Your SlideShare is downloading. ×

Open fractures jaaos


Published on

Published in: Health & Medicine
  • Be the first to comment

  • Be the first to like this

No Downloads
Total Views
On Slideshare
From Embeds
Number of Embeds
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

No notes for slide


  • 1. Open Fractures: Evaluation and Management Charalampos G. Zalavras, MD, and Michael J. Patzakis, MDAbstractOpen fractures are complex injuries that involve both the bone and surrounding Veliskakis2 proposed a classifica-soft tissues. Management goals are prevention of infection, union of the fracture, tion system for open fractures thatand restoration of function. Achievement of these goals requires a careful approach included three types based on in-based on detailed assessment of the patient and injury. The classification of open creasing severity. This concept wasfractures is based on type of fracture, associated soft-tissue injury, and bacterial con- refined by Gustilo and Anderson,3tamination present. Tetanus prophylaxis and intravenous antibiotics should be ad- and their classification system, sub-ministered immediately. Local antibiotic administration is a useful adjunct. The sequently modified by Gustilo et al,4open fracture wound should be thoroughly irrigated and débrided, although the op- has found widespread application.timal method of irrigation remains uncertain. Controversy also exists regarding the Type I includes puncture wounds ≤1optimal timing and technique of wound closure. Extensive soft-tissue damage may cm, with minimal contaminationnecessitate the use of local or free muscle flaps. Techniques of fracture stabilization and muscle damage. Type II in-depend on the anatomic location of the fracture and characteristics of the injury. cludes lacerations >1 cm, with mod- J Am Acad Orthop Surg 2003;11:212-219 erate soft-tissue injury. Bone cover- age is adequate and comminution is minimal. Type III includes three sub- types. Type IIIA involves extensiveOpen fractures often result from Assessment and soft-tissue damage with adequatehigh-energy trauma and are charac- Classification of Open bone coverage. Usually it is the re-terized by variable degrees of soft- Fractures sult of a high-velocity injury with atissue and skeletal injury, both of severe crushing component. Typewhich impair local tissue vasculari- Patients who present with associated IIIA also includes heavily contami-ty. Open fractures communicate life-threatening injuries should be nated wounds with severe commu-with the outside environment, and initially evaluated and resuscitated nition and segmental fractures. Typethe resulting contamination of the according to Advanced Trauma Life IIIB involves extensive soft-tissuewound with microorganisms, cou- Support protocols. Injured extremities damage, with stripping of the peri-pled with the compromised vascular then should be assessed for neurovas- osteum and exposure of the to the region, leads to an in- cular injury and compartment syn-creased risk of infection as well as to drome. The presence of an open frac-complications in healing. In addi- ture wound does not exclude the Dr. Zalavras is Assistant Professor, Departmenttion, bone, tendons, nerves, and ar- extremity from the complication of of Orthopaedic Surgery, University of Southernticular cartilage may be exposed and compartment syndrome.1 In addition, California Keck School of Medicine, Los Angeles,subject to damage. complete assessment of the open frac- CA. Dr. Patzakis is Professor and Chairman, The The principles that govern open ture includes reviewing the mecha- Vincent and Julia Meyer Chair, Chief of Ortho- paedic Surgery Service, University of Southernfracture management include as- nism of injury, condition of the soft California University Hospital and Los Angelessessment of the patient and classifi- tissues, degree of bacterial contami- County+University of Southern California Med-cation of the injury, prevention of in- nation, and characteristics of the frac- ical Center, Department of Orthopaedic Surgery,fection, wound management, and ture. The evaluation of these factors University of Southern California Keck School offracture stabilization, including ear- will help to classify the fracture, de- bone grafting. Management of termine the treatment regimen, and Reprint requests: Dr. Patzakis, GNH 3900, 2025open fractures can be challenging, establish the prognosis and potential Zonal Avenue, Los Angeles, CA 90089-9312.and multiple surgical procedures clinical outcome. In particular, the de-frequently are needed to achieve gree of bacterial contamination and Copyright 2003 by the American Academy ofsoft-tissue coverage and fracture soft-tissue damage is important in Orthopaedic Surgeons.union. classifying an open fracture.212 Journal of the American Academy of Orthopaedic Surgeons
