• Definition : An open fracture is one in which a break in the skin and underlying soft tissues leads directly into or communicates with fracture and its haematoma.• Synonym: Compound fracture.
• Several specific consequences may result according to the extent of injury ; – Contamination with bacteria. – Devascularisation of fascia & muscle & the underlying bone makes the extremity more susceptible for infection. – Loss of soft tissue affects surgeon’s option for fracture stabilization
– Lack of soft tissue coverage delays bone healing. – Direct loss of function due to damaged muscles, tendons, nerves, vessels & skin.• The most important and ultimate goal in the treatment of open fractures is to restore limb and patient function as early and as fully as possible.• The role of surgeon is to work towards this goal.
HISTORY• Hippocrates considered war is the most appropriate training ground for surgeons. – Surgeons can only facilitate the healing and cannot impose it. – He opposed frequent meddling with wounds, except to extrude purulent material. – His principle misconception was diseases not curable by steel (knife) are curable by fire (cautery).• Brunschwig and Botello, in 15th & 16th centuries, advocated the removal of non vital tissue from wounds that did not progress properly.
• Desault, in 18th century, adopted the term debridement for making a deep incision to explore a wound, remove dead tissue, and provide drainage.• His pupil, Larrey, extended the principle as the sooner debridement is done after wounding, the better the result.• Trueta brought together the combination of debridement and an occlussive dressing that also served as a splint during spanish civil war.
Current recommendations for acute management of open fractures:• Provide airway management and urgent resuscitation.• Immobilize extremity & sterile dressing.• Administer early intravenous antibiotics.
• Urgent operative debridement and irrigation, leave the wound open & stabilise skeletal injuries.• Perform repeated debridements, as needed.• Delay wound closure/coverage.
DIAGNOSIS• In most of the cases it is straightforward.• All open fractures are not obvious, timely and proper diagnosis and treatment depends upon careful clinical examination.• Before detailed evaluation of an open fracture, life threatening injuries must be diagnosed and treated according to the Advanced Trauma Life Support.
Advanced Trauma Life Support• Establish Airway, Breathing and Circulation to sustain life.• Once patient is stable, systemic search for other injuries should be performed.• Cervical collar is placed until lateral cervical spine X-ray is obtained and injury is ruled out.• A chest and pelvis radiograph is taken to evaluate potential sources of hemorrhage & pulmonary dysfunction.
• Airway :– – Removal of oral debris – Gentle jaw thrust maneuver – Nasotrachoel intubation in spontaneously breathing – Emergency endotrachoeal intubation – No patient should expire from lack of an airway because of concern over a possible cervical injury.
• Breathing :- – Common reasons of ineffective ventilation (breathing) after successful establishment of airway are malposition of the ET tube, pneumothorax, and haemothorax – Mechanical ventilation
• Circulation :- – Hypotension following injury must be considered to be hypovolumic in origin until proved otherwise – Haemodynamic status can be assesed by • Level of consciousness • Skin colour • Pulse – External haemorrhage is identified and controlled in the primary survey
• Compressive bandage on open, bleeding wounds.• Tourniquets can only be used in traumatic amputations otherwise may cause crushing of tissues and distal ischaemia.• If shock persists immediate search for occult hemorrhage in body cavities.
• Disability (neurological evaluation) :- – Determine the neurological function – Level of consciousness, pupillary response, sensation and motor activity of all extremities – Rectal examination to determine the sphincter tone. – Precise measurement of neurological function is provided by Glasgow Coma Scale (GCS).
CLINICAL EXAMINATION• A careful examination of extremities to diagnose fractures & dislocations.• Must document neurological & vascular function: – Circulatory status- Capillary blush, filling of veins & peripheral pulses. – Neurological status- Sensory examination with pressure & light touch grossly and two point discrimination especially in upper extremity. – Motor examination may be difficult due to pain and splinting but should be compared with normal side.
• After documentation reduce the fractures or dislocations and give adequate splinting.• If limb continues to show signs of vascular insufficiency arterial injury should be considered & ruled out.• Next, the skin: – Dimensions, shape & nature of wound. – Circumferential examination of extremities. – Examination of back and buttocks.
