Open fractures allow direct communication between the fracture site and the external environment, with prognosis influenced by soft tissue damage, bacterial contamination, and fracture geometry. Management involves immediate assessment, wound care, and classification systems like the Gustilo-Anderson for treatment planning. Antibiotics and surgical interventions are critical for preventing infection and promoting healing in these injuries.

1. Presented by:-
DR.RANAT VISHNOI

2. INTRODUCTION
An open fracture is one in which a break in the skin
allows for direct communication of the fracture site or
fracture hematoma with the elements external to the
usual protection of the skin.
The prognosis in open fractures is determined by :-
 the amount of devitalized soft tissue.
 the level and type of bacterial contamination.
 geometry of fracture.

3. Incidence
 Open fractures of the tibia
are more common than in
any other long bone
 Rate of tibial diaphysis
fractures reported 2 per
1000 population and of
these approximately one
fourth are open tibia
fractures.

4. PRINCIPLES OF MANAGEMENT
 ABC’S
 Assoc Injuries
 Tetanus
 Antibiotics
 Soft Tissue
Management
 Fixation
 Long term issues

5. DIAGNOSIS
The diagnosis of an open fracture is straight forward in
most cases. An injured patient usually has:-
 bleeding deep laceration overlying or near a fracture of the
underlying bone.
 In some cases, the fractured bone may be exposed.
However, not all open fractures are obvious, and their
timely and proper diagnosis and treatment depend on a
careful examination of the patient, delineating salient
features from the patient's history, a critical reading of x-
rays, and good clinical judgment.

6.  Examine the neurologic function and vascular function of
each extremity.
 Note the state of circulation to the limb as indicated by
 capillary blush,
 the filling of veins, and
 the status of peripheral pulses.
 Examine meticulously for peripheral nerve function.
 Initial sensory examination by pressure and light touch gives
a gross evaluation of limb sensation.
 Examination for motor function is difficult in the injured
limb owing to pain and muscle spasm. The normal side
should be compared with the abnormal side.

7. Mechanism of Injury
 Can occur in low energy, torsional type injury.
(e.g. skiing)
 More common with high energy, direct force.
(e.g. car bumper)

8. ENVIROMENTAL FACTOR
The location where the injury occurred is essential to delineate.
 People exposed to feces or dirt may occur in a farm setting have
possibility of clostridial infection and need additional antibiotics
(penicillin) and more aggressive surgical debridement.
 In automobile collisions there is less risk for development of a
clostridial infection.
 Unusual environments, such as a barnyards or gardens, streams or
lakes, will likely be contaminated by unusual organisms, such as soil
anaerobes and Aeromonas hydrophilia, respectively.
 Injuries caused by lawn-mowers and other motorized garden
equipment are high-energy injuries with severe contamination.
 Animal Bite or presence of oral flora.

9. HISTORY
 The patient's tetanus immunity must be determined.
 The surgeon must also inquire about medical illnesses:-
 diabetes mellitus,
 peripheral vascular disease,
 liver disease, and
 any immune deficiency syndromes.
 Any previous injuries and their treatments.
 Finally, a history of smoking or chronic use of steroids.

10. Physical Examination
 Due to subcutaneous nature of
tibia, deformity and open wound
usually readily apparent.
 Circumferential inspection of soft
tissue envelope, noting any
lacerations, ecchymosis, swelling,
and tissue turgidity necessary.

11.  Neurologic and vascular exam of extremity must be done.
 Wounds should be assessed and then covered with sterile
gauze dressing until treated or through digital camera /
cell phone.
 True classification of wound best done after surgical
debridement completed.

12. IMAGING EVALUATION
 Full length AP and lateral views
from knee to ankle required for all
tibia fractures.
 Ankle views suggested to examine
mortise.
 Arteriography indicated if vascular
compromise present after
reduction .

