1) The initial management of open fractures, including timing of debridement, choice of antibiotics, and timing of wound coverage, involves several controversies with little consensus in the literature. 2) While early antibiotic administration and debridement are agreed upon, there is no evidence that debridement must occur within 6 hours as was once believed; many surgeons now find urgent rather than emergency debridement acceptable. 3) Timing of wound coverage is also debated, but most evidence suggests covering Type III wounds within 7 days is appropriate once tissues have stabilized and debridement is complete.

1. Controversies in Initial
Management of
Open Fractures
S. P. Ryan, V. Pugliano
Department of Orthopaedic Surgery, Tufts Medical Center, Boston, MA, USA
Scandinavian Journal of Surgery 103: 132–137, 2013

3. Introduction
• Open fractures are one of the most
challenging injuries
• higher risk of infection, nonunion,wound
healing complications
• often require multiple surgeries for definitive
care

4. • multidisciplinary approach including teams of
orthopedic, trauma, and plastic surgeons is
commonly required
• most debated controversies with regard to the
initial management of open fractures include:
1)timing of initial operative debridement,
2)choice of antibiotic
3)time to wound coverage

5. Classification
• Gustilo–Anderson Classification
• based on the
– mechanism of injury
– soft tissue damage,
– length of skin laceration
– fracture pattern
– degree of contamination
Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open
fractures: A new classification of type III fractures. J Trauma 1984;24:742–746.

6. • Type I fractures, the wound is less than 1 cm
in length and clean
Type I open fracture

7. • Type II, the wound is
greater than 1 cm
and has minimal soft
tissue damage and
intact periosteum
• I and II can be closed
either immediately or
delayed
Type II open fracture.

8. • Type III fractures include
those injuries with
1)significant periosteal
stripping
2) Segmental fractures
3)extensive soft tissue wounds
4) Vascular injury requiring
repair
5)high-velocity gunshot
wounds

9. • IIIA injuries are those with
adequate soft tissue coverage
of the bone that does not
require a rotational or free
flap
• IIIB fractures, there is
inadequate soft tissue
coverage of the bone and
massive contamination,
necessitating flap coverage
Type IIIB open tibia fracture requiring
rotational/free flap.

10. • IIIC injuries are those with vascular disruption
requiring repair
Type IIIC open femur fracture with vascular injury

11. • type of open fracture may not be determined
until after final debridement
• all Type III open fractures have a higher
incidence of gram-negative infection, and the
addition of aminoglycosides is commonly
used for these fracture types
• no data supporting that the addition of gram
negative coverage decreases the infection rate

12. Antibiotic Coverage in Open
Fractures
• strong evidence for using systemic antibiotics
in the treatment of open fractures. this has
been first established by the landmark study
by Patzakis et al.
Patzakis MJ, Harvey P, Ivler D: The role of antibiotics in the management of open fractures. J Bone Joint Surg Am
1974;56:532–541

13. • Patzakis et al.
– prospective RCT
– 330 open fractures were randomized to either receive
a first-generation cephalosporin, penicillin and
streptomycin or a placebo
– duration of antibiotic varied from 10 to 14 days
depending on whether internal fixation was used
– infection rates between the cephalosporin (2%) and
penicillin/streptomycin (10%) or placebo (14%)
Patzakis MJ, Harvey P, Ivler D: The role of antibiotics in the management of open fractures. J Bone Joint Surg Am
1974;56:532–541

14. What is Controversial?
• In contrast to the use of first-generation
cephalosporins, the administration of
aminoglycosides for more complex open
fractures (Type III) is controversial

15. • Gustilo et al.
– Type 3 fractures
– 77% of bacteria isolated from wounds was G-ve
organisms
– Recommended to add aminoglycosides or 3rd gen.
cephalosporins.
– did not study if aminoglycoside decreases the rate of
infection in Type III fractures, So,his recommendation
to add gram-negative coverage is not valid
Gustilo RB, Mendoza RM, Williams DN: Problems in the management of type III (severe) open fractures: A new classification
of type III fractures. J Trauma 1984;24:742–746.

16. – Patzakis et al. (1)
• follow-up retrospective study
• reported that the addition of aminoglycosides to cephalosporin
decreased infection rate compared to cephalosporin alone
(13% vs. 5%).
• However, this study has several flaws affect its validity as
duration of Abx. And closure of wounds varied among groups.
– Patzakis et al.(2)
• Recent prospective study
• Ciprofloxacin vs 1st gen. cephalosporin + gentamicin
• 200 open fractures
• In cipro group infection was 4 times higher.
• But this is not statistically significant due to few type 3
fractures (26 cases).
(1)Patzakis MJ, Wilkins J, Moore TM: Use of antibiotics in open tibial fractures. Clin Orthop Relat Res 1983;178:31–35.
(2)Patzakis MJ, Bains RS, Lee J et al: Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to
combination antibiotic therapy in open fracture wounds. J Orthop Trauma 2000;14:529–533

17. – Thus, the addition of aminoglycosides for Type III
fractures is not currently supported in the literature.
– despite this, the Eastern ssociation for the Surgery of
Trauma (EAST) recommends it.
– penicillin has been used in heavily contaminated or
farm wounds to prevent clostridium infection
• no hard data supports this recommendation
• Gustilo and Anderson in their original study reported no
cases of gas gangrene infection in their original study of
over 1000 patients.

