OPEN

FRACTURES
4
Open fractures are associated with a soft tissue defect III fractures divided into three subtypes based on the ex-
that permits contamination by the outside environment tent of the periosteal damage, the presence of contamina-
(Fig. 4-1). Historically the difficulty of managing soft tis- tion, and the extent of arterial injury. The classification is
sue and bone defects often meant the incidence of infec- shown in Table 4-1.
tion was considerable and the requirement for amputation The Gustilo classification has been shown to be prog-
was high. With the advent of improved plastic surgery and nostic in terms of time of union and the incidence of
fracture fixation techniques, however, complications re- nonunion and infection, particularly with respect to open
lated to open fractures have diminished, although they fractures of the tibia. However, as with all classification
still remain a challenge to orthopaedic surgeons. systems, surgeons should be aware of a number of draw-
backs. The Gustilo classification was formulated with dia-
physeal, rather than metaphyseal or intra-articular, frac-
CLASSIFICATION tures in mind. It was also designed to be used in long
bones such as the femur and tibia rather than in smaller
Although there are other classifications of open fractures, bones such as the metacarpals or metatarsals. As with all
the Gustilo classification has now been adopted world- classifications, it inevitably contains a number of subjec-
wide. It is based on the size of the wound, the amount of tive terms such as “significant periosteal stripping” and
soft tissue damage or contamination, and the type of frac- refers to the length of skin wounds, which will vary consid-
ture. There are three fracture types, with the Gustilo type erably with age. It is impossible to avoid these problems in
any classification system that is practical to use, and the
Gustilo classification has become accepted as the main
classification of open fractures.

EPIDEMIOLOGY
Very little is known about the epidemiology of open frac-
tures. The incidence of open fractures varies in different
places and in different institutions depending on many
factors, including the incidence of road traffic accidents
and gunshot injuries. Level 1 trauma centers obviously
see more open fractures than smaller peripheral hospi-
tals, but the overall incidence of open fractures is proba-
bly similar in many parts of the world. Table 4-2 shows
the epidemiology of 960 consecutive open fractures seen
in Edinburgh, Scotland, over a 6-year period. It is likely
this information is applicable to many parts of the world.
The overall incidence of open fractures was 3.2%, with
3.3% in the upper limb, 3.7% in the lower limb, and
0.3% in the limb girdles. Table 4-2 shows the wide vari-
ation in the incidence of open fractures. The highest in-
cidence is in tibial diaphyseal fractures, where about
21% are open. Fractures of the femoral diaphysis, hand
Figure 4-1 A Gustilo IIIa open tibial fracture. and foot phalanges, forearm diaphyses, tibial plafond,

19
 20 Section I / General Principles

TABLE 4-1 THE GUSTILO CLASSIFICATION OF OPEN FRACTURES

Type Definition

I Open fracture with a clean wound <1cm in length

II Open fracture with a laceration of >1 cm long and without extensive soft-tissue
damage, flaps, or avulsions
III Either an open fracture with extensive soft-tissue laceration, damage, or loss; an
open segmental fracture; or a traumatic amputation. Also:
High-velocity gunshot injuries
•1• Open fractures caused by form injuries
Open fractures requiring vascular repair
Open fractures older than 8 hours
IIIa Adequate periosteal cover of a fractures bone despite extensive soft-tissue
laceration or damage
High-energy trauma irrespective of size of wound
IIIb Extensive soft-tissue loss with significant periosteal stripping and bone damage
Usually associated with massive contamination
IIIc Association with arterial injury requiring repair, irrespective of degree of soft-tissue
injury

From Gustilo RB, Mendoza RM, Williams DM. Problems in the management of type III (severe) open
fractures. A new classification of type III open fractures. J Trauma 1984;24:742–746.

