management_of_open_fractures.pptx

Definition
• Break in the skin and underlying soft tissue
leading directly into or communicating with
the fracture and its hematoma

• Last century, high mortality with open fractures
of long bones
• Early amputation in order to prevent death
• WWI, mortality of open femur fractures > 70%
• 1939 Trueta “closed treatment of war fractures”
– Included open wound treatment and then enclosure
of the extremity in a cast
– “Greatest danger of infection lay in muscle, not bone”
Trueta J: "Closed" treatment of war fractures, Lacet 1939;1:1452-1455
History

• 1943 PCN on the battlefield quickly reduced
rate of wound sepsis
• Delayed closure of wounds
• Hampton: closure btwn 4th and 7th day
• Larger defects continued to be left open to
heal by secondary intention
Hampton OP Jr: Basic principles in management of open fractures; JAMA 1955; 159:417-419
History

• Advances shifted the focus
– Preservation of life and limb  preservation of
function and prevention of complications
• However, amputation rates still exceed 50% in
the most severe open tibial fractures assoc
with vascular injury*
Lange RH, Bach AW, Hansen ST et al: Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma; 25(3):203-
208
History

Epidemiology
• 3% of all limb fractures
• 21.3 per 100,000 per year

http://www.lww.com/static/docs/product/samplechapters/978-0-7817-5096-7_Chapter%204.pdf

Open fracture classification
• Allows comparison of results
• Provides guidelines on prognosis and
treatment
– Fracture healing, infection and amputation rate
correlate with the degree of soft tissue injury
• Gustilo upgraded to Gustilo and Anderson
• AO open fracture classification
• Host classification of open fractures

Gustilo and Anderson Classification
• Model is tibia, however applied to all types of
open fractures
• Emphasis on wound size
– Crush injury assoc with small wounds
– Sharp injury assoc with large wounds
• Better to emphasize
– Degree of soft tissue injury
– Degree of contamination

Type 1 Open Fractures
• Wound less than 1 cm,
• Inside-out injury
• Clean wound
• Minimal soft tissue damage
• No significant periosteal
stripping
http://www.unboundedmedicine.com/2005/11/08/open-fractures-classification-and-its-clinical-manifestations-3/

Type 2 Open Fractures
• Moderate soft tissue
damage
• Outside-in
• Higher energy
• Some necrotic muscle
• Some periosteal
stripping

Type 3a Open Fractures
• High energy
• Outside-in
• Extensive muscle
devitalization
• Bone coverage with
existing soft tissue

Type 3b Open Fractures
• High energy
• Outside in
• Extensive muscle
devitalization
• Requires a flap for
bone coverage
and soft tissue
closure
• Periosteal stripping

Type 3c Open Fractures
• High energy
• Increased risk of
amputation and
infection
• Any grade 3 with
major vascular injury
requiring repair

Why use this classification?
• Grades of soft tissue injury correlates with infection
and fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2% 2-7% 10-25% 10-50% 25-50%
Fracture
Healing
(weeks)
21-28 28-28 30-35 30-35
Amputation
Rate
50%

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

What they found…
• Patients with any compromising risk factor has
increased risk of infection
• May benefit from additional therapies that
decrease the risk of infection.
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:205-11.
Class Compromising factors Infection rates
A 0 4%
B 1-2 15%
C 3 or more 31%

Gustilo Classification:
a simple and useful tool, but is it accurate?
• 1994 Brumback et al.
• 125 randomized open fractures
• 245 surgeons of various levels of training
• 12 cases of open tibia fractures, videos used
• Interobserver agreement poor
– Range 42-94% for each fracture
• Ortho attendings - 59% agreement
• Ortho Trauma Fellowship trained attendings - 66% agreement
Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two
hundred and forty-five orthopaedic surgeons. J Bone and Joint Am; 76(8):1162–1166.

So……….
• Fracture type should not be classified in the
ER
• Most reliably done in the OR at the
completion of primary wound care and
debridement

Radiological Examination
• Usually, only AP and lateral radiographs are
required
– They should include adjacent joints and any
associated injuries.
• There are a number of features that the
surgeon should look for when examining the
radiographs

Radiological Examination
• 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.