18. • duration of antibiotic therapy in open fractures
has also been the subject of much debate

19. • Merritt et al.
– Retrospective study
– Infection was higher in pateints received Abx. More
than 3 days to pt. who received abx. For 24 hrs. only
!!
– This could be due to that worse fracture received
Abx for longer time.
Merritt K: Factors increasing the risk of infection in patients with open fractures. J Trauma 1988;28:823–827.

20. • Dellinger et al.
– Prospective randomized trial
– Evaluate time and duration of Abx.
– 240 Pt
– similar infection rate was noted in patients
receiving antibiotics for 24 h or greater than 24 h
after admission
– Type of fracture was more predictive for infection
than abx. Duration.
Dellinger EP, Miller SD, Wertz MJ et al: Risk of infection after open fracture of the arm or leg. Arch Surg 1988;123:1320–1327.

21. • Recently, Al-Arabi et al:
– Six defferent groups
– Less than 2, 4, 6, 8, 12 h and greater than 12 h
– no correlation between timing of antibiotic
administration and infection rate
A l-Arabi YB, Nader M, Hamidian-Jahromi AR et al: The effect of the timing of antibiotics and surgical treatment on infection rates in open long-
bone fractures: A 9-year prospective study from a District General Hospital. Injury 2007;38:900–905.

22. • Patzakis and Wilkins:
– reported a difference in infection rate in
antibiotics delivered in less than 3 h (4.7%) and
greater than 3 h (7.4%)
– However, they did not mentioned if this is
statistically segnificant
– And they did not control the fracture type
Patzakis MJ, Wilkins J: Factors influencing infection rate in open fracture wounds. Clin Orthop
Relat Res 1989;243:36–40.

23. • In Practice
– Surgical Infection Society guideline: prophylactic
antibiotic use in open fractures: an evidence-based
guideline:
• first-generation cephalosporin (or clindamycin) should be
administered upon arrival to the emergency room
• ((Although there is no consensus on whether 24 h of
antibiotics after each debridement prevents infection, it
has been our current practice to administer 24 h of
antibiotics after each debridement until wound closure or
coverage)).
H auser CJ, Adams CA Jr, Eachempati SR; Council of the Surgical Infection Society: Surgical Infection Society guideline:
Prophylactic antibiotic use in open fractures: An evidence-based guideline. Surg Infect (Larchmt) 2006;4:379–405.

24. • SIS
– short course of first-generation cephalosporins,
begun as soon as possible after injury, significantly
lowers the risk of infection
– There is insufficient evidence to support other
common management practices, such as
• prolonged courses
• repeated short courses of antibiotics
• the use of antibiotic coverage extending to gram-negative
bacilli or clostridial species
• the use of local antibiotic therapies such as beads.
H auser CJ, Adams CA Jr, Eachempati SR; Council of the Surgical Infection Society: Surgical Infection Society guideline:
Prophylactic antibiotic use in open fractures: An evidence-based guideline. Surg Infect (Larchmt) 2006;4:379–405.

25. The Utility of Cultures in Open
Wounds
• Patzakis et al
– also evaluated the use of preoperative culture
data of the wound
– They found less than 20% of initial cultures
predicted the infecting organism
– routine preoperative cultures should not be
pursued.
Patzakis MJ, Bains RS, Lee J et al: Prospective, randomized, double-blind study comparing single-agent antibiotic therapy,
ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma 2000;14:529–533.

26. • many of the infecting organisms in severe
open fracture are hospital acquired
Roth AI, Fry DE, Polk JC Jr: Infections morbidity in extremity fractures. J Trauma 1986;26:757–761.

27. • In contrast, positive cultures at the time of
closure did correlate with infection and may
have clinical usefulness (Caesenti-Ettesse)
– It correlates with development of infection but
not with infecting organism
Carsenti-Etesse H, Doyon F, Desplaces N et al: Epidemiology of bacterial infection during management of open leg fractures.
Eur J Clin Microbiol Infect Dis 1999;18:315–323.

28. Timing to Debridement
• The most heavily debated topic
• In their original article, Gustilo and Anderson
concluded that “open fractures require
emergency treatment …
• ” Nevertheless, this statement is not
supported by data and seems to represent his
expert opinion only
Gustilo RB, Anderson JT: Prevention of infection in the treatment of one thousand and twenty-five open fractures of long
bones. J Bone Joint Surg Am 1976;58:453–458.