TABLE 4-2 THE INCIDENCE OF OPEN FRACTURES: AN ANALYSIS OF 960

FRACTURES OVER A 6-YEAR PERIOD
Gustilo Type (%)
Fracture Open Average
location Fractures (%) I II IIIa IIIb IIIc Age (y)

Tibial diaphysis 21.2 23.5 19.6 23 29.6 4.3 43

Femoral diaphysis 12.3 20.3 16.9 23.7 30.5 8.5 32
Hand phalanges 10.1 32 52.9 5.7 1 8.4 39
Foot phalanges 9.0 28.6 52.2 11.9 — 7.1 38
Forearm diaphysis 8.0 48.8 21.9 9.8 17.1 2.4 35
Tibial plafond 6.1 18.2 9.1 45.4 27.3 — 46
Patella 5.7 18.5 48.1 29.6 3.7 — 41
Distal femur 5.6 30 20 — 50 — 43
Distal humerus 5.4 35.7 50 7.1 7.1 — 41
Humeral diaphysis 5.3 68.7 18.7 6.2 6.2 — 48
Tarsus 3.2 — 30 36.6 23.3 10 35
Tibial plateau 2.4 30 40 20 10 — 44
Distal forearm 2.1 62.3 26.1 10.1 1.4 — 62
Carpus 2.0 13.3 6.7 66.6 13.3 — 33
Ankle 1.4 17.5 42.5 35 5 — 49
Proximal forearm 1.0 37.5 50 12.5 — — 48
Metatarsus 0.9 27.2 36.4 18.2 18.2 — 38
Scapula 0.7 100 — — — — 28
Pelvis 0.6 — — 80 20 — 29
Metacarpus 0.4 43.7 56.3 — — — 43
Proximal humerus 0.3 — 60 40 — — 32
Clavicle 0.2 50 — 50 — — 33
Proximal femur 0.02 100 — — — — 40
Fibula 0 — — — — — —
Spine 0 — — — — — —
 Chapter 4 / Open Fractures 21

patella, distal femur, distal humerus, and humeral diaph- diseases, or neuromuscular conditions may alter the
ysis are all associated with incidences of more than 5%. type of operative treatment, and cardiovascular, pulmo-
In fractures of the metatarsus, scapula, pelvis, metacar- nary, and other medical comorbidities may affect anes-
pus, proximal humerus, and proximal femur, however, thesia and later intensive care.
the incidence is very low. If an open fracture does occur ■ The preaccident mental and physical state of the patient
in these areas, the injury tends to be very severe. The in- is important because, for example, a Gustilo type IIIb
cidence of open spinal fractures is so low that effectively open tibial fracture in a demented nonambulator with
they are unsurvivable. The only exception to this is gun- medical comorbidities might well be successfully
shot spinal fractures, which are relatively uncommon in treated by primary amputation rather than by attempted
civilian practice. Table 4-2 also shows that the age of the bone reconstruction.
patient varies, with younger patients tending to have ■ The mode of injury should be carefully established to
open fractures of the pelvis, femoral diaphysis, proximal determine whether the open fracture has occurred as a
humerus, carpus, and forearm diaphyses as a result of result of a high- or low-energy injury and whether there
road traffic accidents or other high-energy injuries, with is potential for significant fracture contamination.
open fractures of the humeral diaphysis, proximal fore-
High-energy injuries associated with significantly
arm, ankle, and distal forearm occurring in older pa- greater bone and soft tissue damage, and therefore
tients as a result of low-energy injuries. open fractures following road traffic accidents, falls
Table 4-2 also shows the incidences of the different from a height, crushing injuries, or gunshot injuries,
Gustilo types for each fracture. The highest incidence of are often more difficult to manage and associated
Gustilo type III fractures occurs in the pelvis, carpus, and with a worse prognosis than those that occur after a
lower limb. With the exception of open carpal fractures, simple fall, a fall downstairs, or a sports injury.
open upper limb fractures tend to be less severe. In the ■ The physical examination must include an assessment
lower limb there is a high incidence of Gustilo type III of other injuries using ATLS principles.
fractures in the femoral diaphysis, around the knee, in
Examination of the limb should include a careful as-
the tibial diaphysis and plafond, and in the tarsus. sessment of the vasculature with palpation of the
Gustilo IIIc fractures are rare but are most commonly pulses and determination of limb color and distal
seen in high-energy injuries to the tarsus, femoral diaph- capillary return. The surgeon should be aware that if
ysis, and tibial diaphysis. They also occur in the fingers the patient is hypotensive or peripherally shut down,
and toes, where they are often treated by amputation (see an incorrect preoperative assessment of the vascular
Chapter 37). status of a limb may be made.