  • 2. Charalampos G. Zalavras, MD, and Michael J. Patzakis, MDUsually it is associated with heavy ity and soft-tissue damage. The risk tered (2.4% [2/84 fractures]) com-contamination and severe comminu- of infection is related to severity of pared with no antibiotics (13.9%tion of the bone. Coverage using free injury. Infection rates range from 0% [11/79]) or with penicillin and strep-muscle flaps is necessary. Type IIIC to 2% for type I, 2% to 10% for type tomycin (9.8% [9/92]). The antibiot-involves any open fracture with ar- II, and 10% to 50% for type III.3,8 Pre- ics were administered before woundterial injury requiring repair, regard- vention of infection is based on im- débridement. However, furtherless of the degree of soft-tissue inju- mediate antibiotic administration questions regarding administrationry. Gustilo et al5 later classified open and wound débridement. Tetanus involve selection of antibiotics, in-fractures more than 8 hours old at prophylaxis should be administered cluding choice of single or combina-presentation as a special category of based on the patient’s immunization tion therapy; duration of therapy;type III fracture. Despite its wide status. and usefulness of local administra-acceptance, however, the reliability tion. It is important that, in the set-of this classification has been ques- Wound Cultures ting of an open fracture, antibioticstioned. Brumback and Jones6 report- In the early postfracture period, not be considered prophylactic. Thised that the average agreement results of wound cultures may indi- term can be confusing because anti-among orthopaedic surgeons on the cate the most probable infecting or- biotics routinely administered in or-classification of open tibial fractures ganism and determine the patho- thopaedic elective procedures arewas 60% overall, which was deemed gen’s sensitivity to antibiotics. prophylactic. But because infectionto be moderate to poor. However, the usefulness of initial commonly occurs in open fractures Classification systems have the cultures (obtained either at patient not treated with antibiotics, their ad-inherent limitation of attempting to presentation or intraoperatively be- ministration is better viewed as ther-classify a continuous variable, such fore and after débridement of open severity of injury, into distinct cat- fracture wounds) has been contro-egories. Nevertheless, the classifica- versial because they often fail to Selectiontion of open fractures is important identify the causative organism.9,10 The antibiotics used in the man-because it directs the attention of the In one prospective randomized agement of open fractures should betreating surgeon to the presence and double-blind trial, only 3 (18%) of 17 selected based on the wound micro-extent of injury variables. Misclassi- infections that developed in a series biology. Wound contamination withfication of an open fracture can oc- of 171 open fracture wounds were both gram-positive and gram-cur, especially in a patient with a caused by an organism identified by negative microorganisms occurs;relatively small skin wound. To im- the initial cultures.11 therefore, the antimicrobial regimenprove the accuracy of the classifica- The predictive value of wound cul- should be effective against bothtion of open fractures, the extent and tures obtained before wound débri- types of pathogens. Currently, sys-severity of the injury should be as- dement is especially low. This may be temic combination therapy using asessed only during surgery, after attributed to early wide-spectrum an- first-generation cephalosporin (eg,wound exploration and débride- tibiotic coverage, multiple wound dé- cefazolin), which is active againstment, and not at presentation in the bridements, and late contamination gram-positive organisms, and anemergency department. with nosocomial pathogens.10 Thus, aminoglycoside (eg, gentamicin or multiple initial cultures are not rec- tobramycin), which is active against ommended. Only postdébridement gram-negative organisms, appearsPrevention of Infection cultures should be obtained, which to be optimal, although other can be useful in the management of combinations also may be effective.All open fracture wounds should be early infections or in wounds with Substitutes for aminoglycosides in-considered contaminated because of marine or other unusual environmen- clude quinolones, aztreonam, third-the communication of the fracture tal contamination. generation cephalosporins, or othersite with the outside environment. A antibiotics with coverage for gram-contamination rate of approximately Antibiotics negative organisms. Ampicillin or65% has been reported.3,7,8 Infection The crucial role of antibiotic ad- penicillin should be added to the an-is promoted by the bacterial contam- ministration in the management of tibiotic regimen when conditions fa-ination and colonization of the open fractures was established in a voring development of anaerobicwound, the presence of dead space prospective randomized study by infections, such as clostridial myo-with devitalized tissues, foreign ma- Patzakis et al,7 who demonstrated a necrosis (gas gangrene), are present,terial, and the compromised host re- marked reduction in the infection as in farm injuries and vascular in-sponse resulting from poor vascular- rate when cephalothin was adminis- juries (ischemia, low-oxygen ten-Vol 11, No 3, May/June 2003 213
