& Management of

Open Fractures

Robert Blease¹, Enes M. Kanlić²*

. Department of Orthopaedics, Fort Leonard Wood, MO , USA

. Department of Orthopaedics, TTUHSC,  Alberta Avenue, El Paso, Texas , USA

* Corresponding author

Abstract

The large spectrum of open fractures is an amalgamation of injuries with the single variable in
common of communication of the fractured bone with the outside environment, and thus an
increased risk for infection. Contributing to the presence of bacteria within the fracture site
is devascularized soft tissue, the degree of which can be directly attributed to the amount of
energy imparted to the tissues. The currently used classification system aids in defining the
degree of severity of these injuries and their subsequent risk for infection. The basic manage-
ment principal for all of these injury patterns remains essentially the same, however: preven-
tion of infection through debridement, wound management, antibiotic usage, and fracture
stabilization. Frequently multiple surgical procedures will be required in order to obtain an
infection free, united fracture with adequate soft tissue coverage ().

KEY WORDS: open fractures, management

Open Fracture Classification

After initial trauma assessment and appropriate ATLS (Advanced Trauma Life
Support) protocols have been met, the injured extremities often remain patient’s
most significant injuries. Evaluation and treatment of these injuries includes not
only the fracture itself, but also includes the soft tissue envelope, to include liga-
ments, tendons, nerves, and vascular structures. Further, the presence of a com-
partment syndrome must be ruled out despite the existence of an open fracture
(). Gustilo and Anderson () modified the proposed classification system of
Veliskakis () and was later re-modified by Gustilo et al. (). This system, which
was initially intended for tibial fractures, has nonetheless found widespread accep-
tance for most long-bone open fractures. As modified by Gustilo et al. (, ), Type I
fractures include puncture wounds up to cm in size with minimal contamination

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 ROBERT BLEASE, ENES M. KANLIĆ: MANAGEMENT OF OPEN FRACTURES

and devascularization of muscle and other soft tissues. solutions for wound irrigation remains controversial
Type II fractures include injuries in a spectrum of  to due to questions about its effectiveness, it’s potential
ten centimeters with only moderate soft tissue com- for selecting out resistant organisms, and its cost versus
promise. There are three sub-classifications of type III benefit ratio. More important perhaps than irrigation
injuries. Type IIIA injuries comprise those open frac- is proper surgical debridement of these wounds. The
tures with extensive soft-tissue damage and or heavy desired end result is a sterile wound with viable tissues
contamination with segmental or severely comminuted in which to prepare the bone for fixation and eventual
fractures. However, these wounds do have adequate union. Tourniquets should be used only when neces-
soft tissue coverage of the exposed bones. Type III B sary, as they tend to interfere with the identification of
injuries have all of those components found in IIIA in- ischemic, nonviable tissues. Often the skin laceration
juries with the addition of periosteal stripping and with is insufficient for adequate debridement and is extend-
the exception of adequate soft tissue coverage. These ed in a longitudinal fashion as far as is necessary. The
injuries will generally need more complex treatment skin and subcutaneous tissues are trimmed sharply,
and management of the soft tissue component of their yet minimally in order to establish healthy, bleeding
wounds (local or distant flaps, Figure ). Often multiple edges. Muscle debridement is performed on the basis
procedures will be required in order to obtain adequate of the -C’s; color, consistency, contractility, and capil-
debridement, to manage infection, and to obtain soft tis- lary bleeding. With the exception of articular fragments,
sue coverage, in addition to fracture fixation and union. devascularised sections of cortical bone, without soft
Type IIIC injuries include any of the above open frac- tissue attachment, should be removed, as they will con-
ture types with the addition of an arterial injury which tinue to act as a nidus for infection. Repeat debridement
requires repair. Although widely accepted this classifi- should be performed every  to  hours as needed
cation system has been questioned with regards to its until the desired surgical wound is obtained. If implant
inter-observer reliability. Brumback and Jones found (nail or plate) is going to be used for fracture fixation
that only  agreement was obtained as to classifica- immediately after debridement, extremity should be
tion of open fractures amongst orthopaedic surgeons. first reprepped and re draped, and than all new sterile
Perhaps the most important caveat to this classification instruments, gowns and gloves must be brought in.
system, and an explanation as to this level of inter-ob-
server disagreement, is that the true classification can Prevention of Infection
only be determined intra-operatively, after wound ex-
ploration and debridement has been performed. More By definition all open fractures are presumed to be con-
importantly, this classification system helps draw the taminated due to their communication with the outside
attention of and direct the care of the most signifi- environment. Factors including bacterial colonization
cant limb threatening injuries in a systematic fashion. of the wound, devitalized tissue, foreign bodies, dead
space areas, and poor vascularity contribute to the high
Wound Management rates of infection seen with these injuries. There is a di-
Irrigation and Debridement rect correlation between the type of open fracture and
the relative risk of infection. Reports range from -
The techniques of irrigation and debridement are un- for type I injuries, - for type II injuries, and  to
questionably the most important tools available to the  for type III injuries (, ). Countermeasures to the
surgeon during the early phase of open fracture man- development of infection include irrigation and debride-
agement. There has been no ideal method established ment as previously mentioned, in addition to the use of
however to address the important variables of volume, immediate broad-spectrum antibiotics. Further, tetanus
delivery method and type of irrigation solution to be prophylaxis should be included in the initial treatment
used (). High-pressure irrigation is excellent at the of these injuries due to the propensity for soil contami-
removal of wound debris and bacteria. However, there nation, which is frequently seen, with these injuries.
remain questions as to the potential that this technique
has for damaging bone (). Chemical antiseptic solu- Wound Cultures
tions may damage healthy tissues and in general should
not be used. Detergent solutions are however showing The use of wound cultures during the initial stages
some promise as an alternative to antibiotic laden irriga- of open fracture care is not uniformly recommend-
tion solutions (, ). The use of antibiotic containing ed. Although the cultures may indicate a probable