• Foreign bodies and debris in the wounds like stones, leaves or grass should be removed manually with sterile forceps and sterile dressing applied.• To avoid subsequent opening of the wound a photograph or a sketch can be drawn.• To diagnose occult open fractures, all clothing must be removed.
• A pelvic fracture in case of vaginal lacerations is considered open fracture. A vaginal examination with speculum should be done to rule out occult open pelvic fracture.• Tetanus immunity must be determined and tetanus booster as well as immune globulins should be given.
• History :- – Age -General health – Specific co morbidities -Previous disability – Alcohol and drugs -Ambulatory status – Residence -Cause of injury – High or low energy -Potential for infection – Other injuries -Previous injuries – Any chronic illness – Peripheral vascular disease, liver disease and immunodeficiency disease
CLASSIFICATION• The ideal classification system can: – Accurately and reliably quantify a fracture. – Give guidance in management. – Allow long-term prognosis to be estimated.
Gustillo classification: -• Open fractures are usually classified by the Gustillo system.
Type I- Open fracture with a cleanwound <1cm in length
Type II-Open fracture with a laceration of >1 cm II-long and without extensive soft-tissue damage,flaps, or avulsions
Type IIIa-Adequate periosteal cover of a IIIa-fractures bone despite extensive soft-tissuelaceration or damage
Type IIIb-Extensive soft-tissue loss with IIIb-significant periosteal stripping and bone damage.Usually associated with massive contamination
Type IIIc-Association with arterial injury requiring IIIc-repair, irrespective of degree of soft-tissue injury
EPIDEMIOLOGY• Very little is known about the epidemiology of open fractures.• The incidence of open fractures varies in different places and in different institutions depending on many factors, including the incidence of road traffic accidents and gunshot injuries.
• Level 1 trauma centers obviously see more open fractures than smaller peripheral hospitals, but the overall incidence of open fractures is probably similar in many parts of the world.• The highest incidence is in tibial diaphyseal fractures, where about 21% are open.
• Fractures of the femoral diaphysis, hand and foot phalanges, forearm diaphyses, tibial plafond, patella, distal femur, distal humerus, and humeral diaphysis are all associated with incidences of more than 5%.• In fractures of the metatarsus, scapula, pelvis, metacarpus, proximal humerus, and proximal femur, however, the incidence is very low.
• The incidence of open spinal fractures is so low that effectively they are unsurvivable. The only exception to this is gunshot spinal fractures, which are relatively uncommon in civilian practice.
PRE-OPERATIVE ASSESSMENT • A complete history and physical examination is essential. • Age does not affect patient management, but older patients tend to be osteoporotic and the fractures may be associated with greater comminution.
• Information about general health is important because conditions such as diabetes mellitus, hypertension, or neuromuscular conditions may alter the type of operative treatment, and cardiovascular, pulmonary and other medical co morbidities may affect anesthesia and later intensive care.
• The pre-accident mental and physical state of the patient is important: A Gustilo type IIIb open tibial fracture in a demented nonambulator with medical co morbidities might well be successfully treated by primary amputation rather than by attempted bone reconstruction.
• High-energy injuries are associated with significantly greater bone and soft tissue damage, and therefore open fractures following RTAs, falls from a height, crushing injuries, or gunshot injuries, are often more difficult to manage and associated with a worse prognosis than those that occur after a simple fall, a fall downstairs, or a sports injury.• The mode of injury should be carefully established to determine whether the open fracture has occurred as a result of a high- or low-energy injury.
• The physical examination must include an assessment of other injuries using ATLS principles.• Examination of the limb should include a careful assessment of the vasculature.• The surgeon should be aware that if the patient is hypotensive or peripherally shut down, an incorrect preoperative assessment of the vascular status of a limb may be made.
• If there is any doubt about the vascular supply, a Doppler examination or angiogram should be obtained.• Examination of the neurological status of the limb is also important. Abnormal sensation or motor power may suggest intracranial, spinal, or peripheral nerve damage. A peripheral nerve lesion associated with a limb fracture suggests considerable soft tissue injury and probably a poor prognosis for the limb.
EXAMINATION OF WOUND• Ideally the open wound should not be examined by every member of the medical and nursing staff prior to surgery.• If possible, a digital image of the wound should be obtained soon after the patient is admitted to the hospital, so that it, rather than the wound, can be repeatedly examined.• This policy has been shown to be associated with a lower infection rate.