  • 3. Open Fractures: Evaluation and Managementsion, and necrotic tissues). The re- group.11 Therefore, in type III open quently sealed with a film dressingsults of cultures obtained after fractures, ciprofloxacin should be or similar semipermeable barrier.débridement and of antibiotic- used only in combination with a Commercially available antibiotic-sensitivity testing may help in select- cephalosporin as a substitute for an impregnated PMMA beads have noting the best agents for a subsequent aminoglycoside. Oral ciprofloxacin been approved by the Food andsurgical procedure or in case of an can be used for open fracture Drug Administration for use in theearly infection. wounds secondary to low-velocity United States, so they must be made The lowest reported infection rate gunshot injuries because it is as ef- by the physician. Forty grams ofwith various systemic antibiotic fective as intravenous administra- PMMA beads are mixed with the an-regimens occurred with combina- tion of cephapirin and gentamicin.13 tibiotic in powder form and are po-tion therapy with a cephalosporin However, further studies are war- lymerized; the beads then are strungand an aminoglycoside. Patzakis ranted to elucidate the clinical ben- onto or incorporated with a beadand Wilkins8 reported that the com- efits of quinolones because their use mold onto a 24-gauge wire. The an-bination therapy was associated has been associated with the inhibi- tibiotic selected should be heat sta-with a 4.6% infection rate (5/109 tion of experimental fracture healing ble, water soluble, and available inopen tibial fractures), whereas ad- and of osteoblasts.14,15 powder form and have wide-ministration of only cephalosporin spectrum antimicrobial activity (forwas associated with a 13% infection Duration of Therapy example, 3.6 g of tobramycin mixedrate (25/192). Type I and II open Antibiotics should be started as with 40 g of PMMA). Vancomycin isfractures were not analyzed sepa- soon as possible after the injury oc- not recommended as an initial agentrately, but the distribution of frac- curs because a delay >3 hours in- because of concerns regarding resis-ture types was comparable between creases the risk of infection.8 The du- tant enterococci.the two groups. Templeman et al12 ration of antibiotic administration is The bead pouch technique is mostproposed administration of a ceph- controversial. Dellinger et al16 dem- often used for select type II or typealosporin as a single agent in type I onstrated that a prolonged course of III open fractures. If the anteromedi-and II open fractures. However, 5-day antibiotic administration was al aspect of the tibia is exposed, re-cephalosporin does not provide cov- not superior to a 1-day course for quiring delayed closure or muscleerage against contaminating gram- prevention of fracture site infections. transfer, the beads are placed insidenegative organisms. Moreover, a po- The duration of therapy should be the bone defect, if present, and ontential misclassification of an open limited to 3 days, with repeated top of the exposed bone. If the soft-fracture because of its small wound 3-day administration of antibiotics tissue coverage is delayed, the beadsize could result in a type IIIA frac- at wound closure, bone grafting, or pouch does not need to be changedture being treated with a single any major surgical procedure.8,12 because the antibiotics have beenagent. shown to elute at levels above the Quinolones are a promising alter- Local Administration minimum inhibitory concentrationnative to intravenous antibiotics In a series of 1,085 open fractures, for at least 1 month.18 However, ifbecause they offer broad-spectrum Ostermann et al17 demonstrated that the patient undergoes repeat dé-antimicrobial coverage, are bacteri- the additional use of local amino- bridement, the bead pouch can becidal, can be administered orally glycoside-impregnated polymethyl- changed.with less frequent dosing than intra- methacrylate (PMMA) beads signif- The advantages of the beadvenous antibiotics, and are well tol- icantly (P < 0.001) reduced the pouch technique include (1) a higherated clinically. Ciprofloxacin as overall infection rate to 3.7%, com- local concentration of antibiotics, of-single-agent therapy is effective in pared with 12% when only intrave- ten 10 to 20 times higher than thatthe management of type I and II nous antibiotics were used. When with systemic administration; (2) aopen fractures. In a randomized pro- the types of open fractures were an- low systemic concentration, whichspective study, ciprofloxacin was alyzed separately, the reduction of protects from the adverse effects ofcompared with combination therapy infection was statistically significant aminoglycosides (although when a(cefamandole and gentamicin). In- (P < 0.001) in only the type III frac- tobramycin bead pouch is used, sys-fection rates were similar (6%) in the tures (6.5% versus 20%, respectively, temic aminoglycoside administra-type I and II fractures; however, in for PMMA beads and intravenous tion is not needed); (3) a decreasedtype III open fractures, the ciproflox- antibiotics). need for the use of systemic ami-acin group had an infection rate Antibiotic-impregnated PMMA noglycosides; and (4) sealing of theof 31% (8/26) compared with 7.7% beads are inserted into the open wound from the external environ-(2/26) in the combination therapy fracture wound, which is subse- ment with film dressing. This tech-214 Journal of the American Academy of Orthopaedic Surgeons
