Open fractures are unique, complex, and emergently presenting injuries that expose sterile bone to the contaminated environment. Because a fracture disrupts the intramedullary blood supply, the additionally stripped soft tissue envelope further devitalizes the bone. The more severe the soft tissue injury or open wound, the more severe the osseous injury. Historically, open fractures were associated with infection, delayed union, nonunion, amputation, or death.

1. Open fractures
Mohamed Abulsoud (M.D)
Lecturer of orthopedic surgery
Faculty of medicine – Al-Azhar university
Cairo- Egypt

2. Introduction
• Open fractures are unique, complex, and
emergently presenting injuries that expose sterile
bone to the contaminated environment.
• Because a fracture disrupts the intramedullary
blood supply, the additionally stripped soft tissue
envelope further devitalizes the bone.
• The more severe the soft tissue injury or open
wound, the more severe the osseous injury.
• Historically, open fractures were associated with
infection, delayed union, nonunion, amputation,
or death.

3. • open fracture is defined as an injury where
the fracture and the fracture hematoma
communicate with the external environment
through a traumatic defect in the surrounding
soft tissues and overlying skin.
Definition

4. 11.5 / 100,000 persons per year.
Incidence

5. Evolution

6. • in-to-out fractures : axial load , torsion or
bending moment
• Out to in fractures : Direct Blow, Crush Injury,
Explosion and Blast Injury .
Mechanism of injury

7. Four components characterize the injury:
• Fracture.
• soft-tissue damage.
• neurovascular compromise.
• contamination.
Mechanism of injury

8. • The primary blast wave is caused
by the direct effect of the blast
wave on the body.
The effect depends on distance.
The most lethal injury
• The secondary blast injury occurs
from the casualty of being struck
by fragments from the explosive
device or by secondary missiles
being energized by the blast.
• The tertiary blast injury occurs
when the victim is thrown against
the ground or solid objects
Mechanism of injury

9. Bacteriology
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

10. Coagulase negative Staphylococci (COST)

11. • open injury is not just a simple combination of a
fracture and a wound.
• The size and nature of the external wound may
not reflect the damage to the deeper structures.
• The presence of an open wound does not
preclude the occurrence of a compartment
syndrome in the injured limb.
• the extent of injury to the soft tissues and bone
may not be fully exposed on day 1 and the actual
“zone of injury” may be revealed only over the
next few days.
Considerations

13. • 1. history and mechanism of injury;
• 2. vascular and neurological status of the extremity;
• 3. size of the skin wound;
• 4. muscle crush or loss;
• 5. periosteal stripping or bone necrosis;
• 6. fracture pattern, fragmentation, and/or bone loss;
• 7. contamination;
• 8. compartment syndrome.
• 9. Documentation (photo)
• 10.Cirumferential examination(Don’t forget the back)
Clinical evaluation

14. Signs of Vascular Injury
Hard Signs
• Absent or significant difference in
pulsations compared to normal side.
• Severe hemorrhage from the wound.
• Expanding and pulsatile hematoma.
• Bruit or thrill.
Associated Signs
• Associated numbness and neurologic
deficit.
• Difference in skin temperature distal
to injury.
• Absence of venous filling.
• Absence of pulse-oximeter reading.
No capillary blanching

15. Emergency room treatment
• Sterile dressing
• Support (resuscitation)
• Analgesics
• Second generation cephalosporin
• Splint
• Scan
• Snap

16. Radiographic evaluation

17. IM NAIL TIBIA GRADE I GRADE II GRADE
IIIA
GRADE
IIIB
Fracture
HEALING
21-28
WKS
26-28 WKS 30-35 WKS 30-35
WKS
Amputation 50%
Classification

19. Limitations of Gustilo classification
• Includes wide spectrum of injuries in Type IIIB
injuries.
• Mainly depends on size of the skin wound.
• Does not evaluate the severity of injury to skin,
bone and musculotendinous units separately.
• Does not address the question of salvage.
• Poor interobserver reliability (60%).
Classification

21. • IO 1
AO Classification
Skin breakage from inside out

22. • IO 2
AO Classification
Skin breakage from outside in < 5 cm, contused edges

23. • IO 3
AO Classification
Skin breakage from outside in > 5 cm, increased contusion, devitalized edges

24. • IO 4
AO Classification
Considerable, full-thickness contusion, abrasion, extensive open degloving, skin loss