Microbiology
• Most acute infections are caused by pathogens
acquired in the hospital
• 1976 Gustilo and Anderson
– most infections in their study of 326 open fxs
developed secondarily
• When left open for >2wks, wounds were prone to
nocosomial contaminants such as Pseudomonas
and other GN bacteria
• Currently most open fracture infections are
caused by GNR and GP staph
Gustilo RB, Anderson JT: Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones; JBJS,
58(4):453-458, June 1976

Nocosomial infection?!!!!
• Only 18% of infections were caused by the
same organism initially isolated in the
perioperative cultures*
• Carsenti-Etesse et al. 1999
– 92% of open fracture infections were caused by
bacteria acquired while the patient was in the
hospital**
*Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res. 1983
Sep;(178):36-41.
*Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized, double-blind study comparing
single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000 Nov;14(8):529-33.
**Carsenti-Etesse H, Doyon F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B, Dellamonica P. Epidemiology of bacterial infection
during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:315-23.
Cover the
wounds
quickly

Common bacteria encountered with
open fractures
Blunt Trauma, Low Energy GSW Staph, Strept
Farm Wounds Clostridia
Fresh Water Pseudomonas, Aeromonas
Sea Water Aeromonas, Vibrios
War Wounds, High Energy GSW Gram Negative

What systemic antibiotic?
1st Gen Ceph Gent PCN
Grade 1 
Grade 2  +/-
Grade 3   +/-
Farm/War
Wounds
  
(Gustilo, et al; JBJS 72A 1990)

Antibiotic comparisons
• No difference btwn clindamycin and cefazolin*
• Patzakis et al. **
– For type 1&2, cipro = cefamandole+gentamicin
– For type 3, cipro worse (31% vs 7.7% infection)
• Cipro and other fluoroquinolones inhibit
osteoblast activity and fracture healing***
*Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a prospective study. J Trauma.
1983;23:25-30.
**Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P. Prospective, randomized, double-blind study comparing
single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000;14:529-33.
***Holtom PD, Pavkovic SA, Bravos PD, Patzakis MJ, Shepherd LE, Frenkel B. Inhibitory effects of the quinolone antibiotics trovafloxacin,
ciprofloxacin, and levofloxacin on osteoblastic cells in vitro. J Orthop Res. 2000;18:721-7.
***Huddleston PM, Steckelberg JM, Hanssen AD, Rouse MS, Bolander ME, Patel R. Ciprofloxacin inhibition of experimental fracture healing.
J Bone Joint Surg Am. 2000;82:161-73.

When and for how long?
• Start abx as soon as possible*
– Less than 3 hours  4.7 % infection rate
– Greater than 3 hours  7.4%
• No difference btwn 1 and 5 days of post op
abx treatment**
• Mass Gen recommended treatment:***
– Cefazolin Q 8 until 24 hours after wound closed
– Gentamicin or levofloxacin added for type 3
*Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36-40.
**Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou MA. Duration of preventive
antibiotic administration for open extremity fractures. Arch Surg. 1988;123:333-9.
***Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.

Local antibiotic therapy
• High abx conc within the wound and low
systemic conc
– Reduces risk of systemic side effect
• Vancomycin or aminoglycosides
– Heat stable
– Available in powder form
– Active against suspected pathogens
Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-
impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.

Antibiotics - locally
• Prevents secondary contamination by
nocosomial pathogens
• Useful adjunct to systemic abx
• Potential for abx impregnated bone graft,
bone graft substitute, and abx coated IMN
Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases; J Bone Joint
Surg Br. 1995 Jan;77(1):93-7.
Antibiotic Infection Rate
IV Abx 12%
IV Abx + local aminoglycoside
impregnated PMMA beads
3.7%

Antibiotic Beads
• Pros
– Very high levels of
antibiotics locally
– Dead space
management
• Cons
– Requires removal
– Limited to heat
stable antibiotics
– Increased drainage
from wound

Goals of treatment
• 1. preserve life
• 2. preserve limb
• 3. preserve function
• Also….
– Prevent infection
– Fracture stabilization
– Soft tissue coverage

Stages of care for open fractures

Initial assessment & management
• ABC’s
• Assess entire patient
• Careful PE, neurovasc
• Abx and tetanus
• Local irrigation 1-2 liters
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.