  • 4. Charalampos G. Zalavras, MD, and Michael J. Patzakis, MDnique prevents secondary bacterial is applied to the extremity, to be used We recommend leaving all opencontamination by nosocomial patho- only when necessary. Débridement fracture wounds open initially. De-gens, which have been shown to be without inflating the tourniquet fa- layed wound closure (within 3 to 7responsible for many of the infec- cilitates identification of viable tis- days) prevents anaerobic conditionstions in type III open fracture sues and prevents additional is- in the wound, facilitates drainage,wounds. 8,9 In addition, this tech- chemic damage to the already allows for repeat débridements atnique allows for the period for soft- traumatized tissues. The injury 24- to 48-hour intervals, offers thetissue transfers to be safely extend- wound may be insufficient for thor- opportunity to reexamine tissues ofed. Also, film dressing establishes an ough débridement, as in type I and questionable viability, and permitsaerobic wound environment, which II open fractures, so the wound usu- use of the antibiotic bead pouchis important for avoiding cata- ally is extended. Skin and subcuta- technique. Sealing the wound withstrophic anaerobic infections; main- neous tissues are sharply débrided film dressing prevents secondarytains the local antibiotic within the back to bleeding edges. Viable mus- contamination and makes delayedwound; and promotes patient com- cle can be identified by its bleeding, wound closure even more prefera-fort by avoiding painful changes of color, consistency, and contractility. ble. Dressings are not changed in thewound dressing. Cortical bone fragments without any surgical ward; instead, the wound soft-tissue attachments are avascular remains sealed with film dressing. and should be débrided, even if this Split-thickness skin grafts are ap-Wound Management will result in a large bone defect. Ar- plied on well-vascularized granula- ticular fragments, however, should tion tissue. Small wounds, especiallyIrrigation and Débridement be preserved even when they have in type I open fractures, may be al- Irrigation is an essential part of no attached blood supply, provided lowed to heal secondarily.wound management; however, the they are large enough and recon- In type I and II open fractures, theoptimal volume, delivery method, struction of the involved joint is pos- extended wound made to facilitateand irrigation solution have not sible. If necessary, a repeat débride- débridement can be safely closedbeen determined.19 Although high- ment can be done after 24 to 48 hours primarily, leaving the original injurypressure irrigation improves the re- based on the degree of contamina- wound open. 24 Part of the injurymoval of bacteria and debris, it also tion and soft-tissue damage. In inju- wound also can be sutured if it is di-may damage the bone.20 Pulsatile ries requiring muscle flap coverage, rectly over bone, tendons, nerves, orflow per se does not add to the effec- débridement also should be repeat- vessels, but the rest of the woundtiveness of irrigation. Antiseptic so- ed at the time of soft-tissue recon- should be left open.lutions may be toxic to host cells and struction.should be avoided. Antibiotic solu- Soft-Tissue Reconstructiontions have been shown in animal Wound Closure Severe damage to the soft tissues,and in vitro studies to be more effec- Wound closure is possible when as in type IIIB open fractures, pre-tive than saline alone, but clinical the available soft tissues are ade- cludes adequate bone coverage, anddata on open fracture wounds are quate; otherwise, soft-tissue recon- soft-tissue reconstruction is neces-lacking. Detergent solutions help re- struction will be necessary later. The sary. A well-vascularized soft-tissuemove bacteria and appear to be a optimal time for wound closure envelope is critically importantpromising alternative.21 One proto- remains controversial. Primary because it enhances vascularity atcol is a 10-L saline solution delivered wound closure after a thorough the fracture site, promotes fractureto the wound by gravity tubing, with débridement is not associated with healing, allows for delivery of anti-50,000 U of bacitracin and 1,000,000 an increased rate of infection, may biotics, and enhances action of theU of polymyxin added to the last li- prevent secondary contamination, host defense mechanisms. Soft-ter of irrigation fluid. and may reduce surgical morbidity, tissue coverage prevents secondary After irrigation of the wound, hospital stay, and cost.22 Neverthe- wound contamination, desiccation,surgical débridement is the most im- less, it carries the potential for and damage to bone, articular carti-portant principle in open fracture clostridial myonecrosis, which can lage, tendons, and because nonviable tis- lead not only to loss of the limb but The location and magnitude ofsues and foreign material enhance also to loss of life.23 Primary wound the soft-tissue defect determine thebacterial growth and hinder the closure, inadequate débridement, choice of method of coverage. Re-host’s defense mechanisms. The goal and inadequate antibiotic therapy construction usually is achievedis a clean wound with viable tissues increase the risk of these complica- with local or free muscle transfers.25and no infection. A sterile tourniquet tions.7 Fasciocutaneous flaps are usefulVol 11, No 3, May/June 2003 215