• It is important, however, that the surgeon examine the wound carefully. The location and extent of the wound may allow a preoperative determination of the need for plastic surgery, particularly if it is obvious there will be exposed subcutaneous bone after debridement.• The degree of wound and skin contamination should be assessed, as should the presence of bone fragments in the wound.
• The presence of skin degloving should be noted.• The length of the wound is used in the Gustilo classification, and a loose relationship exists between wound length and prognosis.• But it should never be assumed a small wound necessarily carries a good prognosis because there may be significant associated contamination and tissue damage.
RADIOLOGICAL EXAMINATION• Important features in open fractures are;- – Location and morphology of the fracture. – Comminution signifying a high-energy injury. – Secondary fracture lines that may displace on treatment.
– The distance the bone fragments have travelled from their normal location. (Wide displacement- avascularity.)– Bone defects suggesting missing bone.– Gas in the tissues.
• MRI and CT scans are rarely required in the acute situation but may be helpful in open pelvic, intra-articular, carpal, and tarsal fractures.• Angiography may be required in Gustilo IIIb or IIIc fractures.• In the polytraumatized patient, the surgeon must decide if a delay for further imaging is appropriate.
Operative treatment• Surgeons tend to concentrate on the method of fracture treatment when treating open fractures, but a number of procedures are involved if their treatment is to be successful.• Irrigation & Debridement – Skin & subcutaneous fat -Fascia – Muscle -Tendons – Bone -Joints – Nerves & vessels -Fasciotomy – Foreign bodies
Irrigation• The two adages that apply to open fracture irrigation are;- – IF A LITTLE DOES SOME GOOD, A LOT WILL DO A GREAT DEAL MORE – THE SOLUTION TO POLLUTION IS DILUTION• Irrigation must be done thorough and copious.
• Advantages of irrigation: - – Flushing away of blood & other debris- good inspection – Fluid floats undetected necrotic fronds of fascia, fat or muscle. – Lavage floats contaminated blood clots and loose pieces of tissue & debris from unseen recesses. – Lavage restores normal colour of tissue. – Reduces bacterial contamination.
Intermittent pressurelavage :-• Initially, 1 to 2 litre irrigating solution should be used for type I and 5 to 10 L for type II & type III fractures.• For final irrigation around 2 L solution should be used.
• Use of soap (detergent) solution with normal saline is proven the best lavage solution.• Antibiotic solution has proven no better may increase the risks of wound healing. (JBJS,July2oo5)
Debridement• The primary surgical debridement should be aggressive when required.• The objectives of debridement are; - – Extension of wound to allow identification. – Detection and removal of foreign material. – Detection and removal of necrotic tissues. – Reduction of bacterial contamination.
– Creation of wound that can heal without infection.– All affected tissue planes should be explored.– The bone ends must be exposed and carefully examined for contamination and soft tissue stripping.– The wound should not be closed primarily
Skin• Skin is very resistant to direct trauma but susceptible to shearing forces, the plane of cleavage being outside the deep fascia.• Shearing forces may produce extensive degloving injuries, which particularly affect the lower limb and may be circumferential.• Local excision of the contaminated wound edges.
• If there are several wounds in close proximity, they should be excised en bloc, as there will be extensive associated soft tissue damage.• All degloved skin should be resected until dermal bleeding is encountered.• If a large area of degloved skin is excised, split skin graft can be harvested from the excised skin for later use.
• After the initial skin excision, extend the open wound to allow adequate exposure of the underlying bone and soft tissues. – There are no indications not to do this. Even small skin incisions may be associated with considerable contamination.• The direction and length of the skin extensions depend on the location and size of the open wound• Ideally extensions should be longitudinal and, where possible, follow normal surgical approaches
Fat and fascia• All devitalized fat must be removed.• The extent of fat necrosis may well be greater than was apparent preoperatively, and extensive fat resection with excision of the overlying skin may be required in some cases.• Fascial resection rarely presents a problem, but it should be borne in mind that foreign material may spread between the deep fascia and the underlying muscles.