Initial assessment & management
• Sterile compressive dressings
• Realign fracture and splint
• Do not culture wound in the
ED*
– 8% of bugs grown caused deep
infection
– cultures were of no value and not
to be done
• Recheck pulse, motor and
sensation
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.

Primary surgery
• Objectives of initial surgical
management
– Preservation of life and limb
– Wound debridement
– Definitive injury assessment
– Fracture stabilization
Stages of open fracture management in the OR

Surgical emergency!
• 1898 Friedrich guinea pigs
– Take to the OR within 6-8 hours*
• 1973 Robson:
bacteria multiply in contaminated
wounds **
– 105 organisms/gram of tissue is the
infection threshold
– Reached at 5.17 hours
• 1995 Kindsfater et al:
– 47 G2/3 fxs at 4.8 months out….
• Less than 5 hrs  7% infection
• Greater than 5 hrs  38% infection
– However G3 fxs were treated later
*Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:288-310.
**Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426-30.

Or not?....
Calling the “6 hour rule” into question
• 1993 Bednar and Parikh…. No significant difference *
– 3.4% vs 9%; 82 open femoral/tibial fxs
• 2004 Ashford et al…. No significant difference **
– 11% vs 17%; pts from the austrailian outback
• 2004 Spencer et al.... No significant difference ***
– 10.1% vs 10.9%; 142 open long bone fxs from UK
• 2003 Pollack and the LEAP investigators…. No correlation****
– 315 open long bone fxs
• 2005 Skaggs et al….No significant difference *****
– children with all types of open fractures; 554 open fractures
*Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities
caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5.
**Ashford RU, Mehta JA, Cripps R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures. Injury. 2004;35:411-6.
***Spencer J, Smith A, Woods D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Ann R
Coll Surg Engl. 2004;86:108-12.
****Pollack AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive treatment significantly influences incidence of infection
after open high-energy lower-extremity trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake City, UT.
*****Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open
Fractures in Children.” JBJS-A 2005. 87:8-12
No significant
difference
before or after 6
hours!!!

Do we even need to do operative
debridement?
• Orcutt et al... No significant difference, BUT…*
– 50 type 1 &2 open fractures
– less infection in nonoperative group (3% vs 6%)
– Less delayed union in nonop group (10% vs 16%)
• Yang et al….0% infections **
– 91 type 1 open fractures treated without I&D
*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the
Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.
**Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat Res
2003. 410: 289-294.
Do we even
need to debride
low grade open
fractures?

However, after review of all literature….….
• Okike et al. states….
• “Thorough operative debridement is the standard
of care for all open fractures.”
• “Even if the benefits of formal I&D were
insignificant for low grade fractures, operative
debridement is still required for proper wound
classification.”
• “Open fractures graded on the basis of superficial
characteristics are often misclassified.”
• Huge risk not to explore and debride!
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006 Dec;88(12):2739-48.

URGENTLY debride, not EMERGENTLY
• Time to OR is probably less important than:*
– Adequacy of debridement
– Time to soft tissue coverage
• Timing depends on….**
– Is patient stable?
– Is the OR prepared?
– Is appropriate assistance available?
• Ortho trained scrub techs, assistant surgeons, xray
techs, and other OR staff
• 2005 Skaggs et al:***
– If after 10pm, keep until the morning! Or at least
within 24 hours.
– Unless….
• neurovasc compromise
• horrible soft tissue contamination
• compartment syndrome
*Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.
**Werner CM, Pierpont Y, Pollak AN: The urgency of surgical débridement in the management of open fractures. J Am Acad Orthop Surg.
2008 Jul;16(7):369-75.
***Stewart DJ, Kay RM, Skaggs DL: Open Fractures in Children. Principles of Evaluation and Management. JBJS-A. 2005;87:2784-2798.
Within
24
hours
Within
6 hours

I&D in the OR
• Trauma scrub
– Soap and saline to remove gross debris
• “Zone of injury”
– Skin wound is the window through which
the true wound communicates with the
exterior
• Extend the traumatic wound
– Excise margins
– Resect muscle and skin to healthy tissue
• color, consistency, capacity to bleed and
contractility

I&D in the OR
• Bone ends are exposed and debrided
• Irrigate
• Serial debridements?
– If needed, 2nd or 3rd debridement after 24-
48 hours should be planned

The Irrigation
• Amount
– No good data, copious is better
– Animal studies show improved
removal of particulate matter
and bacteria but effect plateaus
– Irrigation bags typically contain
3 L of fluid
– Anglen recommends:*
• 3L (one bag) for type 1
• 6L (two bags) for type 2
• 9L (three bags) for type 3
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS 2001. 9: 219-226.

