Open

Fractures
Dr. Sukhpal Singh
 Definition
• These are the fractures in which there is
breach in the soft tissue envelope over or
near the fracture, such that fracture
haematoma communicates with external
environment.
 History
• Egyptians 1st time recognised he need for
coverage over fracture wounds to minimise
morbidity.
• Hippocrates favoured the debridement of
purulent material.
• Galen considered purulence as necessary
“Laudable pus” & considered it as essential for
healing.
• Ambroise Parè also favoured the debridement
as the mainstay of treatment of open
 History
• Desault (coined the term ‘debridement) in
18th century reiterated this belief by advising
debridement of dead necrotic material.
• Still in the 19th century, prior to aseptic
technique & antibiotics, emergency
amputation was the life saving measure after
open fracture.
 History
• Last century, high mortality with open fractures
of long bones
• WWI, mortality of open femur fractures > 70%
• By the WWI the main principle of treatment was
debridement and stabilization & all healing by
secondary intention.
• 1939 Trueta “closed treatment of war fractures”
– Included open wound treatment and then enclosure
of the extremity in a cast
– “Greatest danger of infection lay in muscle, not bone”
 History
• During the WW-II use of local antibiotics like
sulfonamides was started for wound
treatment.
• Use of PCN on the battlefield quickly reduced
the rate of wound sepsis.
 History
• Advances shifted the focus
– Preservation of life and limb  preservation of
function and prevention of complications
• However, amputation rates still exceed 50% in
the most severe open tibial fractures assoc
with vascular injury.
 Epidemiology
• More than 4.5 million open fractures occur
per year in India. (IJO)
 Etiology
• Generally a result of high energy mechanisms which cause
greater soft tissue disruption that leaves the wound more
susceptible to infection by contaminating bacteria.
• The energy is stored in soft and hard tissues until the strength
of respective material is exceeded.
• Comminuted pieces may acquire high velocity after which
they propel into the surrounding soft tissues and cause
additional damage.
• More severe injury, limb absorbs energy  releases in
explosion  tears the skin  momentary vacuum sucks
foreign material into the wound depth.
• Soft tissue damage  enormous muscle swelling 
compartment syndrome (more in open injuries) of the intact
compartments
 Cell tissue Trauma
death /contamination

Damaged tissue
Vascular flow is slowed & exchange releases
(co2, o2, glu, urea) diminished mediators of
inflammation

Viscious cycle
leading to
compartment
syndrome

Extrinsic pressure from interstitium “Leaky

compresses the microvasculature capillaries”

Intravascular
Pressure
fluid to the
builds in the
interstial
interstitium
space
 Prognosis
• Fracture pattern
• Local factors
– Amount of foreign debris and contaminant
material
– Extent of soft tissue and bone devitalization.
• Systemic fractures
– Host nutrition
– Medications
– Nicotine abuse
 Open fracture classification
• Allows comparison of results
• Provides guidelines on prognosis and
treatment
– Fracture healing, infection and amputation rate
correlate with the degree of soft tissue injury
• Gustilo upgraded to Gustilo and Anderson
• AO open fracture classification
• Host classification of open fractures
Gustilo and Anderson Classification
• Model is tibia, however applied to all types of
open fractures
• Emphasis on wound size
– Crush injury assoc with small wounds
– Sharp injury assoc with large wounds
• Better to emphasize
– Degree of soft tissue injury
– Degree of contamination
 Type 1 Open Fractures
• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal
stripping
 Type 2 Open Fractures
• Moderate soft tissue
damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal
stripping
Type 3a Open Fractures
• High energy
• Outside-in
• Extensive muscle
devitalization
• Bone coverage with
existing soft tissue
 Type 3b Open Fractures
• High energy
• Outside in
• Extensive muscle
devitalization
• Requires a flap for
bone coverage
and soft tissue
closure
• Periosteal stripping
 Type 3c Open Fractures

• High energy
• Increased risk of
amputation and
infection
• Any grade 3 with
major vascular injury
requiring repair
 Why use this classification?
• Grades of soft tissue injury correlates with infection
and fracture healing
Grade 1 2 3A 3B 3C
Infection
0-2% 2-7% 10-25% 10-50% 25-50%
Rates

Fracture
Healing 21-28 28-28 30-35 30-35
(weeks)