Muscle• All devitalized muscle should be removed.• It can be difficult to assess muscle viability fully at the initial debridement, particularly if the patient is hypotensive.• The classic signs of muscle viability are; -Colour Beefy red, rarely CO exposure can be deceivingConsistency Firm, not easily disruptedCapacity to May deceive as arterioles can bleed.bleed Typically reliableContractility Responsive to forceps pinch or low cautery. Typically reliable.
Tendon• Paratenon contains main blood supply of tendon and must be preserved to maintain tendon viability.• If excised or destroyed, exposed tendon will not survive for long.• Early skin coverage, primary closure, or muscle or skin flap, is necessary to preserve its viability.
Nerves & vessels• Nerve injuries amenable to repair should be sutured before delayed primary closure.• Even when repaired the prognosis for associated injury to the posterior tibial nerve is poor, frequently leading to amputation.• Brisk, small vessel or arterial bleeders require immediate ligation or coagulation to avoid further blood loss.• Major vessel injuries requiring repair must be identified before surgery and appropriately planned.
• In larger vessels, rather than carrying out immediate end to end anastomosis or vein grafting, it may be better to insert a temporary shunt.• This permits irrigation & debridement and stabilization of bone before final vascular repair.• Loss of total blood supply to the limb for more than 8 hours nearly always results in amputation.
Bones• Resection of bone should be dealt with in the same way as soft tissue resection.• All devitalized separate bone fragments should be removed regardless of their size.• As with muscle, it may be difficult to determine bone vascularity, and if the surgeon is concerned about the viability of periosteal or muscle attachment to a bone, it may be advantageous to re-examine the bone fragments during the re- look procedure.
Joints• Any wound that extends joint mandates exploration.• Wound itself may permit exploration or extensile incision may be necessary.• If adequate exploration with arthrotomy is not possible it should be combined with arthroscopy.• Unexpected foreign bodies or osteochondral fractures may be found.
Fasciotomy• After arterial repair, massive swelling of distal limb due to ischemia of the muscles is very common which necessitates fasciotomy to release intracompartmental pressure.• If there is any doubt about its indication, it should be done. (Better to early than too late.)• In calf, all four compartments should be released.
• After formal fasciotomy, the skin should not be closed as it may be as constricting as fascia if swelling occurs.• Frequently, skin grafting is required for coverage because swelling recedes too slowly to permit suturing.
Foreign bodies• Foreign bodies, especially organic, must be sought and removed.• Fragments of wound, after becoming blood soaked resembles muscles.• The intrinsic recesses, pits of foreign bodies may harbor pathogenic organisms or their spores.
Wound closure• Open wounds should not be closed primarily. (adequately debrided wound can be under tension.)• If wound closure is possible - Re-look procedure 36 to 48 hours after the initial surgery.• Even closure of the wound extensions may cause tissue tension.• The only exception to the rule about closing wounds primarily is if a primary flap is undertaken.• Vacuum-assisted closure (VAC) systems have been used for a number of years to close skin defects with good results.
Antibiotics• Some 60% to 70% of open wounds are associated with positive cultures in the emergency department.• Most surgeons use a first- or second-generation cephalosporin as prophylaxis for Gustilo type I and II open fractures. – Initial dose as soon as possible after diagnosis with a three-dose intravenous regimen being used.
• In Gustilo type III open fractures, – 3 dose I V regimen of a 3rd generation cephalosporin or a combination of a 2nd generation cephalosporin and an amino glycoside.• Chance of clostridial contamination, I V penicillin should be given. If allergic - clindamycin or metronidazole should be used.• This is important in open pelvic fractures where the open fracture may have entered the rectum or vagina.
Antibiotic impregnated bids• Antibiotic-impregnated polymethylmethacrylate beads can be placed into the wound after debridement has been undertaken.• These beads usually contain gentamycin or tobramycin.
• They leak out at rates sufficient to produce bactericidal levels in the surrounding tissues and fluids.• 2.4 gm of antibiotic powder is mixed with 40 gm of PMMA and beads are prepared over a steel wire or non-absorbable suture material.• Local wound levels of antibiotics produced are higher than parenteral route alone.• Beads then removed or replaced at subsequent debridements or during the closure of wound.