  • 5. Open Fractures: Evaluation and Managementwhen dead space is minimal, when was not used; therefore, secondary tures have been satisfactorily stabi-the flaps are pliable, and when they contamination may have played a lized with unreamed intramedullaryfacilitate tendon gliding. They may notable role in contributing to the in- nailing,30-33 but controversies remainrestore sensibility to the affected area creased infection rate in patients regarding the role of external fixa-if the flap remains innervated. with delayed flap coverage.9,27,28 tion and reamed intramedullary Local pedicle muscle flaps in- nailing in the stabilization of theseclude the gastrocnemius for frac- fractures.tures in the proximal third of the tib- Fracture Stabilizationia and the soleus for fractures in the Intramedullary Nailing Versusmiddle third. However, for fractures Adequate stabilization protects the External Fixationin the distal third of the tibia, free soft tissues from further injury by Both unreamed intramedullarymuscle flaps are necessary; com- fracture fragments and facilitates the nailing and external fixation havemonly used flaps include the rectus host response to bacteria despite the been used widely in the manage-abdominis, gracilis, and latissimus presence of implants. In addition, ment of open tibial fractures, but fewdorsi muscles. In considering local stable fixation improves wound care prospective randomized studiesmuscle flaps, the condition of the and mobilization of the patient and have compared the two techniques.muscle to be transferred must be allows for early motion of adjacent Tornetta et al30 evaluated the twocarefully evaluated. Muscle that is joints, which contributes to function- methods in 29 type IIIB open tibialtraumatized, crushed, or affected by al rehabilitation. fractures. All fractures healed and noa compartment syndrome should The choice of fracture fixation de- difference in the infection rate wasnot be transferred; free muscle trans- pends on the fractured bone, the lo- found. In a prospective series of 174fer should be used instead. Pollak et cation of the fracture (eg, intra- open tibial fractures, Henley et al31al26 reported that in the presence of articular, metaphyseal, diaphyseal), reported no difference between un-severe osseous injury, use of rota- and the extent of soft-tissue injury. reamed nailing and external fixationtional flaps was notably more likely Available techniques for fracture sta- regarding infection and bone heal-to lead to wound complications bilization include intramedullary ing. They observed that the severitycompared with free flaps. nailing, external fixation, and plate- of the soft-tissue injury rather than Soft-tissue reconstruction should and-screw fixation. More than one the choice of implant appeared to bebe done early, within the first 7 days. technique may be applicable in a the main factor influencing injuryDelays beyond this period have specific injury. site infection and bone healing.been associated with increased com- However, half-pin external fixatorsplications related to the flap or infec- Intramedullary Nailing were associated with malalignmenttion under the flap.9 Some have ad- Intramedullary nailing is an effec- in 31% of cases and with a pin tractvocated that flap coverage be done tive method of stabilization of di- infection in 50%. A meta-analysis ofwithin 72 hours.27,28 Godina27 report- aphyseal fractures of the lower the management of open tibial frac-ed a failure rate of free muscle flaps extremity.29-32 It is a biomechanically tures demonstrated that unreamedin <1% (1/134) when done within 72 advantageous method that does not intramedullary nails reduced thehours compared with a failure rate interfere with soft-tissue manage- risk of revision surgery, malunion,of 12% (20/167) when done from 72 ment. Static interlocking fixation and superficial infection comparedhours to 90 days. In the same series, maintains the length and alignment with external fixators.32the infection rate was 1.5% (2/134) of the fractured bone and thus has Although no advantages in frac-in the early surgical group compared expanded the applicability of nailing ture healing and injury site infectionwith 17.4% (29/167) in the late sur- to unstable, comminuted fracture have been established, intramedul-gical group. Gopal et al28 showed patterns. However, it disrupts the lary nailing is considered preferablethat results of an early aggressive endosteal bone circulation to a vari- to external fixation. It does not re-protocol in type IIIB and IIIC open able degree, especially when the quire the same high level of patientfractures also were satisfactory. In medullary canal is reamed. Open compliance, and it is aestheticallytheir series, deep infection devel- femoral fractures are best treated more acceptable than external fixa-oped in 6% of fractures (4/63) that with reamed intramedullary nailing: tion. Unreamed intramedullary nail-were covered with a flap within 72 Brumback et al29 observed no infec- ing can be used for types I to IIIAhours compared with 29% of frac- tions in 62 type I, II, and IIIA open and for select type IIIB open frac-tures (6/21) covered after 72 hours. fractures, although infection devel- tures of the tibial diaphysis. An ex-However, in these studies, the oped in 3 (11%) of 27 type IIIB open ternal fixator may be particularlyantibiotic-impregnated bead pouch femoral fractures. Open tibial frac- useful in cases with heavy bacterial216 Journal of the American Academy of Orthopaedic Surgeons