If there is any doubt about the vascular supply, a
Doppler examination or angiogram should be ob-
PREOPERATIVE ASSESSMENT tained.
■ Examination of the neurological status of the limb is
■ A complete history and physical examination is essen- also important.
tial.
Abnormal sensation or motor power may suggest in-

Some of the main factors that should be obtained in tracranial, spinal, or peripheral nerve damage.
the history are shown in Box 4-1.
A peripheral nerve lesion associated with a limb frac-
■ Age does not affect patient management, but older pa- ture suggests considerable soft tissue injury and
tients tend to be osteopenic and the fractures may be probably a poor prognosis for the limb.
associated with greater comminution.
■ Information about general health is important because
conditions such as diabetes mellitus, metabolic bone
Examination of the Open Wound
■ Ideally the open wound should not be examined by
every member of the medical and nursing staff prior to
BOX 4-1 IMPORTANT FEATURES OF THE CLINI- surgery!
CAL HISTORY AND PHYSICAL EXAMINATION
If possible, a digital image of the wound should be
obtained soon after the patient is admitted to the
History Previous injuries hospital, so that it, rather than the wound, can be re-
Age Physical Examination peatedly examined. This policy has been shown to be
General health Other injuries associated with a lower infection rate.
Specific comorbidities Limb vascularity ■ It is important, however, that the surgeon examine the
Previous disability Peripheral pulses
wound carefully.
Alcohol and drugs Capillary refill
Ambulatory status Hypotension
The location and extent of the wound may allow a
Residence Neurological status preoperative determination of the need for plastic
Cause of injury Skin and soft tissue surgery, particularly if it is obvious there will be ex-
High or low energy damage posed subcutaneous bone after debridement. The
Potential for infection presence of skin degloving should be noted.
Other injuries
The length of the wound is used in the Gustilo classifi-
cation, and a loose relationship exists between wound
22 Section I / General Principles

Figure 4-2 Anteroposterior and lateral radi-

ographs of the fracture shown in Figure 4-1.
Radiographs taken after intramedullary nailing
are shown in Figure 33-7 in Chapter 33.

length and prognosis, but it should never be assumed a
There are a number of features that the surgeon
small wound necessarily carries a good prognosis be- should look for when examining the radiographs
cause there may be significant associated contamina- (Box 4-2).
tion and tissue damage. ■ MRI and CT scans are rarely required in the acute situ-
■ The number of skin wounds should be determined. Two ation but may be helpful in open pelvic, intra-articular,
or three small wounds placed close together strongly carpal, and tarsal fractures.
indicates a high-energy injury and degloving in the ■ Angiography may be required in Gustilo IIIb or IIIc
area. fractures. In the polytraumatized patient, the surgeon
■ The degree of wound and skin contamination should be must decide if a delay for further imaging is appropriate.
assessed, as should the presence of bone fragments in
the wound.
■ The apparently intact tissues of the limb should also be
examined because there may be other injuries or evi-
TREATMENT
dence of skin tattooing from the road or from a vehicle
Surgeons tend to concentrate on the method of fracture
wheel having passed over the limb.
treatment when treating open fractures, but a number of
procedures are involved if their treatment is to be success-
Radiological Examination ful. (Box 4-3).
■ Usually, only anteroposterior and lateral radiographs are
required (Fig. 4-2).

They should include adjacent joints and any associ-
ated injuries.
BOX 4-3 PROCEDURES INVOLVED IN THE
TREATMENT OF OPEN FRACTURES
BOX 4-2 IMPORTANT RADIOLOGICAL FEATURES Debridement
IN OPEN FRACTURES Skin
Fat and fascia
Muscle
The location and morphology of the fracture Bone
The presence of comminution signifying a high-energy Wound closure
injury Antibiotics
■ Secondary fracture lines that may displace on treatment
Intravenous
■ The distance the bone fragments have traveled from their
Bead pouch technique
normal location. Wide displacement suggests bone Fracture stabilization
avascularity Secondary debridement
■ Bone defects suggesting missing bone
Soft tissue cover
■ Gas in the tissues
 Chapter 4 / Open Fractures 23

Debridement
■ The most important procedure in the treatment of open
fractures is debridement, or wound excision.