25. • IO 5
AO Classification
Extensive degloving

26. • IC 1
AO Classification
No evident skin lesion

27. • IC 2
AO Classification
No skin laceration, but contusion

28. • IC 3
AO Classification
Circumscribed degloving

29. • IC 4
AO Classification
Extensive, closed degloving

30. IC 5
AO Classification
Necrosis from contusion

31. AO Classification

32. AO Classification

33. AO Classification

34. 7 or more = Amputation
Mangled Extremity Severity Score
(MESS)

35. 14 or below are advised salvage.
• 17 and above usually end up in
amputation.
• 15 and 16 fall into Grey zone where
decision is made on patient to patient
basis.
Ganga hospital injury severity score
(GHOIS)

36. Goals of treatment
• prevention of infection.
• fracture stabilization.
• soft-tissue coverage.
Treatment

37. prevention of infection
Give antibiotics as soon as possible (within 3 hours).
• Agent of choice co-amoxiclav (1.2 g 8 hourly), or a
cephalosporin (e.g., cefuroxime 1.5 g 8 hourly),
continued until first debridement (excision).
• At the time of first debridement, co-amoxiclav
(1.2 g) or a cephalosporin (such as cefuroxime 1.5 g)
and gentamicin (1.5 mg/kg) should be administered
and co-amoxiclav/cephalosporin continued until
soft tissue closure or for a maximum of 72 hours,
whichever is sooner.

38. • Gentamicin 1.5 mg/kg and either vancomycin 1 g or
teicoplanin 800 mg should be administered on induction of
anesthesia at the time of skeletal stabilization and definitive
soft tissue closure. These should not be continued
postoperatively.
Ideally start the vancomycin infusion at least 90 minutes
before surgery.
• True penicillin allergy (anaphylaxis) clindamycin (600 mg IV
pre-op/qds) in place of co-amoxiclav/cephalosporin. Lesser
allergic reaction to penicillin (rash, etc.) a cephalosporin is
considered to be safe and is the agent of choice.
prevention of infection

39. Evidence Does Not Support
• Prolonged and continuous use of antibiotics.
• Continuing antibiotics as long as the drains are in.
• Continuation of the empirical antibiotic regime till
wound drainage is present.
• Prophylactic antibiotics to prevent pin tract
infections.
• Antibiotic therapy as a substitute for debridement
in presence of necrotic and contaminated material.
prevention of infection

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

41. Local Factors
• Organic, farm yard, or sewage contamination.
• Poor debridement with retention of foreign debris and nonviable
tissues.
• Inadequate skeletal stabilization.
• Presence of dead space.
• Debridement later than 24 hours.
Systemic Factors
• Presence of shock and ARDS
• Comorbid factors like age above 65 years, metabolic disorders
like diabetes mellitus, history of smoking.
• Compartment syndrome and hypovascular tissues.
• Prolonged hospital stay and exposure to resistant organisms.
• Poor nutrition.
prevention of infection

42. Indications of emergency
(a) Gross contamination of the wound
(b) Compartment syndrome
(c) A devascularized limb
(d) A multiply injured patient.
• The patient should not be taken to the operating room
until medically stabilized
• If possible, the patient should be taken to the operating
room within 24 hours of injury
Surgical treatment

43. Debridement: Principles
• Must be performed by an experienced team
and as early as possible.
• Orthoplastic approach with involvement of
plastic surgeons even at the time of index
surgery.
• Pre-debridement photographs are taken in
different angles.
Surgical treatment

44. Skin and Fascia
• Wounds must be longitudinally
extended to provide adequate
visualization of deeper structures.
• Margins must be trimmed to
bleeding dermis to create a clean
wound edge.
• Gentle handling of the skin and
prevention of degloving are
essential.
• All avascular fascia must be
excised.
Surgical treatment

45. Muscles
• • All muscles in the compartment must be
evaluated for viability
• (“4 C” Color, Consistency, Contractility,
Capacity to bleed) and debrided.
Surgical treatment

46. Bone
• Bone ends and medullary cavity must be
carefully examined for impregnated paint, mud,
and organic material.
• All fragments without soft tissue attachment
must be excised.
Surgical treatment

47. Lavage
Evidence Supports
• Adequate quantity of fluid must be used for
lavage. Typically
at least 9 L of fluid are used for Type Ill B fractures.
• Lavage clears blood clot, nonviable tissues and
debris from tissue planes and dead spaces.
• Lavage reduces bacterial population.
• No advantage in adding antiseptic solutions or
antibiotics to lavage fluid.
Surgical treatment