13. Associated Injuries
 Approximately 30% of patients
have multiple injuries.
 Fibula commonly fractured
and its degree of comminution
correlates with severity of
injury.
 Proximal or distal tib-fib joints
may be disrupted.
 Ligamentous knee injury
and/or ipsilateral femur
(‘floating knee’) more
common in high energy
fractures.

14.  Neurovascular structures
require repeated assessment.
 Foot fractures also common.
 Compartment syndrome
must be looked.

15. CLASSIFICATION
OF
OPEN
FRACTURES

16. HELPFUL FOR
 Communication between health care professionals
 Formulating a treatment plan
 Decision on limb salvage
 Detailed audit of care to ensure optimal management

17. METHODS OF CLASSIFICATION
 GRADING SYSTEM – focus on severity of limb injury only
Eg: Gustilo Anderson , Tscherne and Gotzen, Byrd and
Spicer etc
 SCORING SYSTEM – focuses on limb injury and general
health; also give ‘amputation score’.
Eg: MESS , NISSSA ,LSI,etc
 COMPREHENSIVE SYSTEM – combines the above two
systems
Eg: AO system , Ganga hospital score

18. GRADING SYSTEMS

19. Gustilo Anderson System
 In 1976 , Gustilo and Anderson treated 1025 open fractures
based on his grading system that offered prognosis about
outcome of infected fractures
 In 1984, it was modified and was based on
a. Size of wound
b. Soft tissue damage
c. Periosteal stripping
d. Vascular injury
 Segmental fractures, farmyard injuries, fractures occurring in a highly
contaminated environment, shotgun wounds, or high-velocity
gunshot wounds automatically result in classification as type III open
fracture.

20. Type Wound Level of Soft Tissue Injury Bone Injury
Contaminatio
n
I <1 cm long Clean Minimal Simple, minimal
comminution
II >1 cm long Moderate Moderate, some muscle Moderate comminution
damage
III
Usually >10 cm long High Severe with crushing Usually comminuted;
A soft tissue coverage of
bone possible
Usually >10 cm long High Loss of coverage; periosteal Bone coverage poor;
B stripping & usually requires variable, may be
soft tissue reconstructive moderate to severe
surgery comminution
Usually >10 cm long High Very severe loss of coverage Bone coverage poor;
C plus vascular injury requiring variable, may be
repair; may require soft tissue moderate to severe
reconstructive surgery comminution

21. Tscherne System
GRADE DESCRIPTION
1 Skin laceration mostly inside out injury with little or no contusion
of skin
2 Skin laceration with circumscribed skin or soft tissue contusion
with moderate contamination
3 Fractures with severe soft tissue injury often with NV injury , severe
bone comminution or compartment syndrome
4 Sub total (remaining soft tissue not exceeding ¼ of limb
circumference) or total amputation
 This system includes compartment syndrome which is not
included in other grading systems

22. Byrd and Spicer
TYPE DESCRIPTION
I Both endosteal and periosteal supply intact and surrounding soft tissue
is healthy
II Endosteal supply interrupted but periosteal supply maintained by
surrounding soft tissues
III Devascularised bone fragment and requires flap coverage
 This system lacks sophistication and hence not widely used

23. SCORING SYSTEMS

24. Mangled Extremity Severity Score
(MESS)
TYPE CHARACTERISTICS INJURIES POINTS
SKELETAL/ SOFT-TISSUE GROUP
1 Low energy Simple closed #, small calibre gun shot 1
2 Medium energy Open # , D/L , mulltiple level # 2
3 High energy Shot gun blast , high velocity gun shot 3
4 Massive crush Rail road, oil rig accidents 4
SHOCK GROUP
1 Normotensive BP stable in field and OT 0
2 Transiently BP unstable in field but responds to IV 1
hypotensive fluids
3 Prolonged SBP<90 in field and responding to IV 2
hypoptensive fluids only in OT

25. MESS Contd…
TYPE CHARACTERISTICS INJURIES POINTS
ISCHEMIA GROUP
1 None Pulsatile limb w/o signs of ischemia 0*
2 Mild Diminished pulses w/o signs of 1*
ischemia
3 Moderate No pulse, sluggish capillary refill, 2*
paraesthesia, motor activity
4 Advanced Pulseless, cool, paralysed, numb, no 3*
capillary refill
AGE GROUP
1 < 30 yrs 0
2 30 – 50 yrs 1
3 > 50 yrs 2
* If ischemia time > 6 hrs, add 2 points.

