1) An open fracture involves both a soft-tissue injury and a bone fracture. Immediate management includes radical surgical debridement of the wound, administration of antibiotics, and splinting of the limb. 2) Surgical treatment consists of extensive irrigation, debridement of nonviable tissue, and stabilization of the fracture. The wound is then covered temporarily until later reconstruction if needed. 3) Multiple stages of reconstruction may be required, including bone and soft-tissue procedures, skin grafting or flaps to achieve closure, with the goals of preventing infection, achieving union, and restoring function.

1. AOTrauma Principles CourseRobert Vander Griend, US
Management of open fractures

2. An open fracture is a soft-tissue injury
which also involves the bone

3. The management of open fractures
The assessment of an open injury:
• Immediate management of the open fracture
• Importance of a radical surgical debridement
• Choices for skeletal stabilization
• Choices for soft-tissue closure

4. Open fractures
• Treatment = amputation
• Mortality = 75%
• Function in survivors poor

5. Goals in the treatment of open fractures
• Preservation of viable soft tissues
• Prevent infection
• Achieve fracture union
• Restore function

6. Factors affecting outcome
• Type of injury
- High-energy vs low-energy
• Location and extent of injury(s)
- To the soft tissues
- To the bone
• Degree of contamination
• Health status of the patient
• Initial treatment

7. Management of open fractures
• Accident scene and transport
• Emergency room
• Operating room for emergency procedure
– Treatment of the wound
– Treatment of the bone
• Secondary/tertiary reconstruction
• Rehabilitation

8. Emergency room
Evaluation entire patient
• Injury protocols (ATLS)
Evaluation limb
• Complete evaluation (as possible)
• Wound covered and limb splinted - one look
• Antibiotics
• Tetanus “prophylaxis”
Preoperative planning

9. Antibiotics
• Extent of wound and degree of contamination
• Injury environment
• Practice protocols
- Cephalosporin
- Aminoglycoside or alternative gram negative coverage
- Penicillin (farm/soil/ischemia)

10. Classification: open fractures
• Gustilo and Anderson 1976, 1984
- Open fracture classification
• Tscherne and Oestern 1982
- Open and closed fracture classification
• AO
• OTA

11. Gustilo and Anderson
• Type I Low-energy, minimal soft-tissue damage,
wound < 1cm
• Type II Higher energy, laceration > 1cm minimal
contamination
• Type IIIA High-energy, adequate soft-tissue cover
• Type IIIB High-energy, extensive soft-tissue stripping,
inadequate cover, massive contamination
• Type IIIC Vascular injury requiring repair

12. Interobserver agreement on classification
Brumback et al 1994
• Other factors/variables influence treatment options:
• May underestimate zone of injury
• Inter-observer variability
• Agreement on simple vs complex
Low grade injury High grade injury

13. Stages of surgical treatment—the plan
• Gross decontamination
• Irrigation and debridement
• Stabilization of fracture
• Final inspection wound culture
• Initial wound coverage
• Re-prep and drape between 1, 2, 3

14. Operative treatment: extend the wound
• Zone of injury
• May need atypical incisions
Consider:
• Fracture treatment options
• Soft-tissue coverage and reconstruction options
• Remember—irrigation and debridement is 1st priority

15. Systematic wound debridement
• Remove debris
• Remove nonviable soft tissues
• Layer by layer
• Tourniquet used only if major bleeding
• Experienced surgeon
- Inexperience → under debridement

16. Soft-tissue debridement
• Skin
• Subcutaneous
- Fascia
- Fat
• Muscle viability 4 C’s
- Contractility
- Capacity to bleed
- Color
- Consistency

17. Bone debridement
• Remove avascular, contaminated fragments
• Protect soft-tissue attachments
• Retain key bone fragments
- Articular surface
• Re-evaluate crucial tissues at 2nd debridement

18. Operative treatment: irrigation
• Gravity irrigation
• Minimum six liters

19. Initial fracture stabilization
• Temporary vs definitive
• External vs internal fixation vs combination
• Anatomical site of injury
- Degree of contamination
- Status of the wound and soft tissues
- Other associated injuries and treatment
- Experience of surgeon and surgical team
- Implant availability

20. External fixation
• Soft-tissue management
• Severe contamination
• Extensive bone loss
• Vascular injury
• Unstable
- Dislocation or fracture dislocation
• Complex periarticular fracture
• Polytrauma

21. Goal of external fixation
• Definitive fracture treatment
• Temporary spanning external fixator
- Until soft-tissue stabilization
- Then change to another fixation method
• Early fracture healing
- Then change to another fixation method

22. Intramedullary fixation
Literature
• Supports use in open
shaft fractures
• IM better than external fixator
for definitive treatment
• Timing
• Reamed vs unreamed

23. Plate fixation
• Intraarticular and
metaphyseal fractures
• Upper extremity
(forearm and humerus)
• Femur in ARDS
• Plate techniques
- Standard
- MIPO
- LISS
- Locked
- Periarticular

24. Initial wound management
• Goal: Cover nerves, vessels, tendons, bone
• Avoid: Dead tissues and space, wound tension
• Loose re-approximation of skin flaps
• Antibiotic bead pouch
• VAC dressing
• Biological dressing

25. Antibiotic bead pouch
• Antibiotic-PMMA beads
• Occlusive dressing
• Useful in large wounds
- Dead space control
- High local antibiotic
concentration
- Seal wound from
external contamination

26. VAC Dressing
• Closed system
• Ongoing debridement
• Wound size
• Tissue edema
• Excellent for
staged coverage

27. Biological dressings
• Semipermeable films
• Epigard
• Allograft and enografts

28. Second stage management
• Antibiotics 24–48 hrs
• Repeat debridement 48–72 hrs as needed
• Repeat antibiotics 24–48 hrs with repeat surgery

29. Soft-tissue coverage
• Condition of the wound
• Location
• Size of the defect
• Tissue available
• Other reconstruction
- Bone
- Joints
- Soft-tissues
• Patient factors
- Age and general health
- Smoking
- Associated vascular
disease
• Expertise of surgical team

30. Soft-tissue coverage options
• 1° vs 2° closure
• Skin graft
• Flaps fasciocutaneous muscle pedicle
• Tissue transfer
• Goal: coverage < 5–7 days

31. Early flap coverage
M Godina: Early microsurgical reconstruction of complex
trauma of the extremities; Plast Recon Surg
• < 72 hrs
- Flap failure 1/134
- Infection 2/134 (1.5%)
• 72 hr to 90 days
- Flap failure 20/167
- Infection 29/167 (17%)

32. Staged reconstruction
• Definitive fixation
• Secondary bone procedures
- Bone grafting
- Exchange nailing/fixation
- Bone defect reconstruction
- Joint reconstruction/salvage
• Secondary soft-tissue reconstruction
- Tendon
- Nerve

33. Rehabilitation
• Of the limb
• Of the injury
• Of the patient
• Of the family

34. Summary: open fractures
• Evaluation of patient and injury
• Initial debridement
• Soft-tissue management
• Fracture stabilization
• Early soft-tissue closure/coverage
• Bone and soft-tissue reconstruction PRN
• Rehabilitation