48. • Use of hydrogen peroxide,
alcohol solution, povidone iodine,
and other chemical agents may
impair osteoblast function,
inhibit wound healing and cause
cartilage damage.
• Low-pressure pulsatile lavage is
equally effective as high pressure
pulsatile lavage and has less
harmful effects on tissues.
Surgical treatment

49. fracture stabilization
• Splint
– Good option if operative fixation
not required
• infection rate of >15% and a
malunion rate of up to 70% in
tibial fractures (Puno et al
1988)
• Internal fixation
– Wound is clean and soft tissue
coverage available
• External fixation
– Dirty wounds or extensive soft
tissue injury

50. 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

51. 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

52. 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
– (Bach AW, Hansen ST Jr. 1989).
– DCO in selected cases
• Open periarticular fractures
– Treatment of choice in both upper and lower
extremities
– Wound closure within 72 hours

53. 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

54. To ream or not to ream?
• Solid IM nails without reaming has a lower risk of
infection that tubular nails with a large dead space
• 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
• 2008 Bhandari et el
No difference in patients with open fractures

55. 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

56. External fixation
• Historically was definitive treatment
• Now, more commonly as temporary fixation
• Can be applied almost always and everywhere
• Severe soft tissue damage and contamination

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

58. Disadvantages
• Pin track infections
• Mal alignment
• Delayed union
• Poor patient compliance
External fixation

59. Need for Second Look Debridement
• High-energy blast injuries
• Severe contamination, farmyard, and sewage
contamination
• Delayed presentation >12 hours
• Evidence of infection during debridement
• Initial debridement considered unsatisfactory
Surgical treatment

60. Completion
• Deflate tourniquet and evaluate viability of all retained
structures.
• Assess loss of tissues and document with photograph for
future reference and planning.
• Decide on method and timing of wound closure or coverage
and bone stabilization.
• Document sequence of reconstruction.
• In very severe tissue loss VAC may be used as a bridging
procedure till the patient is fit for flap cover.
Surgical treatment

61. 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%

62. Primary closure
Contraindications
• Type IIIC injuries.
• Ganga Hospital skin score of 3 or more and a total score
of >10.
• Wounds in patients with severe polytrauma involving
and an injury severity score >25.
• Sewage or organic contamination/farmyard injuries.
• Peripheral vascular diseases/thromboangiitis obliterans.
• Drug-dependent diabetes mellitus/connective tissue
disorders/peripheral vasculitis.

63. Skin cover and soft tissue reconstruction
• Do these early!
• 1994 Osterman et al.
• 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

64. 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

65. The V.A.C. method is not a substitute
for adequate wound debridement
Contraindications
• Presence of necrotic skin with eschar.
• Untreated osteomyelitis
• Exposed neurovascular bundle.
• Exposed vascular anastomosis
VAC

66. VAC

68. Definitive Limb Reconstructive
Pathways
• “Fix and close” protocol
• “Fix, bone graft and close” protocol.
• “Fix and flap” protocol
• “Fix and delayed flap” protocol
• “Stabilize, observe, assess and reconstruct”
protocol
Rajasekaran S, Sabapathy SR. A philosophy of care of open injuries based on the Ganga hospital score. Injury. 2007;38:137–146.

70. 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

71. 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.

73. Summary and recommendations
• Prompt intravenous antibiotics should be given at
the time of initial presentation to treat wound
contamination in most open fractures
• Tetanus toxoid should be given if indicated, based
on patient’s immunization history
• Initial wound management should include a sterile
dressing moistened with normal saline and
temporary skeletal stabilization

74. • The timing of irrigation and debridement is not as
important as the prompt administration of antibiotics
but should occur within 24 hours of injury
• The wound should be irrigated with normal saline
• Additives have not demonstrated clear benefit and
have additional risks to host tissue
• Pulsed lavage should not exceed 50 psi (345kPa)
Summary and recommendations

75. • There is insufficient data to make a
recommendation for an antibiotic bead pouch over
negative pressure wound therapy
• Both V.A.C. therapy and antibiotic beads are
adjunctive modalities in the management of open
wounds associated with fractures
• The V.A.C. method is not a substitute for adequate
wound debridement
Summary and recommendations

76. • There is a current trend toward coverage or closure
of open fracture wounds within 5–7 days
• Exceptions to early coverage include concern for
anaerobic infection or incomplete debridement of
nonviable tissue
• Type IIIB and IIIC defects should be managed in a
concerted effort by subspecialist teams
Summary and recommendations