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 ROBERT BLEASE, ENES M. KANLIĆ: MANAGEMENT OF OPEN FRACTURES

infecting organism and its antibiotic sensitivity, they attractive in situations in which the use of oral antibiot-
often fail to identify the correct causative organism ics is favored such as in austere environments. One trial
(, ). This may in part be due to early broad-spec- comparing ciprofloxacin compared to a combination of
trum antibiotic usage, and the development of late cefmandole and gentamicin revealed a similar infection
nosocomial infection. One level- study showed that rate of  for both groups, but a drastically increased in-
only  (/) infections seen in a series of  open fection rate of  for the quinalone group vs. , in the
fractures were the result of the organism identified combination therapy group for type III fractures ().
by initial cultures (). Routinely only post-debride- Questions remain however regarding the association
ment cultures should be obtained or in those inju- of fracture healing and the use of quinolones (, ).
ries sustained in abnormal or marine environments.
Duration of Therapy
Antibiotics
The proper duration for antibiotic coverage remains
Patzakis et al., (,) initially demonstrated the criti- somewhat controversial as well. It is known that a delay
cal role played by the initial early administration of an- of greater than  hours is associated with an increased
tibiotics in these fractures. They showed a significant risk of infection (). Dellinger at al. () showed that a
reduction in infection rates by administering cephalo-  day course of anti-microbial agents was not superior to
thin (, or / fractures) compared to those given a  day course. General consensus is that an initial ther-
no antibiotics (, or / fractures) or with peni- apy regimen lasting  days, followed by repeat courses
cillin or streptomycin administration (, or / at wound closure, bone grafting, or other major proce-
fractures). Of note, they administered their antibiotic dure related to the open fracture is appropriate (, ).
regimens before the initial irrigation and debridement.
Local Administration
Antibiotic Selection
The usage of locally applied antibiotics in combination
Typically open fractures are contaminated with a mix- with polymethylmethacrylate (PMMA) beads is rapidly
ture of both gram-positive and gram-negative bacteria. becoming recognized as a useful adjunctive therapy to
Therefore patients with open fractures should be treated irrigation, debridement and the systemic application of
with a combination of antibiotics to sufficiently cover antibiotics. Ostermann at al. () showed in their series
the wide spectrum of potential infecting agents. A first of , open fractures that the use of PMMA beads lad-
Generation cephalosporin such as cefazolin is chosen en with aminoglycoside antibiotics significantly reduced
for its gram-positive coverage, and an aminoglycoside the rate of infection versus the use of intravenious an-
such as gentamicin or tobramycin is chosen to control tibiotics alone. They noted an infection rate of , vs.
gram-negative organisms. Aminoglycoside alterna-  in the two groups (P<,). However, when ana-
tives include agents such as quinolones, aztreonam, and lyzed by fracture type, only the type III fractures showed
third generation cephalosporins. Ampicillin or penicil- a significant reduction in infection rates at , vs. 
lin should be included in injuries at high risk for the de- for the two groups respectively. Typically the antibiotic
velopment of clostridial infections, i.e. anaerobic infec- impregnated PMMA beads are placed directly within
tions. Farm type injuries are at particularly high risk for the wound and are covered with a semi-permeable bar-
the development of clostridial infections. Patzakis and rier when the wounds are left open. Unfortunately to
Wilkins () reported that the combination of a cepha- date Food and Drug administration approval has not
losporin with and aminoglycoside resulted in a , in- been obtained for the use of commercially produced
fection rate (/ open tibial fractures), whereas use of antibiotic beads, and thus physicians must make them
a cephalosporin alone was associated with a  infec- at the time of surgery. Typically  g of PMMA cement
tion rate (/ open tibial fractures). Some authors is mixed with a heat stable antibiotic such as Tobramy-
support the use of single agent cephalosporin coverage cin (, g of antibiotic per  g PMMA) or Vancomycin.
for type I and II injuries, however, this is fraught with These beads are strung on -gauge wire or equivalent
hazards such as the potential for misclassification and while still moldable, for ease of removal. Bead pouches
under-treatment of a wound based on initial evaluation have many potential benefits vs traditional daily dress-
is high. The use of quinolones as a single agent in type I ing changes and systemic administration of aminogly-
and II injuries is showing promise. They are particularly cosides; a) they obtain higher local concentration of