All devitalized or contaminated tissue must be
removed.
■ Until relatively recently, it was difficult to reconstruct
large soft tissue and bone defects, and surgeons tended
to be conservative with tissue resection.
■ With the introduction of improved surgical fixation and
bone reconstruction techniques, and particularly with
the development of free flaps and distally based fascio-
cutaneous flaps, it is now much easier to reconstruct
tissue defects. Therefore the primary surgical debride-
ment should be aggressive when required.
■ The literature suggests that debridement should be per-
formed within 6 hours of the injury. Figure 4-3 Degloving associated with a Gustilo IIIb fracture. The

No clinical evidence indicates the results of debride- degloving was circumferential.
ment after 6 hours are worse than the results prior to
6 hours, but logic dictates that debridement should
be done as soon as possible after injury and there ■ If a large area of degloved skin is excised, split skin graft
should be no unnecessary delay. can be harvested from the excised skin for later use.
■ The basic rules of debridement are given in Box 4-4. ■ After the initial skin excision, the surgeon should extend
the open wound to allow adequate exposure of the un-
derlying bone and soft tissues.
Skin
There are no indications not to do this. Even small
■ Skin is very resistant to direct trauma but susceptible to skin incisions may be associated with considerable
shearing forces, the plane of cleavage being outside the contamination.
deep fascia. ■ The direction and length of the skin extensions will de-
■ Shearing forces may produce extensive degloving in- pend on the location and size of the open wound, but
juries, which particularly affect the lower limb and may ideally extensions should be longitudinal and, where
be circumferential. possible, follow normal surgical approaches.
■ Elderly patients are particularly at risk of degloving, and
circumferential degloving in an elderly multiply injured Fat and Fascia
patient may require amputation (Fig. 4-3). ■ All devitalized fat must be removed.
■ Isolated skin wounds caused by direct trauma can be ■ The extent of fat necrosis may well be greater than was
treated by local excision of the contaminated wound apparent preoperatively, and extensive fat resection with
edges. excision of the overlying skin may be required in some
■ If there are several wounds in close proximity, they cases.
should be excised en bloc, as there will be extensive as- ■ Fascial resection rarely presents a problem, but it
sociated soft tissue damage. should be borne in mind that foreign material may
■ After the initial skin excision, it is important to examine spread between the deep fascia and the underlying
for skin degloving. All degloved skin should be resected muscles.
until dermal bleeding is encountered.

Muscle
■ All devitalized muscle should be removed.
■ It can be difficult to assess muscle viability fully at the
BOX 4-4 SURGICAL PRINCIPLES OF initial debridement, particularly if the patient is hy-
potensive.
DEBRIDEMENT
The classic signs of muscle viability are color, consis-
tency, contractility to mechanical stimulation, and
■ With the exception of low-velocity gunshot wounds, bleeding.
which can be treated with antibiotics and local wound
Muscle bleeding is probably the best test of viability,
care, all open fractures require surgical debridement.
but the surgeon should be guided by the appearance
Failure to do this constitutes inadequate treatment.
■ All affected tissue planes should be explored. and consistency of the muscle.
■ The bone ends must be exposed and carefully examined
Muscles that are shredded or disintegrate on touch
for contamination and soft tissue stripping. should be excised.
■ All devitalized and contaminated tissue should be ex-
It is often easier to determine muscle viability at a re-
cised and all devitalized bone fragments removed. look debridement 36 to 48 hours after the initial ex-
■ The wound should not be closed primarily. ploration. By this time the patient’s condition has sta-
bilized and muscle vascularity is easier to determine.
24 Section I / General Principles

Bone ■ Most of the contaminating bacteria are normal skin

■ Resection of bone should be dealt with in the same way flora, although more virulent bacteria also gain entry to
as soft tissue resection. the wound.
■ All devitalized separate bone fragments should be re- ■ Although 7% of bacteria isolated in the initial culture
moved regardless of their size. cause later infection, where gram-negative bacteria are
■ As with muscle, it may be difficult to determine bone recovered from the initial culture, 50% cause later
vascularity, and if the surgeon is concerned about the vi- infection.
ability of periosteal or muscle attachment to a bone, it ■ Early antibiotic administration has been useful in both
may be advantageous to reexamine the bone fragments animal and clinical studies, and animal work has shown
during the re-look procedure. that the sooner the antibiotics are administered, the
lower the infection rate.
■ Most surgeons use a first- or second-generation
Lavage cephalosporin as prophylaxis for Gustilo type I and II
■ Lavage with fluids such as normal isotonic saline or an- open fractures.
tibiotic solutions is an essential part of the debridement
The initial dose should be given as soon as possible
procedure. after diagnosis with a three-dose intravenous regimen
■ Ten to 15 liters of lavage fluid should be used to remove being used.
bone clots and other devitalized debris and ideally re- ■ In Gustilo type III open fractures, surgeons may use a
duce the level of bacterial contamination. three-dose intravenous regimen of a third-generation
■ Some experimental evidence indicates that the addition cephalosporin or a combination of a second-generation
of antibiotics is associated with a lower infection rate, cephalosporin and an aminoglycoside.
but there is no clinical evidence of the usefulness of an-
If there is any chance of clostridial contamination,
tibiotic solutions. intravenous penicillin should be given. If the patient
is allergic to penicillin, clindamycin or metronidazole
should be used.
Wound Closure
This is important in open pelvic fractures where the
■ Open wounds should not be closed primarily. open fracture may have entered the rectum or