How to deliver the irrigation?
(what animal studies show)
• Bulb Syringe vs Pulsatile Lavage
– Pulsatile lavage
• Detrimental for early bone healing
– this is no longer present at 2 wks*
• More soft tissue destruction**
• More effective in removing
particulate matter and bacteria***
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on
Fracture Healing.” JOT 1998. 12(7): 460-463.
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial
Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.

How to deliver the irrigation?
(what animal studies show)
• High or low pressure?
– Higher pressure
• Better bone cleaning
• Worse soft tissue cleaning
• Slows bone healing
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on
Fracture Healing.” JOT 1998. 12(7): 460-463.
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR 2004. 427: 13-17
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial
Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT 1999. 13: 526-533.

Antibiotics in the irrigation?
• Antibiotics (bacitracin and/or neomycin)
– Mixed results, controversial
– Costly
• bacitracin alone around $500/washout
– ?? Causing resistance
– Wound healing problems?
– Few reported cases of anaphylaxis
– Anglen: “No proven value in the care of open
fracture wounds…some risk, albeit small.”
No proven
benefit!

Soaps in the irrigation?
• Surfactants (i.e. Soaps)
– Less bacteria adhesion
– Emulsify and remove debris
– No significant difference in
infection or bone healing
compared to bacitracin
solution, but more wound
healing problems in
bacitracin group
Anglen JO. “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A Prospective, Randomized
Study.” JBJS-A 2005. 87(7):1415-1422.

Level 4 evidence based recommendations
• 1st washout, highly contaminated
 Soap solution
• Repeat washout of clean wounds
 Saline
• Infected wounds
 Soap, then antibiotic

Wound closure after contaminated fracture
• Timing and technique is
controversial
OPEN WOUND should be left OPEN!
– Prevents anaerobic conditions in
wound: Clostridium
– Facilitates drainage
– Allows repeat debridement
Zalavras CG, Patzakis MJ:Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun;11(3):212-9.
Dubunked!

To close or not to close?
• Recently, renewed interest
in primary closure
• Collinge, OTA 2004
• Moola, OTA 2005
• Russell, OTA 2005
• DeLong, J Trauma 2004/
• Bosse, JAAOS 2002
– Improved abx management
– Better stabilization
– Less morbidity
– Shorter hospital stay, lower
cost
– NO increase in wound
infection
• These wounds are at
higher risk of clostridia
perfringens if they do get
infected.
• 1999 Delong et al: 119 open fxs
– No significant difference
• delayed/nonunion and infection rates btwn
immediate and delayed closure
– Immediate closure is a “viable option”
DeLong WG Jr, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture wounds. J Trauma. 1999
Jun;46(6):1049-54.
infection rate 7%
Overall delayed/nonunion rate 16%
Grade Percent of primary closures
1 88%
2 86%
3a 75%
3b 33%
3c 0%

Contraindications to primary closure
• Inadequate debridement
• Gross contamination
• Farm related or freshwater immersion injuries
• Delay in treatment >12 hours
• Delay in giving abx
• Compromised host or tissue viability

When to cover the wound?
• ASAP after wound adequately debrided
– Only 18% of infections are caused by the same organism
isolated in initial perioperative culture*
• Suggests hospital acquired etiology of infection
• “Fix and Flap”**
– For Type IIIB & IIIC open tibia fractures
– Early if not immediate flap coverage
•Patzakis MJ, Bains RS, Lee J, et al. “Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to
combination antibiotic therapy in open fracture wounds.” JOT 2000. 14: 529-533.
**Gopal S, Majumder S, Batchelor A, Knight S, De Boer P, Smith RM. “Fix and flap: the radical orthopaedic and plastic treatment of severe
open fractures of the tibia.” JBJS-B 2000. 82(7): 959 – 966.
Timing of flap placement Infection rate
< 72 hours 6%
> 72 hours 30%