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 ROBERT BLEASE, ENES M. KANLIĆ: MANAGEMENT OF OPEN FRACTURES

antibiotics (up to  to  times greater) than is seen fractures of the tibia typically require free muscle flaps.
with systemic administration (), b) the patient is con- Most commonly free muscle flaps include the rectus
versely protected from high systemic concentrations abdominis, gracilis, and latissimus dorsi muscle groups.
of aminoglycosides and potential severe side effects, c) Important in the consideration of flap coverage type is
there exists a potential for decreased risk of nosocomial the quality of the tissue to be transferred. Damaged tis-
infection by reducing the amount of contact between sue or that which has been subjected to compartment
the wound and the outside environment through use syndrome is likely to do poorly and alternatives should
of the semi-permeable membrane. It is important to be considered (). Whenever practicable, soft-tissue
remember not to establish an anaerobic environment reconstruction should be performed within the first 
with potentially devastating infections by using only days post-injury. Further delays are associated with in-
semi-permeable membranes and not occlusive dressings. creased wound complications and infections (). Cer-
tain authors have advocated coverage within  hours
Closure of Wounds to be ideal (, , ). Godina () reported that free
muscle flaps had a less than  (/) risk of failure
Management of wounds as regards the preferred when performed within  hours as compared to a 
method and timing of closure also remains controver- (/) failure rate when performed later than  hours
sial. Advantages of primary closure following irriga- after initial injury. Infection rates were also favorable
tion, debridement and fracture fixation include a low to early flap coverage within the same study with ,
risk of infection with type I and II fractures, decreased (/) in the early group as compared to , (/)
hospital length of stay and subsequent overall cost (). within the delayed group. Of note, no antibiotic bead
However, if an infection such as clostridial myonecrosis pouch technique was used in their series, thus nosoco-
does arise within a closed wound, devastating conse- mial infection may have played a role in the higher in-
quences can result to include limb and life threatening fection rates and flap failure rates in the delayed group.
complications (). This is exacerbated by inadequate
debridement and antibiotic therapy (). Many au- Fracture Stabilization
thors recommend delayed wound closure for all open Techniques
fractures, often - days following initial care. Delaying
closure has the benefits of preventing the development Available fracture stabilization techniques span the
of anaerobic conditions, providing the opportunity for range of external fixation, plate fixation, and intra-
repeat debridement and the potential use for antibiotic medullary fixation. Regardless of the specific tech-
pouch therapy. Some authors do recommend letting nique used, benefits include protection of soft tissues
small type I wounds close secondarily and only partial from further injury, improved host response to in-
closure of type II wounds (closing only the surgical ex- fecting microorganisms, improved wound care and
tensions and leaving the original traumatic laceration early joint range of motion and rehabilitation. The
open) (). Loosely closing soft tissue is however rec- specific technique to be used is based on multiple
ommended to provide soft tissue coverage of directly factors and each fracture should be individually as-
exposed bone, tendons, nerves and major blood vessels. sessed and treated based on its unique characteristics.