There is no logical reason to do so because all vagina.
wounds that have been adequately debrided can be ■ A bead pouch technique has recently been introduced
closed only under tension. to reduce the incidence of late infection.
■ If wound closure is possible, it should be undertaken at
Antibiotic-impregnated polymethylmethacrylate beads
the re-look procedure 36 to 48 hours after the initial can be placed into the wound after debridement has
surgery. been undertaken.
■ Primary wound extensions can be closed, but there is no
These beads usually contain gentamycin or to-
practical advantage if the main wound is being left bramycin.
open.
Evidence indicates that the incidence of infection in

Even closure of the wound extensions may cause tis- open tibial fractures treated by intramedullary nailing
sue tension. decreases from 16% to 4% with the use of a bead
■ The only exception to the rule about closing wounds pri- pouch technique.
marily is if a primary flap is undertaken.
The technique is not a substitute for either a thor-

This is not always logistically possible, and if it is ough debridement or prophylactic intravenous antibi-
done, it deprives the surgeon of the opportunity to re- otics, however.
examine the soft tissues at a re-look procedure.

In expert hands, primary flap cover can be associated
with good results, although it is unlikely the results Fracture Stabilization
will be better than those associated with a re-look ■ Open fractures should be treated by surgical stabiliza-
procedure and wound closure within 48 hours of the tion.
injury. ■ The main exception to this rule is open fractures of the

Vacuum-assisted closure (VAC) systems have been terminal phalanges of the hand and foot.
used for a number of years to close skin defects
In severe open distal phalangeal fractures, K-wire fix-
with good results. At the moment, they cannot be ation may be used to stabilize the distal phalanx, but
recommended for the closure of open wounds re- generally these fractures are treated by debridement,
lated to fractures in view of the time taken for the antibiotic cover, and nonoperative management. The
soft tissues to close and the consequent risk of outcome is usually favorable because the blood sup-
infection. ply to the terminal phalanges of the hand in particu-
lar is good.
■ Cast management is associated with poorer results than
Antibiotic Prophylaxis operative management in open long-bone fractures.
■ Some 60% to 70% of open wounds are associated with ■ Surgical stabilization minimizes later soft tissue injury
positive cultures in the emergency department. and promotes capillary ingrowth.
 Chapter 4 / Open Fractures 25

■ There is also good evidence it is associated with a de-

creased infection rate.
■ If plastic surgery is required, fracture stabilization is
mandatory.
■ Traction should not be employed for open fractures.
■ The surgical treatment of different fractures is dis-
cussed in Chapters 10 through 30.

Secondary Debridement
■ It is suggested that all open long-bone and pelvic frac-
tures be reexplored 36 to 48 hours after the initial de-
bridement.
■ Primary flap cover can be undertaken, but the advan-
tages of a secondary debridement are considerable.

Residual contamination can be excised and the vas- Figure 4-5 A distally based fasciocutaneous flap use to cover a de-
cularity of the soft tissues and bone fragments re- fect on the leg.
assessed once the patient has been stabilized.

It is also an excellent time to carry out definitive soft
tissue closure because in the majority of cases there Obviously, there is wide variation in the types of soft tis-
will be no residual contamination or devascularized sue treatment used, but an analysis of soft tissue surgery
tissue. used in the 960 open fractures detailed in Table 4-2 does
■ If the wound does require further debridement, this allow an appreciation of the need for the different types of
should be undertaken, and the patient returned to the soft tissue cover (Table 4-3). Of the open fracture, 716
operating room 36 to 48 hours later for a further de- (74.5%) did not need plastic surgery in their management.
bridement. A number of these patients were very seriously injured and