Dressings
• Temporary closures – rubber bands
• Wet to dry dressings
• Semi-permeable membranes
• Antibiotic bead pouch
• VAC

VAC
• Vacuum assisted wound closure
– Recommended for temporary management
– Mechanically induced negative pressure in a closed
system
– Removes fluid from extravascular space
– Reduced edema
– Improves microcirculation
– Enhances proliferation of reparative granulation tissue
• Open cell polyurethane foam dressing ensures an
even distribution of negative pressure
-Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002 Sep-Oct;10(5):303-11.
-Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in
the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT. 2007

Types of fracture stabilization
• Splint
– Good option if operative
fixation not required
• Internal fixation
– Wound is clean and soft tissue
coverage available
• External fixation
– Dirty wounds or extensive soft
tissue injury

Fracture stabilization
• Gustilo type 1 injury can be treated the same
way as a comparable closed fracture
• Most cases involve surgical fixation
• Outcome is similar to closed counterparts

Fracture stabilization
• Gustilo type 2&3 usually displaced and unstable
– dictate surgical fixation
• Restore length, alignment, rotation and provide
stability
– ideal environment for soft tissue healing and reduces
wound infection
– reduces dead space and hematoma volume
• Inflammatory response dampened
• Exudates and edema is reduced
• Tissue revascularization is encouraged

When to use plates?
• Open diaphyseal fractures of arm & forearm
• Open diaphyseal fractures lower extremity
– NOT recommended
– Open tibial shaft plating assoc high infection rate*
• Open periarticular fractures
– Treatment of choice in both upper and lower
extremities
Bach AW, Hansen ST Jr.: Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin Orthop Relat Res.
1989 Apr;(241):89-94.

When to use IM nails?
• Treatment of choice for most
diaphyseal fractures of the
lower extremity
• Inserted without disrupting
the already injured soft tissue
envelope
• Preserves the remaining extra
osseous blood supply to
cortical bone
• Malunion is uncommon

To ream or not to ream?
• Does reaming cause additional damage to the
endosteal blood supply?
• Solid IM nails without reaming has a lower risk of
infection that tubular nails with a large dead space*
• However reamed IM nails are biomechanically stronger
and can reliably maintain fracture reduction if statically
locked
• 2000 Finkemeier et al.
– reamed vs unreamed interlocked nails of open tibias
– NO statistical difference in outcome and risk of
complication**
*Melcher GA, Claudi B, Schlegel U, Perren SM, Printzen G, Munzinger J.Influence of type of medullary nail on the development of local
infection. An experimental study of solid and slotted nails in rabbits; .J Bone Joint Surg Br. 1994 Nov;76(6):955-9.
**Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM: Locking intramedullary nailing with and without reaming for open fractures
of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am. 1997 Mar;79(3):334-41.
**Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF: A prospective, randomized study of intramedullary nails inserted with
and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma. 2000 Mar-Apr;14(3):187-93.

When to use external fixation?
• Diaphyseal fractures
not amenable to IM
nails
• Ring fixators for
periarticular
fractures
• Temporary joint
spanning ex fix is
popular for knee,
ankle, elbow and
wrist
• If temporary, plan
for conversion to IM
nail within 3 weeks

Ex-fix: Weigh the pros and cons!
• Historically was definitive treatment
• Now, more commonly as temporary fixation
• Can be applied almost always and everywhere
• Severe soft tissue damage and contamination

Advantages
• Easy and quick
• Relatively stable fixation
• No further damage done
• Avoids hardware in the open wound

Disadvantages
• Pin track infections
• Malalignment
• Delayed union
• Poor patient compliance

Skin cover and soft tissue reconstruction
• Do these early!
• 1994 Osterman et al.*
– Retrospective 1085 fractures, 115 G2 and 239 G3
• All treated with appropriate IV Abx and I&D
– No infection if wounds closed at 7.6 days
– Yes infection if wounds closed at 17.9 days
*Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures: A review of 1085 consecutive cases. J Bone Joint
Surg Br 1995;77:93–97.
Infection risk
increases if wound
open > 7 days