Soft-Tissue Reconstruction Intramedullary Nailing

In certain instances such as open type IIIB fractures and The biomechanical advantages of intramedullary nail-
those that have required extensive surgical debridement, ing are unquestioned; however questions persist as to
adequate soft tissue coverage of bone and other struc- the relative risk of infection using this technique. Di-
tures cannot be obtained. In such instances, alterna- aphyseal fractures of the lower extremity (Figure )
tive soft tissue coverage techniques must be employed. are particularly appropriate for intramedullary nailing
Once a healthy, well-vascularized bed has been estab- (-). The advantages of intramedullary nailing pri-
lished, a local (fasciocutaneous or muscle flap, Figure marily include; a) stable fracture fixation, especially with
) or free flap can be performed (). Typically a local modern interlocking techniques, and b) lack of interfer-
pedicle flap is used from the gastrocnemius for proxi- ence with wound care and soft-tissue management. The
mal third tibia fractures, and soleus flaps are likewise disadvantages include a) potential for deep seeding of
used for middle third fractures of the tibia. Distal third infection, and b) disruption of endosteal blood supply

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 ROBERT BLEASE, ENES M. KANLIĆ: MANAGEMENT OF OPEN FRACTURES

with reamed technique. Brumback et al. () found no lated deep infection, b) the devices are quickly and easily
infections in a cohort of  type I-IIIA fractures, how- applied with little blood loss or compromised vasular-
ever  () of type IIIB open femoral fractures devel- ity, c) there is no added obstacle to wound management,
oped infection. Open tibial fractures have likewise been especially with spanning external fixation which avoids
successfully treated by intramedullary nailing (-). the zone of injury, d) fine wire ring fixators are particu-
larly useful for periarticular fracture fixation (Figure ).
External Fixation vs. Multiple authors (-), with the adjunct of early bone
Intramedullary Nailing grafting as appropriate, advocate definitive treatment
of these injuries by use of external fixation. Marsh et
There are few studies that have directly compared ex- al. () noted that  (/) type II and III fractures
ternal fixation for final stabilization vs intramedullary healed with little malalignment in over  of patients
nailing. Torneta et al. () presented a case series us- and a  infection rate Pin tract infections continue to
ing either method, which demonstrated no increased be problematic to external fixation devices however.
risk of infection. Henly et al. () found no difference Techniques which can help decrease the rate of such
in infection rates between undreamed nails and external infections include pre-drilling of holes for half pin fix-
fixation, but did note a rate of  malalignment in the ators in order to avoid thermal necrosis of the bone, as
external fixation group plus a  incidence of pin tract well as careful selection of patient population, and rigid
infection. Overall the risk of infection appears to be de- pin care protocol. Often a temporary spanning exter-
creased with the use of intramedullary nails, as is the risk nal fixator is placed during the initial phases of wound
for revision surgery and malunions established by meta- management with the intention of later conversion to
analysis (). Further, patient compliance is generally less intramedullary or plate fixation. This has been associ-
problematic with those treated with intramedullary nail- ated with infection rates of up to  if performed in
ing. Intramedullary nailing is thus acceptable for treat- an overly delayed fashion (, ). Blachut et al. ()
ment of types I-IIIB diaphyseal fractures with external studied early vs late conversion to internal fixation
fixation reserved for heavily contaminated/severe soft and noted that when performed early, with a mean of
tissue compromised IIIB fractures, and for IIIC injuries  days, and in the absence of active pin tract infection,
conversion to intramedullary nail an be performed with
External Fixation an infection rate of . Further disadvantages to ex-
ternal fixation include the potential for loss of alignment
The advantages of external frame fixation for fractures and/or refracture after removal of the external-fixator.
are multiple; a) there is decreased risk for implant re-

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 ROBERT BLEASE, ENES M. KANLIĆ: MANAGEMENT OF OPEN FRACTURES

Plate Fixation

Open reduction and plate fixation of intra-articular, peri- fixation of open fractures has been associated with an in-
articular and metaphyseal fractures remains the current creased incidence of hardware failure and infection (,
standard of care due to the unique ability of this tech- ). The newer generation of locking plate technology
nique to stabilize and support intra-articular and peri-ar- has the improved advantage of minimally invasive inser-
ticular fractures. Further, plate fixation is the preferred tion and fixation with minimal periosteal stripping and
method of treatment for most upper extremity diaphyse- thus improved preservation of bone perfusion (, ).
al fractures as well (Figure ). However, in the tibia, plate

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 ROBERT BLEASE, ENES M. KANLIĆ: MANAGEMENT OF OPEN FRACTURES

Conclusion

The principals for management of open fractures remain largely unchanged by newer technical advances. The cor-
ner stone of treatment remains adequate irrigation and debridement with early broad-spectrum antibiotic us-
age. Delayed wound closure remains, as a valid, and often preferred technique in order to avoid the complications
of late infection and clostridial myonecrosis. The use of antibiotic bead pouches is a new and useful addition to the
surgeon’s armamentarium. Early stabilization through external fixation, internal fixation, and/or intramedul-
lary nailing is critical to the restoration not only of the bony anatomy, but to stabilization of the soft tissues as well.
If external fixation is to be removed as a temporary stabilization device in preference to intramedullary fixation or
plate fixation, then this should be done through a healthy soft tissue bed within the first  days after initial fixation.

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