Amputation
50%
Rate
 Gustilo and Anderson
Bowen and Widmaier*

• 2005 Host classification predicts infection

after open fracture
– Gustilo and Anderson classification and the
number of comorbidities predict infection risk
– 174 patients with open fractures of long bones
– Sorted into three classes based on 14
immunocompromising factors
• Age>80, current nicotine use, DM, malignancy,
pulmonary insufficiency, systemic immunodeficiency,
etc
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205-11.
 What they found…
Class Compromising factors Infection rates

A 0 4%
B 1-2 15%
C 3 or more 31%

• Patients with any compromising risk factor has

increased risk of infection
• May benefit from additional therapies that
decrease the risk of infection.
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205-11.
 Gustilo Classification:
a simple and useful tool, but is it accurate?
• 1994 Brumback et al.
• 125 randomized open fractures
• 245 surgeons of various levels of training
• 12 cases of open tibia fractures, videos used
• Interobserver agreement poor
– Range 42-94% for each fracture
• Ortho attendings - 59% agreement
• Ortho Trauma Fellowship trained attendings - 66% agreement

Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two
hundred and forty-five orthopaedic surgeons. J Bone and Joint Am; 76(8):1162–1166.
 So……….
• Fracture type should not be classified in the
ER
• Most reliably done in the OR at the
completion of primary wound care and
debridement
 Microbiology
• Most acute infections are caused by pathogens
acquired in the hospital
• 1976 Gustilo and Anderson
– most infections in their study of 326 open fxs
developed secondarily
• When left open for >2wks, wounds were prone to
nocosomial contaminants such as Pseudomonas
and other GN bacteria
• Currently most open fracture infections are
caused by GNR and GP staph

Gustilo RB, Anderson JT: Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones; JBJS,
58(4):453-458, June 1976
 Nocosomial infection?!!!!
• Only 18% of infections were caused by the
Cover the
same organism initially isolated in the
perioperative cultures*
• Carsenti-Etesse et al. 1999
wounds
– 92% of open fracture infections were caused by

quickly
bacteria acquired while the patient was in the
hospital**

*Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res. 1983
Sep;(178):36-41.
*Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized, double-blind study comparing
single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-33.
**Carsenti-Etesse H, Doyon F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B, Dellamonica P. Epidemiology of bacterial infection
during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:315-23.
 Common bacteria encountered with
open fractures

Blunt Trauma, Low Energy GSW Staph, Strept

Farm Wounds Clostridia

Fresh Water Pseudomonas, Aeromonas

Sea Water Aeromonas, Vibrios

War Wounds, High Energy GSW Gram Negative

 What systemic antibiotic?

1st Gen Ceph Gent PCN

Grade 1 

Grade 2  +/-

Grade 3   +/-

Farm/War
  
Wounds

(Gustilo, et al; JBJS 72A 1990)

 Antibiotic comparisons
• No difference btwn clindamycin and cefazolin*
• Patzakis et al. **
– For type 1&2, cipro = cefamandole+gentamicin
– For type 3, cipro worse (31% vs 7.7% infection)
• Cipro and other fluoroquinolones inhibit
osteoblast activity and fracture healing***

*Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a prospective study. J Trauma.
1983;23:25-30.
**Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P. Prospective, randomized, double-blind study comparing
single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000;14:529-33.
***Holtom PD, Pavkovic SA, Bravos PD, Patzakis MJ, Shepherd LE, Frenkel B. Inhibitory effects of the quinolone antibiotics trovafloxacin,
ciprofloxacin, and levofloxacin on osteoblastic cells in vitro. J Orthop Res. 2000;18:721-7.
***Huddleston PM, Steckelberg JM, Hanssen AD, Rouse MS, Bolander ME, Patel R. Ciprofloxacin inhibition of experimental fracture healing.
J Bone Joint Surg Am. 2000;82:161-73.
 When and for how long?
• Start abx as soon as possible*
– Less than 3 hours  4.7 % infection rate
– Greater than 3 hours  7.4%
• No difference btwn 1 and 5 days of post op
abx treatment**
• Mass Gen recommended treatment:***
– Cefazolin Q 8 until 24 hours after wound closed
– Gentamicin or levofloxacin added for type 3
*Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36-40.
**Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou MA. Duration of preventive
antibiotic administration for open extremity fractures. Arch Surg. 1988;123:333-9.
***Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
 Local antibiotic therapy
• High abx conc within the wound and low
systemic conc
– Reduces risk of systemic side effect
• Vancomycin or aminoglycosides
– Heat stable
– Available in powder form
– Active against suspected pathogens

Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-
impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.
 Antibiotics - locally
Antibiotic Infection Rate
IV Abx 12%
IV Abx + local aminoglycoside 3.7%
impregnated PMMA beads

• Prevents secondary contamination by

nocosomial pathogens
• Useful adjunct to systemic abx
• Potential for abx impregnated bone graft,
bone graft substitute, and abx coated IMN

Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases; J Bone Joint
Surg Br. 1995 Jan;77(1):93-7.
 Antibiotic Beads
• Pros • Cons
– Very high levels of – Requires removal
antibiotics locally – Limited to heat
– Dead space stable antibiotics
management – Increased drainage
from wound
 Goals of treatment
• 1. preserve life
• 2. preserve limb
• 3. preserve function

• Also….
– Prevent infection
– Fracture stabilization
– Soft tissue coverage
Stages of care for open fractures
 Initial assessment & management
• ABC’s
• Assess entire patient
• Careful PE, neurovasc
• Abx and tetanus
• Local irrigation 1-2 liters
• Sterile compressive dressings
• Realign fracture and splint
• Do not culture wound in the ED*
– 8% of bugs grown caused deep
infection
– cultures were of no value and not to
be done
• Recheck pulse, motor and sensation

Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.
 Can I take pictures with my phone and
send it to my senior?
• Documents characteristics accurately
• Prevents multiple examinations
• Decreases contamination*
• Communication via digital
photography was more useful
than verbal communication**
• 1.3-megapixel camera is comparable
with higher resolution cameras when
viewing color images on computer
desktop***
 Primary surgery

• Objectives of initial surgical

management
– Preservation of life and limb
– Wound debridement
– Definitive injury assessment
– Fracture stabilization
Stages of open fracture management in the OR
 Surgical emergency!
• 1898 Friedrich guinea pigs
– Take to the OR within 6-8 hours*
• 1973 Robson:
bacteria multiply in contaminated
wounds **
– 105 organisms/gram of tissue is the
infection threshold
– Reached at 5.17 hours
• 1995 Kindsfater et al:
– 47 G2/3 fxs at 4.8 months out….
• Less than 5 hrs  7% infection
• Greater than 5 hrs  38% infection
– However G3 fxs were treated later

*Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:288-310.
**Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426-30.
 Or not?....
Calling the “6 hour rule” into question
• 1993 Bednar and Parikh…. No significant difference *
– 3.4% vs 9%; 82 open femoral/tibial fxs
• 2004 Ashford et al…. No significant difference **
No significant
– 11% vs 17%; pts from the austrailian outback
• 2004 Spencer et al.... No significant difference ***
– 10.1% vs 10.9%; 142 difference
open long bone fxs from UK
• 2003 Pollack and the LEAP investigators…. No correlation****
– 315 open longbefore
bone fxs or after 6
• 2005 Skaggs et al….No significant difference *****
hours!!!
– children with all types of open fractures; 554 open fractures

*Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities
caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5.
**Ashford RU, Mehta JA, Cripps R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures. Injury. 2004;35:411-6.
***Spencer J, Smith A, Woods D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Ann R
Coll Surg Engl. 2004;86:108-12.
****Pollack AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive treatment significantly influences incidence of infection
after open high-energy lower-extremity trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake City, UT.
*****Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open
Fractures in Children.” JBJS-A 2005. 87:8-12
 Do we even need to do operative
debridement?
• Orcutt et al... No significant difference, BUT…*
– 50 type 1 &2 open
Dofractures
we even
– less infection in nonoperative group (3% vs 6%)
need to debride
– Less delayed union in nonop group (10% vs 16%)
low grade
• Yang et al….0% infections **
open
fractures?
– 91 type 1 open fractures treated without I&D

*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the
Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.
**Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat Res
2003. 410: 289-294.
 However, after review of all literature….….

• Okike et al. states….