Reconstructive ladder: options for wound
coverage
Primary closure
Secondary intention
Skin graft
Local flap
Regional flap
Distant flap
Free flap
Tissue
expansion
Type 1 open fx
Type 3B open
fx
Type 2/3A open fx

Type 3c, a bad injury!
• Devastating damage to
bone and soft tissue
• Major arterial injuries
that require repair
• Poor functional outcome
• Consensus btwn ortho,
vascular and plastics
• Salvage is technically
possible in most cases
• However it is not always
the correct choice esp
type 3c tibia fractures

We can do both, salvage & amputate.
• Vascular surgery can revascularize
with bypass graft
– Generally before fracture stabilization
• Plastics can provide soft tissue
coverage
• However, in the tibia, the severity
to soft tissue envelope and bone
may result in infected nonunion
• If salvage…. long course of
repeated surgical procedures
– Painful and psychologically distressing
– Functional outcome may be poor and
no better than amputation

How to decide, salvage or amputate?
• Important factors in decision making:*
– General condition of the patient (shock)
– Warm ischemia time (>6hours)
– Age (>30 years)
– Cut to crush ratio (blunt injuries has a large zone
of crush)
Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities following combined orthopedic
and vascular trauma. A predictive salvage index. Am Surg. 1987 Apr;53(4):205-8.

Gunshot injuries
• Energy dissipated at impact = damage
severity
• High velocity rifles and close range
shotguns
– Worst, high energy of impact
– Huge secondary cavitation
– Secondary effects of shattered bone
fragments
• Bullets lodged in joints should be removed
– avoid lead arthropathy and systemic lead
poisoning

Low velocity GSW <2000 ft/sec
• Low velocity handguns
– Less severe, not treated like open fractures
– Cavitation is not significant
– Secondary missile effects are minimal
– Bone fragments rarely stripped of soft tissue
attachments and blood supply
– Soft tissue injuries not severe and skin wounds are
small

Low velocity GSW open fractures
• Geisslar et al. *
• If neurovascular status
normal, do local
debridement
• NO formal I&D needed
• IV Abx
• Approach fx fixation as
if closed
• Dickey et al.**
– No abx vs IV Ancef x 3d
– 67 low velocity GSW fxs
– Not requiring operative
fixation
– No difference in
infection rates
*Geisslar ett al, J Ortho Trauma, 4;39-41,1990
**Dickey et al, J Ortho Trauma, 3;6-10,1989
Treat open
fractures from low
velocity GSW as
closed fractures
without Abx

Pitfalls and complications
• Infection  delayed union, nonunion, malunion
and loss of function
• Plan ahead to avoid delayed union and nonunion
• Predict nonunion in severe injuries with bone loss
– Bone grafting usually delayed 6 weeks when soft
tissues have soundly healed
– Autogenous bone grafting is usual strategy
– Fibular transfer, free composite graft or distraction
osteogenesis for complex defects
– Recombinant human BMP in open tibia fracture
reduces risk of delayed union

Advances…
• BMPs
– 40% decreased infection rate with BMP in type 3
open tibia fractures*
• Antibiotic Laden Bone Graft**
– Tobramycin-impregnated calcium sulfate pellets
with demineralized bone matrix
– Animal study: successful in preventing infection
*BESTT Study Group, Govender S, Csimma C, Genant H, Valentin-Opran A. “Recombinant Human Bone Morphogenetic Protein-2 for
Treatment of Open Tibial Fractures: A prospective, controlled, randomized study of four hundred and fifty patients.” JBJS-A 2002.
84(12): 2123-2134.
**Beardmore AA, Brooks DE, Wenke JC, Thomas DB. “Effectiveness of local antibiotic delivery with an osteoinductive and
osteoconductive bone-graft substitute.” JBJS-A 2005. 87(1): 107-112.

Summary
A = good evidence (level 1 studies)
B = fair evidence (level 2/3 studies)
C = poor quality evidence (level 4/5 studies)
I = insufficient or conflicting evidence
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg. 2006 Dec;88(12):2739-48.

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