  • 6. Charalampos G. Zalavras, MD, and Michael J. Patzakis, MDcontamination, extensive soft-tissue fer reamed nailing tend to insert tures without cortical contact and fordamage, or vascular injury (ie, types smaller nails, resulting in little dif- fractures with bone defects treatedIIIB and IIIC). ference between the techniques. with external fixation. However, clinical experience with External fixation may be accom-Unreamed Versus Reamed reamed nailing is limited, whereas panied by pin tract infections andIntramedullary Nailing many investigators have document- fracture malalignment. These com- Unreamed intramedullary nail- ed satisfactory experience with un- plications can be avoided by the se-ing has been widely used in open reamed nailing, including its use lection of compliant patients; imple-tibial fractures.30,31,33 Schemitsch et with type IIIB open fractures.30,31,33 mentation of an external fixational34 showed in a sheep tibia model The unreamed nailing technique can protocol, which includes the use ofthat endosteal blood flow at comple- be used even in type I open tibial half-pins inserted after predrilling totion of the procedure was reduced to fractures to reduce damage to bone avoid thermal necrosis of bone; and18% of the level prior to nailing vascularity. meticulous care of the pin tract. Awhen reaming was done whereas it considerable proportion of the com-was reduced to only 44% with un- External Fixation plications associated with externalreamed nailing. Unreamed nailing External fixation can be helpful in fixation can be attributed to the tran-preserves endosteal blood supply to wounds with severe soft-tissue dam- sition to another form of fixation. In-a greater degree than does reamed age and contamination because it fection has been reported at a ratenailing.34,35 Thus, it may be prefera- avoids hardware implantation and approaching 50% after conversion ofble in open tibial fractures, in which does not compromise fracture vas- the external fixation to delayed in-periosteal vascularity may be al- cularity. External fixation is techni- tramedullary nailing.9,41 However,ready compromised by the traumat- cally expedient and is associated in these series, infection was associ-ic insult. Reamed nailing, on the with minimal blood loss. It is ap- ated with a prior pin tract infectionother hand, allows insertion of plied at a site distant to the injury in the majority of patients. Blachut etlarger-diameter implants, improves and thus does not interfere with al42 showed that by early (mean, 17stability at the fracture site, and wound management. External fixa- days) conversion of the fixator to ahelps reduce implant failure. More- tion is suitable for diaphyseal tibial nail in the absence of pin tract infec-over, the cortical circulation that was fractures because of the subcutane- tions, infection developed in onlydisrupted during reaming is gradu- ous location of the bone, and it be- 5% of patients. Loss of alignment fre-ally reconstituted, although more comes a more attractive option than quently occurs when the fixator isslowly than unreamed nailing.35 intramedullary nailing moving to prematurely removed and the pa- Two prospective randomized the proximal or to the distal tibia, if tient is transferred to a brace.38studies compared reamed with un- the size of the proximal or distal In heavily contaminated openreamed nailing in open tibial frac- fragment does not allow for stabili- fractures, temporary external fixa-tures; neither established a signifi- zation with a nail. Ring or transartic- tion can be a useful option. Howev-cant difference in infection rates.36,37 ular fixators are useful for periartic- er, to minimize the chance of bacte-Keating et al36 reported an infection ular fractures. Spanning external rial colonization of the pin tracts,rate of 2.5% (1/40) in fractures treat- fixation is becoming popular and conversion to intramedullary nail-ed with the unreamed nailing tech- may be safely converted to another ing should be done in the absence ofnique versus 4.4% (2/45) in fractures method when applied away from pin tract infections and when the fix-treated with the reamed nailing tech- the zone of injury. ator has been present for only a shortnique. Finkemeier et al37 observed Many authors38-40 have reported time.42 Otherwise, the fixator shouldinfection rates of 3.8% (1/26) in un- on the effectiveness of external fixa- be maintained until fracture healing.reamed nailing and 5.3% (1/19) in tion as definitive treatment as well asreamed nailing. In both studies, a re- the value of early bone grafting in se- Plate Fixationduced incidence of screw failure was vere injuries.38-40 Marsh et al,40 in a Plate fixation is useful in intra-seen in the group undergoing the prospective study of 101 type II and articular and metaphyseal fracturesreamed nailing technique. III fractures, reported that 96 frac- because it stabilizes an accurate res- Choice of technique remains con- tures (95%) healed, 95% of them toration of joint congruency and ori-troversial. Interestingly, surgeons with <10° of angulation in any plane, entation. In diaphyseal fractures ofwho prefer unreamed nailing try to and that 6 fracture sites (6%) were in- the upper extremity, plate fixation isinsert a nail of sufficient diameter fected. To avoid healing complica- often the method of choice. Plate fix-to accommodate larger locking tions, early bone grafting should be ation in open tibial fractures hasbolts, whereas surgeons who pre- considered for comminuted frac- been associated with an increasedVol 11, No 3, May/June 2003 217