26. MESS Contd…
 It was developed to identify those patients who will be
benefited by primary amputation
 In retrospective analysis, the outcome of injured limb
was either salvage or amputation
 A score of 7 or greater is predictive of amputation.
 MESS is found to be specific but lacks some sensitivity
which infers that score predicting limb salvage(<7) is
more reliable than score predicting amputation
(> or =7) (Bosse MJ JBJS 83A:412,2001)

27. Injury Severity Score (ISS)
 More recently, Rajasekaran et al. proposed a new
scoring system for Gustilo type IIIA and IIIB open
fractures of the tibia that evaluated skin coverage,
skeletal structures, tendon and nerve injury, and
comorbid conditions .
 The high specificity of this new scoring system may
make it a much better predictor of amputation.

28. Injury Severity Score for Gustilo Type IIIA and IIIB Open Tibial Fractures
Covering Structures: Skin and Fascia
Wounds without skin loss
Not over the fracture: 1
Exposing the fracture: 2
Wounds with skin loss
Not over the fracture: 3
Over the fracture: 4
Circumferential wound with skin loss: 5
Skeletal Structures: Bone and Joints
 Transverse or oblique fracture or butterfly fragment <50% circumference: 1
 Large butterfly fragment >50% circumference: 2
 Comminution or segmental fractures without bone loss: 3
 Bone loss <4 cm: 4
 Bone loss >4 cm: 5

29. Functional Tissues: Musculotendinous and Nerve Units
 Partial injury to musculotendinous unit: 1
 Complete but repairable injury to musculotendinous units: 2
 Irreparable injury to musculotendinous units, partial loss of a compartment, or
complete injury to posterior tibial nerve: 3
 Loss of one compartment of musculotendinous units: 4
 Loss of two or more compartments or subtotal amputation: 5
Comorbid Conditions: Add 2 Points for Each Condition Present
 Injury leading to débridement interval >12 h
 Sewage or organic contamination or farmyard injuries
 Age >65 y
 Drug-dependent diabetes mellitus or cardiorespirator diseases leading to
increased anesthetic risk
 Polytrauma involving chest or abdomen with injury severity score >25 or fat
embolism
 Hypotension with systolic blood pressure <90 mm Hg at presentation
 Another major injury to the same limb or compartment syndrome

30. Using this system, they divided type III open tibial
fractures into four groups to assess the possibilities of
limb salvage.
 Group 1 had scores of 5 or less.
 Group 2 had scores of 6 to 10.
 Group 3 had scores of 11 to 15 and,
 Group 4 had scores of 16 or greater.
A score of 14 or greater is an indicator for amputation.

31. Other Scoring Systems
• NISSSA – Nerve injury Ischemia Soft tissue injury
Skeletal injury Shock & Age , is more sensitive and
more specific than MESS.
• LSI – Limb Salvage Index
a.This index is applied to limbs with arterial injury
b.Warm ischemia time together with scores for
injured skin , muscle , bone , NV are added to give
total score.

32. COMPREHENSIVE
SYSTEMS

33.  AO System :
 Skin lesions , muscle -tendon , NV , bone injuries are
graded separately
 AO system allows better prediction of outcome when
compared to Gustilo
 Due to its complexity not widely accepted
• Ganga hospital score :
 Includes additional criteria like age >65 , DM , cardio-
respiratory disease , trauma chest/abdomen,
farmyard/sewage contaminations, delay in debridement
>12h

34. ANTIBIOTIC
 A short course of first-generation cephalosporins, begun as
soon as possible after injury, significantly lowers the risk of
infection when used in combination with prompt, modern
orthopaedic fracture wound management.
 A broad-spectrum antibiotic, first-generation cephalosporin
+ aminoglycoside, such as tobramycin or gentamicin, for highly
contaminated wounds in which there is a risk of gram-negative
contamination (Gustilo type III).
 If possibility of anaerobic organisms, such as Clostridium, high-
dose penicillin is recommended.
 The duration of antibiotic treatment should be limited because
in most series the infecting organisms are hospital acquired.