Immediate or early amputation• In general amputation is performed when; - – limb salvage poses significant risk to patient survival – functional result would be better with a prosthesis – duration and course of treatment would cause intolerable psychological disturbance
• Lange proposed two absolute indications for amputation of tibia open fractures 1. A typeIII C fracture in which vascular repair is required for salvage of extremity. The injury is accompanied by complete transection of posterior tibial nerve. 2. The limb is nonviable.
Mangled Extremity Severity Score• An attempt to help guide between primary amputation vs. limb salvage• A score of 7 or higher was predictive of amputation*• Add 2 points if ischaemia time > 6 hr*Johansen et al. J Trauma 1991
NISSA Score• Modification of MESS score adding a component of nerve injury• Nerve, Ischemia, Soft tissue injury, Shock, and Age Score• Prospective evaluation is not available
Stabilization of bone• When vascular repair has been completed, irrigation and debridement have been done, and limb salvage is planned, stabilization of bone is next concern.• Unless the fracture is inherently stable, some form of skeletal stabilization is usually necessary.
• Methods of stabilization: - 1. Immobilization in a plaster slab or cast. 2. Skeletal traction and suspension. 3. External skeletal fixation. 4. Internal skeletal fixation.
• Goals of skeletal immobilization: - – Restore length and allignment. – Restore articular surfaces. – Allow access to wound. – Facilitate further reconstruction procedures. – Allow early use of limb. – Facilitate fracture union & return of function.
• Contraindications to skeletal stabilization: - – Severe communition. – Minimal soft tissue injury with undisplaced fracture. – Severe ongoing local infection. – Severe systemic compromise precluding anesthesia.
• Immobilization in plaster slab or cast: - – Have limitations in treatment of open fractures. – Access to wound is difficult. – May be appropriate in type I fractures. – There should be an easy way to access the wound for further management. – A bubble can be made over the wound to locate the site for creating window.
• Skeletal traction and suspension: - – Usually as a temporary method can be used for femur and tibia. – No good results are noted as a definitive treatment. – Enforced recumbence and inconsistent outcomes make the use contraindicated in adult patients.
External skeletal fixation• Process of manipulating, aligning, and stabilizing bony structures with pins, wires, screws, or other bone fasteners that affix the bone to an external scaffold or frame.• Since 1970s & early 1980s, emergence of half pin frames have made external fixation as method of choice for stabilization of open fractures.• Most often indicated in type IIIB & IIIC and open fractures of pelvis.• Many different devices are available.
• Advantages of external fixators: - – Relatively easily & quickly applied. – Excellent stability & reasonably anatomic reduction of major fragments. – Minimal additional soft tissue trauma. – Early mobilization. – Easy redisplacement of fracture at subsequent debridements. – Traveling traction- Temporary restoration of length
• Disadvantages of external fixators: - – Application can be complex for complex fractures & large wound. – Pins may entrap musculotendinous units. – Interference with soft tissue reconstruction. – Inappropriate technique of pin insertion- bone necrosis & pin loosening. – Prolonged use- Delayed union or nonunion
• Indications for external fixation: - – Severe contamination – Any site – Periarticular fractures • Definitive – distal radius, elbow dislocation • Temporizing – knee, ankle, elbow, wrist, pelvis – Distraction osteogenesis – In combination with screw fixation (hybrid fixation) for severe soft tissue injury
• Post operative management of external fixators:- – Pin loosening leads to pin infection – Loose pin must never be left in place – Most effective method of skin care is – Daily washing of frame, pins & surrounding skin with soap water. – Pin track infection is a contraindication to conversion to internal fixation. – Temporary immobilization with cast or slab for 10 to 14 days – If the fixator has been in place for a short time immediate internal fixatiion can be done.
Internal fixation• Multiple options depending on fracture pattern and soft tissue injury: – Plating – Percutaneous plating – Intramedullary nailing – reamed & unreamed• Choice of implant depends upon: – ‘Personality’ of fracture – Nature of soft tissue injury – Adequacy of equipments & implants
Plate fixation• Traditional plating technique with extensive soft tissue dissection and devitalization has generally fallen out of favor for open tibia fractures• Increased incidence of superficial and deep infections compared to other techniques• Newer percutaneous plating techniques using indirect reduction may be a more beneficial alternative.