  • 7. Open Fractures: Evaluation and Managementincidence of infection and hardware and restoration of the soft-tissue en- bacterial contamination, soft-tissuefailure.43,44 Bach and Hansen43 re- velope. Then the existing defect is damage, and fracture characteristics.ported wound infection in 35% (9/ bone grafted. Depending on the frac- To avoid the complication of clos-26) and fixation failure in 12% (3/26) ture pattern, grafts are applied either tridial myonecrosis, the woundof type II and III open tibial frac- at the fracture site beneath a flap or should be thoroughly irrigated andtures. Clifford et al44 observed im- posterolaterally away from the site débrided and not closed primarily.plant failure in 7 of 97 open tibial of injury. Early bone grafting in the Early, systemic, wide-spectrum anti-fractures and infection in 4 of 9 type absence of a bone defect also may be biotic therapy is necessary to coverIII fractures. New plating techniques necessary when healing is delayed both gram-positive and gram-using fixed-angle plate screw devic- and no callus is apparent on radio- negative organisms. A 3-day admin-es are characterized by minimally in- graphs at 8 to 12 weeks. Autogenous istration of a first-generation cepha-vasive insertion and preservation of bone graft remains the method of losporin and an aminoglycoside,bone vascularity, and they may choice. The usefulness of graft sub- supplemented with ampicillin orprove to be a useful alternative for stitutes in the management of de- penicillin for injuries occurring on ametaphyseal fractures, especially fects associated with open fractures farm and for vascular injuries, is awhen intra-articular extension is has not been shown to be effective. critically important part of effectivepresent. However, to date, no pub- Exchange nailing is another op- treatment. Local antibiotic deliverylished data are available to support tion to stimulate healing in cases of with the bead pouch technique cantheir use. delayed union, provided no infec- prevent secondary wound contami- tion or bone defect is present. Infec- nation. In the presence of extensiveEarly Secondary Procedures to tion necessitates additional débride- soft-tissue loss and exposed bone,Stimulate Healing ment, whereas bone defects should coverage is accomplished with early In the presence of bone defects or be managed with bone grafting. transfer of local or free muscle flaps.delayed healing, early bone grafting Stable fracture fixation is important;can expedite healing. With bone de- the method chosen depends on thefects, the preferred timing for bone Summary bone and soft-tissue characteristics.grafting ranges from 2 to 6 weeks af- Early bone grafting is indicated forter soft-tissue coverage.38,45 Waiting Assessment and classification of bone defects, unstable fracturesfor 6 weeks after a soft-tissue trans- open fractures should be done intra- treated with external fixation, andfer ensures the absence of infection operatively based on the degree of delayed union.References1. Blick SS, Brumback RJ, Poka A, Burgess 6. Brumback RJ, Jones AL: Interobserver spective, randomized, double-blind AR, Ebraheim NA: Compartment syn- agreement in the classification of open study comparing single-agent antibiot- drome in open tibial fractures. J Bone fractures of the tibia: The results of a ic therapy, ciprofloxacin, to combination Joint Surg Am 1986;68:1348-1353. survey of two hundred and forty-five antibiotic therapy in open fracture wounds.2. Veliskakis KP: Primary internal fixation orthopaedic surgeons. J Bone Joint Surg J Orthop Trauma 2000;14:529-533. in open fractures of the tibial shaft: The Am 1994;76:1162-1166. 12. Templeman DC, Gulli B, Tsukayama problem of wound healing. J Bone Joint 7. Patzakis MJ, Harvey JP Jr, Ivler D: The DT, Gustilo RB: Update on the manage- Surg Br 1959;41:342-354. role of antibiotics in the management of ment of open fractures of the tibial3. Gustilo RB, Anderson JT: Prevention of open fractures. J Bone Joint Surg Am shaft. Clin Orthop 1998;350:18-25. infection in the treatment of one thou- 1974;56:532-541. 13. Knapp TP, Patzakis MJ, Lee J, Seipel sand and twenty-five open fractures of 8. Patzakis MJ, Wilkins J: Factors influenc- PR, Abdollahi K, Reisch RB: Compari- long bones: Retrospective and prospec- ing infection rate in open fracture son of intravenous and oral antibiotic tive analyses. J Bone Joint Surg Am 1976; wounds. Clin Orthop 1989;243:36-40. therapy in the treatment of fractures 58:453-458. 9. Fischer MD, Gustilo RB, Varecka TF: The caused by low-velocity gunshots: A4. Gustilo RB, Mendoza RM, Williams timing of flap coverage, bone-grafting, prospective, randomized study of in- DN: Problems in the management of and intramedullary nailing in patients fection rates. J Bone Joint Surg Am 1996; type III (severe) open fractures: A new who have a fracture of the tibial shaft 78:1167-1171. classification of type III open fractures. with extensive soft-tissue injury. J Bone 14. Holtom PD, Pavkovic SA, Bravos PD, J Trauma 1984;24:742-746. Joint Surg Am 1991;73:1316-1322. Patzakis MJ, Shepherd LE, Frenkel B:5. Gustilo RB, Gruninger RP, Davis T: Clas- 10. Lee J: Efficacy of cultures in the man- Inhibitory effects of the quinolone anti- sification of type III (severe) open frac- agement of open fractures. Clin Orthop biotics trovafloxacin, ciprofloxacin, and tures relative to treatment and results. 1997;339:71-75. levofloxacin on osteoblastic cells in Orthopedics 1987;10:1781-1788. 11. Patzakis MJ, Bains RS, Lee J, et al: Pro- vitro. J Orthop Res 2000;18:721-727.218 Journal of the American Academy of Orthopaedic Surgeons