35.  Gustilo recommended
 Type I and II - 2 g of cefamandole on admission and 1 g every 8
hours for 3 days.
 In type III - an aminoglycoside in dosages of 3 to 5 mg/kg daily.
 Farm injuries - add penicillin, 10 to 12 million U daily.
 Gustilo continued double antibiotic therapy for 3 days only and
repeated the antibiotic regimen during wound closure, internal
fixation, and bone grafting.
 Okike and Bhattacharyya recommended the administration of
cefazolin, 1 g intravenously, every 8 hours until 24 hours after the
wound is closed, with intravenous gentamicin (with weight-
adjusted dosing) or levofloxacin (500 mg every 24 hours) added
for type III fractures.
 Campbell recommend obtaining cultures when obvious clinical
findings of infection are present at the second débridement.

36. MANAGEMENT

37. Initial Management
 ABC of initial management is addressed first.
 Compressive dressings for extremity hemorrhage..
 Rule out cervical injuries , chest , abdominal injuries ,
head injuries in polytrauma patients .
 As soon as possible careful examination of wound is
carried out and serial photographs of wound taken.

38. Initial wound management
In emergency room :
 Don’t do digital exploration (to avoid infection and
bleeding).
 Obvious Foreign Body are removed with forceps.
 If patient will undergo formal debridement in<1 hour
just do sterile saline dressing if not irrigate with 1 or 2 ltr
of NS.
 Povidone dressing alters color and impairs osteoblast
function (controversial) so better avoided.
 Patients immunity to tetanus is determined.
 I.V. antibiotics are given as soon as possible .

39. Objectives of Surgical
Treatment
 Prevent Sepsis
 Achieve Union
 Restore Function

40. DEBRIDEMENT
 Timing - Debridement done as soon as possible.
 Skin and wound preparation - dirt and debris removed by gentle scrub
brush.
 Sterile tourniquets kept ready but not used.
SUPERFICIAL DEBRIDEMENT:
Traumatic wounds extended – to identify and explore the entire zone of
injury and to access ends of bone fragments
 Skin incisions – extensile longitudinal incision to visualize deep
tissue and can be extended till (N) tissue encountered.
 Clearly Nonviable skin and subcutaneous tissue excised but of
marginal viability may be left for later debridement.
 Don’t detach skin and subcutaneous tissue from the fascia.
 Any nonviable shredded fascia and even the marginally viable ones
excised.

41. Extensile longitudinal skin incision

42. DEEP DEBRIDEMENT:
 Where skin tend to tear , fascia split or shred , muscle
because of water content are subjected to hydraulic damage
by fluid waves during injury.
 In muscle debridement the concept ‘when in doubt take it
out’.
 In type I,II and IIIa open # all non-vital and in doubt
muscle can be debrided but IIIb and IIIc removal of entire
muscle compartment may be needed so marginally viable
ones are left for later re-debridement
 Viability of muscle checked by its 4C’s = color, capacity to
bleed, contractility and consistency(last 2 more reliable).

43.  Tendons , unless injured beyond repair should be
preserved.
 In open wounds tendons are subject to dessication and
hence it should be covered with soft tissues if not with
moist dressings.
 In general bone devoid of soft tissue attachment
removed and large ones are utilized provisionally for
skeletal fixation and removed once fixation achieved.
 One exception to strict removal of bone without soft
tissue attachment ,is significant portion of articular
surface attached to bone fragment.

44. IRRIGATION
After meticulous debridement irrigation of wound is
done.
Additives – antiseptics, antibiotics and
surfactants can be used.