• “Thorough operative debridement is the standard
of care for all open fractures.”
• “Even if the benefits of formal I&D were
insignificant for low grade fractures, operative
debridement is still required for proper wound
classification.”
• “Open fractures graded on the basis of superficial
characteristics are often misclassified.”
• Huge risk not to explore and debride!
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006 Dec;88(12):2739-48.
 URGENTLY debride, not EMERGENTLY
• Time to OR is probably less important than:*
– Adequacy of debridement
– Time to soft tissue coverage
• Timing depends on….**
– Is patient stable? Within
Within
– Is the OR prepared? 6 hours
24
– Is appropriate assistance available?
• Ortho trained scrub techs, assistant surgeons, xray
hours
techs, and other OR staff
• 2005 Skaggs et al:***
– If after 10pm, keep until the morning! Or at least
within 24 hours.
– Unless….
• neurovasc compromise
• horrible soft tissue contamination
• compartment syndrome
*Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
**Werner CM, Pierpont Y, Pollak AN: The urgency of surgical débridement in the management of open fractures. J Am Acad Orthop Surg.
2008 Jul;16(7):369-75.
***Stewart DJ, Kay RM, Skaggs DL: Open Fractures in Children. Principles of Evaluation and Management. JBJS-A. 2005;87:2784-2798.
 I&D in the OR
• Trauma scrub
– Soap and saline to remove gross debris
• “Zone of injury”
– Skin wound is the window through which
the true wound communicates with the
exterior
• Extend the traumatic wound
– Excise margins
– Resect muscle and skin to healthy tissue
• color, consistency, capacity to bleed and
contractility
• Bone ends are exposed and debrided
• Irrigate
• Serial debridements?
– If needed, 2nd or 3rd debridement after 24-
48 hours should be planned
 The Irrigation
• Amount
– No good data, copious is better
– Animal studies show improved
removal of particulate matter
and bacteria but effect plateaus
– Irrigation bags typically contain
3 L of fluid
– Anglen recommends:*
• 3L (one bag) for type 1
• 6L (two bags) for type 2
• 9L (three bags) for type 3

*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

 How to deliver the irrigation?
(what animal studies show)
• Bulb Syringe vs Pulsatile Lavage
– Pulsatile lavage
• Detrimental for early bone healing
– this is no longer present at 2 wks*
• More soft tissue destruction**
• More effective in removing
particulate matter and bacteria***
• High or low pressure?
– Higher pressure
• Better bone cleaning
• Worse soft tissue cleaning
• Slows bone healing
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on
Fracture Healing.” JOT 1998. 12(7): 460-463.
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial
Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.
 Antibiotics in the irrigation?
• Antibiotics (bacitracin and/or neomycin)
– Mixed results, controversial
– Costly
No proven
• bacitracin alone around $500/washout
– ?? Causing benefit!
resistance
– Wound healing problems?
– Few reported cases of anaphylaxis
– Anglen: “No proven value in the care of open
fracture wounds…some risk, albeit small.”

*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

 Soaps in the irrigation?
• Surfactants (i.e. Soaps)
– Less bacteria adhesion
– Emulsify and remove debris
– No significant difference in
infection or bone healing
compared to bacitracin
solution, but more wound
healing problems in
bacitracin group

Anglen JO. “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A Prospective, Randomized
Study.” JBJS-A 2005. 87(7):1415-1422.
 Level 4 evidence based
recommendations
• 1st washout, highly contaminated
 Soap solution
• Repeat washout of clean wounds
 Saline
• Infected wounds
 Soap, then antibiotic

*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

 Wound closure after contaminated fracture
• Timing and technique is
controversial
Dubunked!
OPEN WOUND should be left OPEN!
– Prevents anaerobic conditions in
wound: Clostridium
– Facilitates drainage
– Allows repeat debridement

Zalavras CG, Patzakis MJ:Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9.
 To close or not to close?
• Recently, renewed interest
in primary closure • 1999 Delong et al: 119 open fxs
• Collinge, OTA 2004 – No significant difference
• Moola, OTA 2005 • delayed/nonunion and infection rates btwn
immediate and delayed closure
• Russell, OTA 2005
• DeLong, J Trauma 2004/ – Immediate closure is a “viable option”
• Bosse, JAAOS 2002
– Improved abx management
Grade Percent of primary closures
– Better stabilization
– Less morbidity 1 88%
– Shorter hospital stay, lower 2 86%
cost
– NO increase in wound 3a 75%
infection 3b 33%
• These wounds are at 3c 0%
higher risk of clostridia
perfringens if they do get
infected. infection rate 7%
Overall delayed/nonunion rate 16%

DeLong WG Jr, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture wounds. J Trauma. 1999
Jun;46(6):1049-54.
 Contraindications to primary closure
• Inadequate debridement
• Gross contamination
• Farm related or freshwater immersion injuries
• Delay in treatment >12 hours
• Delay in giving abx
• Compromised host or tissue viability
 When to cover the wound?
• ASAP after wound adequately debrided
– Only 18% of infections are caused by the same organism
isolated in initial perioperative culture*
• Suggests hospital acquired etiology of infection