This is a particular problem in crush injuries, in either died or had a primary amputation. The vast majority
which progressive myonecrosis can occur. of patients had their fractures treated successfully without
■ The wound should not be closed until all devitalized or plastic surgery, however. One hundred and forty-one
contaminated tissue has been removed. (14.7%) of the open fractures were treated by split skin
grafting, 12 (1.2%) by muscle flaps, 76 (7.9%) by local
flaps, and 15 (1.6%) by free flap cover. Table 4-3 shows the
Soft Tissue Cover distribution of the different types of soft tissue cover in dif-
■ Most open wounds do not require plastic surgery. ferent body areas. It shows that the requirement for plastic
■ Increasingly, however, plastic surgery techniques are surgery is highest in the tibia and hindfoot, with about
being used in open fractures. 55% of patients requiring some form of plastic surgery.
■ The most frequently used plastic procedures involve Open fractures of the tibial diaphysis, plateau, and plafond
split skin grafting (Fig. 4-4), local muscle flaps such as are associated with the greatest requirement for flap cover.
the gastrocnemius flap, local flaps such as the proximal In this series, patients with open distal humerus, metatar-
or distal fasciocutaneous flap (Fig. 4-5), or free flaps sus, proximal femur, clavicle, proximal humerus, and pelvis
(Fig. 4-6). did not need plastic surgery, although obviously split skin
■ The commonest free flaps are the latissimus dorsi, rec- grafting and flap cover will occasionally be required in
tus femoris, and radial forearm flap. these fractures.

Figure 4-6 A latissimus dorsi free flap used to cover a defect on the
leg. The cosmetic effect is generally better than with a fasciocuta-
Figure 4-4 A split skin graft used on the leg. neous flap (see Fig. 4-5).
26 Section I / General Principles

TABLE 4-3 THE REQUIREMENT FOR PLASTIC SURGERY AND THE TYPE OF
SURGERY IN OPEN FRACTURES
Fracture Plastic Split skin Muscle flap Local flap Free flap
location surgery (%) graft (%) (%) (%) (%)

Tibial diaphysis 55.2 40.1 7.9 44.1 7.9

Ankle 55.0 68.2 — 27.3 4.5
Tibial plafond 54.5 16.7 — 83.3 —
Carpus 46.6 57.1 — 14.3 28.6
Tarsus 40.0 83.3 — 8.3 8.3
Forearm diaphysis 38.2 71.5 — 9.5 19.0
Tibial plateau 30.0 — 66.6 33.3 —
Distal femur 30.0 100 — — —
Femoral diaphysis 28.8 100 — — —
Patella 18.5 100 — — —
Metacarpus 12.5 100 — — —
Distal forearm 8.7 100 — — —
Proximal forearm 6.2 100 — — —
Humeral diaphysis 6.2 100 — — —
Hand phalanges 2.7 62.5 — 37.5 —
Foot phalanges 2.5 100 — — —

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closure (VAC therapy) for the management of patients with high-
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Court-Brown CM, McQueen MM, Quaba AA, eds. Management of Nieminen H, Kuokkanen H, Tukianinen E, et al. Free flap recon-
open fractures. London: Martin Dunitz, 1996. structions of 100 tibial fractures. J Trauma 1999;46:1031–1035.
Court-Brown CM, Rimmer S, Prakash U, et al. The epidemiology of Olson SA, Finkemeier CG, Moehring HD. Open fractures. In: Bu-
open long bone fractures. Injury 1998;29:529–534. cholz RW, Heckman JD, eds. Rockwood and Green’s fractures in
Erdmann MW, Court-Brown CM, Quaba MM. A five year review of adults, 5th ed. Philadelphia: Lippincott, Williams and Wilkins,
islanded distally based fasciocutaneous flaps on the lower limb. Br 2001.
J Plast Surg 1997;50:421–427. Pollak AN, McCarthy ML, Burgess AR. Short-term wound com-
Gopal S, Giannoudis P, Murray A, et al. The functional outcome of plications after application of flaps for coverage of traumatic soft-
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Gustilo RB, Anderson JT. Prevention of infection in the treatment of 82A:1681–1691.
1035 open fractures of long bones: retrospective and prospective Yaremchuk MJ. Acute management of severe soft tissue damage ac-
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Gustilo RB, Mendoza RM, Williams DM. Problems in the manage- 1986;13:621–632.
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type III open fractures. J Trauma 1984;24:742–746. ment. J Am Acad Orthop Surg 2003;11:212–219.
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 Author Query

AU1: Is form injuries correct?