29. • practice trends have been to perform urgent
rather than emergent debridement of open
fractures (Namdariet) 2011
– They found 40% infection if debridement done
after 6 hrs. And 25% done after 24 hrs.
Namdari S, Baldwin KD, Matuszewski P et al: Delay in surgical debridement of open tibia fractures: An analysis of national
practice trends. J Orthop Trauma 2011;25:140–144.

30. What is Agreed Upon?
• most important aspect of managing open
fractures is the delivery of systemic antibiotics
and performing an adequate debridement of
nonviable tissue.
• many surgeons believe that an open fracture
without vascular compromise is not an
emergency (Namdari)
Delay in surgical debridement of open tibia fractures: An analysis of national practice trends. J Orthop Trauma 2011;25:140–144.

31. • Some surgeons continue to treat open
fractures immediately upon presentation.
• Thus, there is no absolute time which is
agreed upon by all surgeons, by which open
fractures should be debrided.

32. What is Controversial?
• debridement within 6 h has propagated
throughout the literature and became the
standard of care for many years
• poor evidence supporting this practice

33. • “6-hour rule” likely originated from a study in
the 1890s
• Experimental study
• garden mold and dust were used as infecting
agents in a guinea pig model of open fracture
• early phases of bacterial growth stopped after 6–8 h
from injury
• difficult to obtain a clean wound after 6–8 h of being
contaminated
riedrich PL: Die aseptische Versorgung frischer Wunden.Arch Klin Chir 1898;57:288–310.

34. • Main studies evaluating the association
between timing of initial debridement and
infection in open fractures are flawed by
design
– 1) These studies compared the complication
rate in fractures receiving debridement in less
than or greater than 6 h only
– 2) Types of open fractures between groups
were not equal ..… these studies are
retrospective.
– 3) many of the earlier studies were
underpowered, and solid conclusions cannot be
reached

35. • In a well-powered study, Pollak et al. (2010)
• 300 lower extremity Type III
• 27% infection rate and no relationship between timing
of initial operative debridement and infection
• They did find, time from injury to arrival at the
definitive trauma center was an independent risk factor
for infection
Pollak AN, Jones AL, Castillo RC et al: The elationship between time to surgical bridement and incidence of infection after high-energy lower extremity trauma. J Bone Joint
Surg Am 2010;92:7–15.

36. • Schenker et al. 2012
– systematic review
– evaluated the relationship between timing of initial
operative debridement and infection
– Authors collected data from previously reported
retrospective studies
– over 3500 open fractures
– controlled these cases for type of open fracture
– analysis did not identify a difference in infection
between early (<6 h) or late (>6 h) debridement
– “6-hour rule” has little support in the literature.
Schenker ML, Yannascoli S, Baldwin KD et al: Does timing to operative debridement affect infectious complications in open
long-bone fractures? J Bone Joint Surg Am 2012;94:1057–1064.

37. • In conclusion
– no absolute recommendations regarding the
optimal timing of open fracture debridements
– “6-hour rule” has little support in the literature
– we recommend urgent debridement of open
fractures, while the safety of waiting more than 24
h needs to be determined.

38. Timing of Wound Closure/
Coverage
• Type I and II open fracture wounds can be
safely closed after initial thorough
debridement, if there is no concern for
ongoing muscle necrosis or contamination

39. • Controversy is focused on Type III
• These wounds usually require a repeat
debridement at 48–72 h after initial
debridement.

40. Wound coverage
• Webb et al. (2007)
– 150 patients with Type III open tibia fractures
– no difference in infection rate in those patients
receiving early (<3 days) or late (>3 days) wound
coverage
Webb LX, Bosse MJ, Castillo RC et al; LEAP Study Group: Analysis of surgeon-controlled variables in the treatment of
limbthreatening type III open tibial diaphyseal fractures. J Bone Joint Surg Am 2007;89:923–928

41. • Pollak et al. (2000)
– No difference in infection rate when comparing
wound coverage at less than 3, 4–7, or greater
than 7 days.
– They did report, however, a 32% complication rate
in those wounds covered at greater than 7 days
Pollak AN, McCarthy ML, Burgess AR: Short-term wound complications after application of flaps for coverage of traumatic
soft-tissue defects about the tibia. J Bone Joint Surg Am 2000;82:1681–1691.

42. • D’Alleyrand et al
– no difference in wound complications in those
covered in less than 7 days
– but every day afterward, complication rate
increased 15% per day
D ’Alleyrand JC, Dancy L, Castillo R et al: Is time to flap coverage an independent predictor of flap complication? Presented at 2010 OTA Annual
Meeting, October 13–16, Baltimore, MD, 2010.

43. • Recommendation
• closure within 7 days of wounds associated with open
fractures once the soft tissues have stabilized, and all
nonviable tissues have been removed

48. Thank You