• “Fix and Flap”**

– For Type IIIB & IIIC open tibia fractures
– Early if not immediate flap coverage
Timing of flap placement Infection rate
< 72 hours 6%
> 72 hours 30%
•Patzakis MJ, Bains RS, Lee J, et al. “Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to
combination antibiotic therapy in open fracture wounds.” JOT 2000. 14: 529-533.
**Gopal S, Majumder S, Batchelor A, Knight S, De Boer P, Smith RM. “Fix and flap: the radical orthopaedic and plastic treatment of severe
open fractures of the tibia.” JBJS-B 2000. 82(7): 959 – 966.
 Dressings
• Temporary closures – rubber bands

• Wet to dry dressings

• Semi-permeable membranes

• Antibiotic bead pouch

• VAC
 VAC
• Vacuum assisted wound closure
– Recommended for temporary management
– Mechanically induced negative pressure in a closed
system
– Removes fluid from extravascular space
– Reduced edema
– Improves microcirculation
– Enhances proliferation of reparative granulation tissue
• Open cell polyurethane foam dressing ensures an
even distribution of negative pressure
-Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11.
-Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in
the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007
 Types of fracture stabilization
• Splint
– Good option if operative
fixation not required
• Internal fixation
– Wound is clean and soft tissue
coverage available
• External fixation
– Dirty wounds or extensive soft
tissue injury
 Fracture stabilization
• Gustilo type 1 injury can be treated the same
way as a comparable closed fracture
• Most cases involve surgical fixation
• Outcome is similar to closed counterparts
 Fracture stabilization
• Gustilo type 2&3 usually displaced and unstable
– dictate surgical fixation
• Restore length, alignment, rotation and provide
stability
– ideal environment for soft tissue healing and reduces
wound infection
– reduces dead space and hematoma volume
• Inflammatory response dampened
• Exudates and edema is reduced
• Tissue revascularization is encouraged
 When to use plates?

• Open diaphyseal fractures of arm & forearm

• Open diaphyseal fractures lower extremity
– NOT recommended
– Open tibial shaft plating assoc high infection rate*
• Open periarticular fractures
– Treatment of choice in both upper and lower
extremities
Bach AW, Hansen ST Jr.: Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin Orthop Relat Res.
1989 Apr;(241):89-94.
 When to use IM nails?
• Treatment of choice for most
diaphyseal fractures of the
lower extremity
• Inserted without disrupting
the already injured soft tissue
envelope
• Preserves the remaining extra
osseous blood supply to
cortical bone
• Malunion is uncommon
 To ream or not to ream?
• Does reaming cause additional damage to the
endosteal blood supply?
• Solid IM nails without reaming has a lower risk of
infection that tubular nails with a large dead space*
• However reamed IM nails are biomechanically stronger
and can reliably maintain fracture reduction if statically
locked
• 2000 Finkemeier et al.
– reamed vs unreamed interlocked nails of open tibias
– NO statistical difference in outcome and risk of
complication**
*Melcher GA, Claudi B, Schlegel U, Perren SM, Printzen G, Munzinger J.Influence of type of medullary nail on the development of local
infection. An experimental study of solid and slotted nails in rabbits; .J Bone Joint Surg Br. 1994 Nov;76(6):955-9.
**Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM: Locking intramedullary nailing with and without reaming for open fractures
of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997 Mar;79(3):334-41.
**Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF: A prospective, randomized study of intramedullary nails inserted with
and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000 Mar-Apr;14(3):187-93.
When to use external fixation?
• Diaphyseal fractures
not amenable to IM
nails
• Ring fixators for
periarticular
fractures
• Temporary joint
spanning ex fix is
popular for knee,
ankle, elbow and
wrist
• If temporary, plan
for conversion to IM
nail within 3 weeks
 Ex-fix: Weigh the pros and cons!
• Historically was definitive treatment
• Now, more commonly as temporary fixation
• Can be applied almost always and everywhere
• Severe soft tissue damage and contamination
• Advantages: • Disadvantages:
– Easy and quick – Pin track infections
– Relatively stable fixation – Malalignment
– No further damage done – Delayed union
– Avoids hardware in the – Poor patient
compliance
open wound
 Skin cover and soft tissue
reconstruction
• Do these early!
• 1994 Osterman et al.*
Infection risk
– Retrospective 1085 fractures, 115 G2 and 239 G3
increases if wound
• All treated with appropriate IV Abx and I&D
– No infection if wounds closed at 7.6 days
– Yes infection if wounds closed at 17.9 days
open > 7 days
*Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures: A review of 1085 consecutive cases. J Bone Joint
Surg Br 1995;77:93–97.
 Reconstructive ladder: options for
wound coverage
Primary closure
Type 1 open fx
Secondary intention
Type 2/3A open fx
Skin graft