47. Skeletal Stabilization
 Once the vascular repair has been completed and limb
salvaged or irrigation and debridement done
, stabilization of bone is next concern.
 Restoring the length ,rotational and angular alignment
has many benefits for healing of soft tissue
 fracture reduction unkinks NV conduits and helps in
soft tissue healing
 minimizing motion of fragments also decreases further
damage, pain and permits mobilization of joints

48. Stabilization of Open Tibia
Fractures
Multiple options depending on fracture pattern and
soft tissue injury:
 Extra osseous immobilisation
 IM nail- reamed vs. unreamed
 External fixation
 ORIF

49. Extra Osseous Immobilisation
Extra osseous immobilisation –eg: plasters ,weight
bearing casts , splints and skeletal tractions
Used in Low grade open fractures – eg: Grade-I Tibia #
(plasters) and open shaft fractures (skeletal traction).

50. IM Nail
 IM Nail- currently
the treatment of
choice for grade
I,II,IIIa and IIIb
fractures.
 Excellent results
with type 1 open
fractures.

51. Unreamed IM Nail
 Time to union with unreamed
nails can be prolonged- in one
study of 143 open tibia
fractures 53% were united at 6
months.
 Vast majority of fractures
united, but 11% required at
least one secondary procedure
to achieve union.

52. Reamed Tibial Nailing
 In one study of type 2 and type
3a fractures good results-
average time to union 24 and 27
weeks respectively; deep
infection rate 3.5%.
 Complications increased with
type 3b fractures- average time
to union was 50 weeks and
infection rate 23%.

53. External Fixation
 Used in high grade open
fractures gives excellent
access to wound dressing
and surveillance possible.
 Compared to IM nails,
increased rate of malunion
and need for secondary
procedures.
 Most common complication
with ex-fix is pin track
infection.

54. Conversion from Ex-Fix to IM Nail
 Conversion between ex-
fix and IM nail.
 9% infection 90%union.
 Infection rates decreased
with shorter duration of
ex-fix time.

55. Plate Fixation
 Traditional plating technique with
extensive soft tissue dissection and
devitalization has generally fallen out of
favor for open tibia fractures.
 After meticulous debridement, copious
irrigation with minimal stripping and
accurate anatomical reduction in
extraperiosteal plate fixation can be done.
 Increased incidence of superficial and deep
infections compared to other techniques.
 In one study 13% patients developed
osteomyelitis after plating compared to 3%
of patients after ex-fix.

56. Percutaneous Plate Fixation
 Newer
percutaneous
plating techniques
using indirect
reduction may be a
more beneficial
alternative
 Large prospective
studies yet to be
evaluated

57. Gunshot Wounds
 Tibia fractures due to
low energy missiles
rarely require
debridement and can
often be treated like
closed injuries
 Fractures due to high
energy missiles (e.g.
assault rifle or close
range shot gun)
treated as standard
open injuries

58. Amputation
 Lange proposed two absolute
indications for amputation of tibia
fractures with arterial injury:
 crush injury with warm ischemia
greater than 6 hours, and
 anatomic division of the tibial nerve.
 In general amputation performed
when limb salvage poses significant
risk to patient survival, when
functional result would be better with
a prosthesis, and when duration and
course of treatment would cause
intolerable psychological disturbance.

59. Bone Defects
PMMA –aminoglycoside +/- vancomycin
 Bead pouch
 Solid spacer

60. Large Fragments: What to do?
• Infection Rates with retained - 21%
• Infection Rates with removed- 9%
• Use to assist in determining length,
rotation and alignment

61. Wound closure and coverage
Wounds without skin loss :
 Definitive coverage should be performed within 7-10 days if possible.
 Most type 1 wounds will heal by secondary intent or can be closed
primarily.
 Delayed primary closure usually feasible for type 2 and type 3a fractures.
 Tension free primary closure after thorough debridement
 Contraindications for primary closure are
1. Delayed presentation >12hr
2. Delayed administration of antibiotic >12hr
3. Deep seated contamination
4. Immunocompromised
5. NV injury
6. Inability to achieve tension free suture
7. High risk of anaerobic contamination like farm yard injuries

62. Wounds with skin loss:
Type 3b fractures require either local advancement
or rotation flap, split-thickness skin graft, or free
flap.