Secondary debridement• All open long-bone and pelvic fractures be reexplored 36 to 48 hours after the initial debridement.• Advantages of a secondary debridement are considerable. – Residual contamination can be excised – Excellent time to carry out definitive soft tissue closure because in the majority of cases there will be no residual contamination or devascularized tissue.• The wound should not be closed until all devitalized or contaminated tissue has been removed.
Soft tissue cover• Most open wounds do not require plastic surgery.• Increasingly, however, plastic surgery techniques are being used in open fractures.• The most frequently used plastic procedures involve split skin grafting, local muscle flaps such as the gastrocnemius flap, local flaps such as the proximal or distal fasciocutaneous flap, or free flaps.
• The requirement for plastic surgery is highest in the tibia and hindfoot.• Open fractures of the tibial diaphysis, plateau, and plafond are associated with the greatest requirement for flap cover.
Biologic dressings• When closure is not appropriate or cannot be carried out, biologic dressings of skin or synthetic material may be of value.• Homologous human skin, heterologous porcine skin and synthetic dressings may suffice.• Seem to be deterrent to infection and existing infection may be controlled or suppressed.• Host granulation tissue invades such grafts and can give readiness of a wound bed for definitive autogenous grafting.
Elevation• Persistent or increased swelling may keep tissues turgid and wound surfaces moist, preventing delayed primary closure.• Edematous tissue increase tension on the suture and may lead to marginal wound necrosis.• Limb should be above the level of heart.• However more than 10 cm height reduces arterial blood supply which may impend compartment syndrome.
Complications• Nonunion• Malunion• Infection- deep and superficial• Compartment syndrome• Fatigue fractures• Hardware failure
Nonunion• Time limits vary from 6 months to one year.• Fracture shows no radiologic progress toward union over 3 month period.• Important to rule out infection.• Treatment options for uninfected nonunion include on lay bone grafts, free vascularized bone grafts, reamed nailing, compression plating, or ring fixator.
Malunion• More common in tibia.• In general varus malunion more of a problem than valgus.• For symptomatic patients with significant deformity treatment is osteotomy.
Superficial infection• Most superficial infections respond to elevation of extremity and appropriate antibiotics (typically gram + cocci coverage)• If uncertain whether infection extends deeper and/or it fails to respond to antibiotic treatment , then surgical debridement with tissue cultures necessary
Deep infection• Often presents with increasing pain, wound drainage, or sinus formation.
• Treatment involves debridement, stabilization (often with ex-fix), coverage with healthy tissue including muscle flap if needed, IV antibiotics, delayed bone graft of defect if needed.• If treated with external fixation earlier, remove fixator, wait for 2 wk and fix with internal fixation.• If IM nail already in place, reamed exchange nail with appropriate antibiotics may prove adequate treatment.
Compartment syndrome• Diagnosis same as in closed fractures.• Common with high energy fractures and Post-vascular repair.• Treatment is compartment fasciotomies.
Associated fatigue fractures• Sometimes seen during rehab after prolonged non-weight bearing.• Can present with localized tenderness in metatarsal, calcaneus, or distal fibula.• Bone scan or MRI may be required to make diagnosis as plain radiographs often normal.• Treatment is temporary reduction in weight bearing.
Hardware failure• Usually due to delayed union or nonunion.• Important to rule out infection as cause of delayed healing.• Treatment depends on type of failure- plate or nail breakage requires revision, whereas breakage of locking screw in nail may not require operative intervention.
Rehabilitation• Rehabilitation of the extremity: -• Should be planned at the very outset of treatment.• Exercise program either active or with assistance• Objectives of rehabilitation: - – Prevention of muscle atrophy and disuse. – Prevention of joint stiffness. – Improvement of circulation in the extremity and around the fracture site.
• Rehabilitation of the patient: -• In our hospital average stay of patients is; – Type I – 12 to 14 days – Type II – 15 to 20 days – Type III – around 3 months• Inform the patient and family members the social and economic implications of the serious injury in the beginning.
• Other extremities are also strengthened in order to facilitate ambulation.• A well-organized discharge planning and rehabilitation program will go a very long way in returning the injured patient to a functional status and gainful employment.
Outcome• Outcome most affected by severity of soft tissue and neurovascular injury.• Most studies show major change in results between type 3a and 3b/c fractures.• For type 3b and 3c fractures early soft tissue coverage gives best results.