  • 8. Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD15. Huddleston PM, Steckelberg JM, Hans- application of flaps for coverage of locked intramedullary nailing: A frac- sen AD, Rouse MS, Bolander ME, Patel traumatic soft-tissue defects about the tured tibia model in sheep. J Orthop R: Ciprofloxacin inhibition of experi- tibia: The Lower Extremity Assessment Trauma 1994;8:373-382. mental fracture healing. J Bone Joint Project (LEAP) Study Group. J Bone 36. Keating JF, O’Brien PJ, Blachut PA, Meek Surg Am 2000;82:161-173. Joint Surg Am 2000;82:1681-1691. RN, Broekhuyse HM: Locking intramed-16. Dellinger EP, Caplan ES, Weaver LD, et 27. Godina M: Early microsurgical reconstruc- ullary nailing with and without ream- al: Duration of preventive antibiotic ad- tion of complex trauma of the extrem- ing for open fractures of the tibial shaft: ministration for open extremity frac- ities. Plast Reconstr Surg 1986;78:285-292. A prospective, randomized study. J Bone tures. Arch Surg 1988;123:333-339. 28. Gopal S, Majumder S, Batchelor AG, Joint Surg Am 1997;79:334-341.17. Ostermann PA, Seligson D, Henry SL: Knight SL, De Boer P, Smith RM: Fix 37. Finkemeier CG, Schmidt AH, Kyle RF, Local antibiotic therapy for severe open and flap: The radical orthopaedic and Templeman DC, Varecka TF: A prospec- fractures: A review of 1085 consecutive plastic treatment of severe open frac- tive, randomized study of intramedul- cases. J Bone Joint Surg Br 1995;77:93-97. tures of the tibia. J Bone Joint Surg Br lary nails inserted with and without18. Greene N, Holtom PD, Warren CA, et 2000;82:959-966. reaming for the treatment of open and al: In vitro elution of tobramycin and 29. Brumback RJ, Ellison PS Jr, Poka A, closed fractures of the tibial shaft. J Or- vancomycin polymethylmethacrylate Lakatos R, Bathon GH, Burgess AR: In- thop Trauma 2000;14:187-193. beads and spacers from Simplex and tramedullary nailing of open fractures 38. Edwards CC, Simmons SC, Browner BD, Palacos. Am J Orthop 1998;27:201-205. of the femoral shaft. J Bone Joint Surg Weigel MC: Severe open tibial fractures:19. Anglen JO: Wound irrigation in muscu- Am 1989;71:1324-1331. Results treating 202 injuries with exter- loskeletal injury. J Am Acad Orthop Surg 30. Tornetta P III, Bergman M, Watnik N, nal fixation. Clin Orthop 1988;230:98-115. 2001;9:219-226. Berkowitz G, Steuer J: Treatment of grade- 39. Behrens F, Searls K: External fixation of20. Bhandari M, Schemitsch EH, Adili A, IIIb open tibial fractures: A prospective the tibia: Basic concepts and prospec- Lachowski RJ, Shaughnessy SG: High randomised comparison of external fix- tive evaluation. J Bone Joint Surg Br and low pressure pulsatile lavage of ation and non-reamed locked nailing. 1986;68:246-254. contaminated tibial fractures: An in vit- J Bone Joint Surg Br 1994;76:13-19. 40. Marsh JL, Nepola JV, Wuest TK, Osteen ro study of bacterial adherence and 31. Henley MB, Chapman JR, Agel J, Har- D, Cox K, Oppenheim W: Unilateral ex- bone damage. J Orthop Trauma 1999;13: vey EJ, Whorton AM, Swiontkowski ternal fixation until healing with the 526-533. MF: Treatment of type II, IIIA, and IIIB dynamic axial fixator for severe open21. Burd T, Christensen GD, Anglen JO, open fractures of the tibial shaft: A pro- tibial fractures. J Orthop Trauma 1991;5: Gainor BJ, Conroy BP, Simpson WA: Se- spective comparison of unreamed in- 341-348. quential irrigation with common deter- terlocking intramedullary nails and 41. McGraw JM, Lim EV: Treatment of gents: A promising new method for de- half-pin external fixators. J Orthop Trau- open tibial-shaft fractures: External fix- contaminating orthopedic wounds. Am ma 1998;12:1-7. ation and secondary intramedullary J Orthop 1999;28:156-160. 32. Bhandari M, Guyatt GH, Swiontkowski nailing. J Bone Joint Surg Am 1988;70:22. DeLong WG Jr, Born CT, Wei SY, Petrik MF, Schemitsch EH: Treatment of open 900-911. ME, Ponzio R, Schwab CW: Aggressive fractures of the shaft of the tibia. J Bone 42. Blachut PA, Meek RN, O’Brien PJ: Ex- treatment of 119 open fracture wounds. Joint Surg Br 2001;83:62-68. ternal fixation and delayed intramedul- J Trauma 1999;46:1049-1054. 33. Shepherd LE, Costigan WM, Gardocki lary nailing of open fractures of the tib-23. Patzakis MJ: Clostridial myonecrosis. RJ, Ghiassi AD, Patzakis MJ, Stevanovic ial shaft: A sequential protocol. J Bone Instr Course Lect 1990;39:491-493. MV: Local or free muscle flaps and un- Joint Surg Am 1990;72:729-735.24. Patzakis MJ, Wilkins J, Moore TM: Con- reamed interlocked nails for open tibial 43. Bach AW, Hansen ST Jr: Plates versus siderations in reducing the infection fractures. Clin Orthop 1998;350:90-96. external fixation in severe open tibial rate in open tibial fractures. Clin Orthop 34. Schemitsch EH, Kowalski MJ, Swiont- shaft fractures: A randomized trial. Clin 1983;178:36-41. kowski MF, Harrington RM: Compari- Orthop 1989;241:89-94.25. Sherman R, Ecker J: Soft tissue cover- son of the effect of reamed and un- 44. Clifford RP, Beauchamp CG, Kellam JF, age, in Browner BD, Jupiter JB, Levine reamed locked intramedullary nailing Webb JK, Tile M: Plate fixation of open AM, Trafton PG (eds): Skeletal Trauma: on blood flow in the callus and strength fractures of the tibia. J Bone Joint Surg Br Fractures, Dislocations, Ligamentous Inju- of union following fracture of the sheep 1988;70:644-648. ries, ed 2. Philadelphia, PA: WB Saun- tibia. J Orthop Res 1995;13:382-389. 45. Blick SS, Brumback RJ, Lakatos R, Poka ders, 1998, pp 419-448. 35. Schemitsch EH, Kowalski MJ, Swiont- A, Burgess AR: Early prophylactic bone26. Pollak AN, McCarthy ML, Burgess AR: kowski MF, Senft D: Cortical bone grafting of high-energy tibial fractures. Short-term wound complications after blood flow in reamed and unreamed Clin Orthop 1989;240:21-41.Vol 11, No 3, May/June 2003 219