principle In Managing Open
Fracture
• Antibiotic
• Debridement
• Fixation/Stabilization
• Soft Tissue Cover
 Treatment Options:
Debridement and Lavage
• All foreign material and tissues that are contaminated
or suspected to be avascular are systematically
removed so that whatever is left behind is
vascularized living tissue, devoid of contamination

• secondary aim of debridement is also to minimize risk

factors for infection such as dead space or hematoma
so that the incidence of infection is reduced
 Debridement
• should be completed within 6 hours.

• The basis of the 6-hour rule was animal studies where a

threshold of organisms was found to be critical to
establish infection.

• This limit was achieved in 5.17 hours.

 “ thoroughness of debridement seems
to be more important than the timing”
• Lavage is used before and after debridement as
it clears the debris and hematoma and provides
optimal exposure and reduces contamination
and the bacterial count

• Typically more than 9L of fluid is required in

Type IIIb injuries
 Principle In Managing Open
Fracture
• Antibiotic
• Debridement
• Fixation/Stabilization
• Soft Tissue Cover
 Skeletal Stabilization
• helps to alleviate pain and prevent further soft tissue
damage

• length of the limb must be restored as this restores the

correct tension to the soft tissues and this decreases
swelling, improves circulation, and aids venous and
lymphatic return

• increases the comfort of the patient during wound

inspection and facilitates early rehabilitation and
movement of joints.
 Plaster Casts and Traction
• wound inspection and dressing is very difficult and
cast contamination can be unpleasant and increase
the risk of infection

• Casts compromise the early detection of compartment

syndrome, skin blistering, and skin necrosis

• Puno et al.150 reported an infection rate of >15% and

a malunion rate of up to 70% in tibial fractures
treated with plaster cast immobilization
 External Skeletal Fixation
• the workhorse for skeletal stabilization in
open fractures as it provides a swift
versatile method of providing stability
without the need for additional exposure or
periosteal striping even in demanding
situations
• Ilizarov ring fixators and
other ring fixators are used
mainly in juxta-articular
fractures with soft tissue
injury and in fractures with
bone loss

• can be used as a definitive

treatment when a stable
fracture configuration with
good reduction and
circumferential contact is
achieved
• External fixators  have a high rate of
complications the most common being pin
loosening, infection, and malunion

• Pin tract infection is the most frequent

complication with external fixation and occurs
in up to 32% of patients
 Primary Internal Fixation
• As a general rule:

plate fixation is ideal for fractures

of the upper limb
 Plate Fixation

• is the method of choice:

• most open upper limb fractures
• femoral fractures involving the periarticular
and articular regions
• all intra-articular and juxta articular fractures
• open injuries with vascular involvement
 Intramedullary Nails
• often the first choice for fixation of lower limb
diaphyseal fractures as they provide superior
biomechanical conditions and also maintain the length
and rotation of the limb

• are ideally suited for Gustilo type I and II injuries and

even in type III injuries where contamination is
minimal and effective debridement has been
performed
Literature
• IMN was associated with lower rates of infection and
fracture healing problems; the differences between the two
approaches for “other complications” were not significant.

• The data indicate that IMN is the treatment of choice for

Gustilo type III fractures.

• The results of our meta-analysis show that IMN is the more

effective approach to Gustilo type III open tibial fractures,
because of the lower incidence of infectious events and
fracture healing problems.
• The forest plots show this clearly. As regards the
“other complications”, there are no significant
differences between the techniques. These findings
are not conclusive.

• Although the present meta-analysis shows IMN as

the better option, each department should analyse
their outcomes to see whether their data are in line
with these findings.
 Definitive ORIF (plating or IM
nailing)

• Can be done for clean wounds up to IIIA

if the patient can be brought to OR
within 6 Hrs (Golden period) after
injury
 Principle In Managing Open
Fracture
• Antibiotic
• Debridement
• Fixation/Stabilization
• Soft Tissue Cover
 The Timing of Soft Tissue Cover

• Traditionally, the protocol in a majority of

units is to limit the initial surgical procedure to
debridement and skeletal stabilization

• The definitive soft tissue and bony

reconstruction is postponed to a later date
 Need for a second look
debridement
• Uncertainty about the presence of
traumatized and devascularized tissue
necessitates a second look to allow
adequate resection
• Godina et al

initiated early soft tissue cover and reported

a significant difference between wounds
reconstructed within 72 hours of injury and
those reconstructed later.
Negative Pressure Wound Therapy

• injuries where soft tissue cover is not

immediately possible, Vacuum-assisted wound
closure (VAC) using NPWT is advised

• –125 mm Hg, applied for 5 minutes at intervals

of 7 minutes
 Negative Pressure Wound Therapy

• Continuous negative pressure increases

granulation tissue by only 63% compared
to 103% with intermittent negative
 Negative Pressure Wound Therapy

• Contraindicated in:

presence of exposed tendons

surgical anastomosis of a nerve or a vessel

when heavy bleeding or oozing is anticipated.

 Open Fracture
Time for Healing- Tibial Fracture
 Principle In Managing Open
Fracture
• Antibiotic
• Debridement
• Fixation/Stabilization
• Soft Tissue Cover
• Rehabilitation
 The Goal of Orthopedic
Management Is Early Return of
Form and Function
THANK
YOU!