63. Soft Tissue Coverage
 Proximal third tibia
fractures can be covered
with gastrocnemius
rotation flap.
 Middle third tibia
fractures can be covered
with soleus rotation
flap.
 Distal third fractures
usually require free flap
for coverage

64. Negative Pressure Would Therapy
(NPWT)/ Vacuum Dressing
 Can lower need for free flaps Dedmond BT, The use of negative-
pressure wound therapy (NPWT) in the temporary treatment of soft-tissue
injuries associated with high-energy open tibial shaft fractures. J Orthop
Trauma 2007
 Cannot lower infection rates for Type IIIB open
fractures Bhattacharyya T, Routine use of wound vacuum-assisted closure
does not allow coverage delay for open tibia fractures. Plast Reconstr Surg
2008

66. BMPs
 BMP-2 (Infuse) FDA approval in subset of open tibia
fractures BESTT study group JBJS 84, 2002
 Significant reduction in the incidence of secondary
procedures
 Accelerated healing
 Lower infections

67. COMPLICATIONS

68. Complications
1. Nonunion.
2. Malunion.
3. Infection- deep and superficial.
4. Compartment syndrome.
5. Fatigue fractures.
6. Hardware failure.
7. Chronic Osteomyelitis.

69. 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 nonunions include
onlay bone grafts, free
vascularized bone
grafts, reamed
nailing, compression
plating, or ring fixator

70. Malunion
 In general varus malunion
more of a problem than
valgus
 In one study deformity up to
15 degrees did not produce
ankle complications*
 For symptomatic patients
with significant deformity
treatment is osteotomy.

71. 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.
 Staged reconstruction with
the used of PMMA +
antibiotics.

72. 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

73. Compartment Syndrome
 Diagnosis same as
in closed tibial
fractures
 Common with high
energy tibia
fractures
 Release ALL 4
compartments

74. 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

75. Chronic Osteomyelitis
 Osteomyelitis is a common complication of compound
fracture of long bones which is difficult to treat.
 Fever, Pain, swelling are seen in acute exacerbation of
chronic osteomyelitis.
 Sequestrectomy and saucerization.
 Open Bone Grafting (Papineau Technique).

76. Management of sequelae of chronic osteomyelitis by Illizarov’s technique
Group A – acute onset but ends up as chronic osteomyelitis with
persistent infection
A 1- no alteration in bone length bifocal osteosynthesis resection and
bone transport
A 2 – with limb length monofocal osteosynthesis and
discrepancy lenthgning.
A 3 – with deformities monofocal osteosynthesis and
deformities correction
A 4- with both length discrepancy monofocal or bifocal osteosynthesis
and deformity with simultaneously lengthening
and deformity correction
A 5 – infective pseudoarthosis and bifocal osteosynthesis compression
non union distraction or distraction –
compression osteosynthesis

77. Outcomes

78. Outcomes
 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
 In one study of reamed nailing, the deep infection
rate was 3.5% for type 2 and 3a fractures, but 23%
for type 3b fractures*
*Court-Brown JBJS 1991

79. Outcomes
 For type 3b and 3c fractures early soft tissue
coverage gives best results
 In one study of 84 type 3b and 3c fractures, results
with single stage procedure involving fixation with
immediate flap coverage better than when
coverage delayed more than 72 hours (deep
infection 3% vs. 19%)*
*Gopal et al. JBJS[Br] 2000

80. Suggested
treatment
algorithm
Melvin JS, Open Tibial
Shaft Fractures: I and
II, JAAOS, Jan-Feb 2010

81. THANK YOU….!!