Local flap

Regional flap

Distant flap Type 3B open

Free flap fx
Tissue
expansion
Flap coverage for type 3b
 Type 3c, a bad injury!
• Devastating damage to
bone and soft tissue
• Major arterial injuries
that require repair
• Poor functional outcome
• Consensus btwn ortho,
vascular and plastics
• Salvage is technically
possible in most cases
• However it is not always
the correct choice esp
type 3c tibia fractures
 We can do both, salvage & amputate.
• Vascular surgery can revascularize
with bypass graft
– Generally before fracture stabilization
• Plastics can provide soft tissue
coverage
• However, in the tibia, the severity
to soft tissue envelope and bone
may result in infected nonunion
• If salvage…. long course of
repeated surgical procedures
– Painful and psychologically distressing
– Functional outcome may be poor and
no better than amputation
 How to decide, salvage or amputate?
• Important factors in decision making:*
– General condition of the patient (shock)
– Warm ischemia time (>6hours)
– Age (>30 years)
– Cut to crush ratio (blunt injuries has a large zone
of crush)

Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities following combined orthopedic
and vascular trauma. A predictive salvage index. Am Surg. 1987 Apr;53(4):205-8.
 Gunshot injuries
• Energy dissipated at impact = damage
severity
• High velocity rifles and close range
shotguns
– Worst, high energy of impact
– Huge secondary cavitation
– Secondary effects of shattered bone
fragments
• Bullets lodged in joints should be removed
– avoid lead arthropathy and systemic lead
poisoning
 Low velocity GSW <2000 ft/sec
• Low velocity handguns
– Less severe, not treated like open fractures
– Cavitation is not significant
– Secondary missile effects are minimal
– Bone fragments rarely stripped of soft tissue
attachments and blood supply
– Soft tissue injuries not severe and skin wounds are
small
 Low velocity GSW open fractures
• Geisslar et al. * • Dickey et al.**
• If neurovascular status – No abx vs IV Ancef x 3d
normal, do local Treat open – 67 low velocity GSW fxs
debridement – Not requiring operative
fractures from fixation
low
• NO formal I&D needed
• IV Abx
velocity GSW as
– No difference in
infection rates
closed
• Approach fx fixation as fractures
if closed
without Abx
**Dickey et al, J Ortho Trauma, 3;6-10,1989

*Geisslar ett al, J Ortho Trauma, 4;39-41,1990

 Pitfalls and complications
• Infection  delayed union, nonunion, malunion
and loss of function
• Plan ahead to avoid delayed union and nonunion
• Predict nonunion in severe injuries with bone loss
– Bone grafting usually delayed 6 weeks when soft
tissues have soundly healed
– Autogenous bone grafting is usual strategy
– Fibular transfer, free composite graft or distraction
osteogenesis for complex defects
– Recombinant human BMP in open tibia fracture
reduces risk of delayed union
 Advances…
• BMPs
– 40% decreased infection rate with BMP in type 3
open tibia fractures*
• Antibiotic Laden Bone Graft**
– Tobramycin-impregnated calcium sulfate pellets
with demineralized bone matrix
– Animal study: successful in preventing infection
*BESTT Study Group, Govender S, Csimma C, Genant H, Valentin-Opran A. “Recombinant Human Bone Morphogenetic Protein-2 for
Treatment of Open Tibial Fractures: A prospective, controlled, randomized study of four hundred and fifty patients.” JBJS-A 2002.
84(12): 2123-2134.
**Beardmore AA, Brooks DE, Wenke JC, Thomas DB. “Effectiveness of local antibiotic delivery with an osteoinductive and
osteoconductive bone-graft substitute.” JBJS-A 2005. 87(1): 107-112.
 Summary

A = good evidence (level 1 studies)

B = fair evidence (level 2/3 studies)
C = poor quality evidence (level 4/5 studies)
I = insufficient or conflicting evidence

Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
Thank you