Open fractures are fractures where hematoma is in communication with external environment. An open fracture may have a wound size ranging from a pin prick to complete baring of the bone. Open fractures have been further classified according to their severity and helps the treating doctor to plan the treatment and measure the prognosis.
Open fractures are associated with higher risk of infection, bone loss, neurovascular injury and union problems.
An open fracture may involve a very small wound caused by a sharp bone spike to tissue crushing and devitalization. Direct inoculation of the tissue is a basic issue in the pathophysiology of open fracture management.
Open fractures are a serious injuriesto deal despite the advances made in fracture care and the prevention of and management of infection.
In the past, open fractures had been associated with loss of life or limb. But the outcome is better now a days because with the advances in fracture care, most of the effort in managing open fractures has been devoted to the preservation of function.
Routine x-rays suffice in most cases. In children, comparison views of the contralateral extremity or joint may be taken.
Computed tomography and magnetic resonance imaging provide further detail of bone and soft tissue injury and are most useful in the management of complex periarticular injuries.
Classification of Open Fractures
Open fracture is the fracture in which there is an associated wound over or near fracture site and that communicates with fracture hematoma.
Classification of open fractures aims to put them into increasing grades of severity. Open fracture in general takes longer time to unite than closed fractures
There are many classifications of open fractures but most followed has been that of Gustilo. It was later modified by Anderson and the classification now used is thus Gustilo Anderson.
This classification is as follows
- Wound less than 1 cm with minimal soft tissue injury
- Wound bed is clean
- Fracture is usually a simple transverse, short oblique fracture, with minimal comminution
- Wound is greater than 1 cm with moderate soft tissue injury
- Fracture is usually a simple transverse, short oblique fracture, with minimal comminution
Fractures that involve extensive damage to the soft tissues, including muscle, skin and neurovascular structures. It is often accompanied by a high velocity injury or a severe crushing component.
Special patterns classified as Type III:
- Segmental Open fracture, irrespective of the size of the wound
- Gunshot wounds high velocity and short-range shotgun injuries
- Open fracture with neurovascular injury
- Farm injuries, with soil contamination, irrespective of the size of the wound.
- Traumatic amputations
- Open fractures over 8 hours old
- Mass casualties, e.g. war and tornado victims
Adequate soft tissue coverage despite soft tissue laceration or flaps or high energy trauma irrespective of the size of the wound. This includes segmental fractures or severely conminuted fractures.
Extensive soft tissue lost with periosteal stripping and bony exposure. This is usually associated with massive contamination.
Fracture in which there is a major arterial injury requiring repair for limb salvage
A fracture classification helps to plan the treatment and indicates the severity of injury without much description
It is important to note that the severity of the injury may not be fully appreciated at the time of initial evaluation, and therefore, classification should be based on the intraoperative findings.
Treatment of Open Fractures
Many open fractures are associated with motor vehicle accidents, gunshot wounds, falls and other major trauma. Consequently, an examination that includes neurologic status, head, spine, abdomen, and pelvis is completed before stating treatment of the open fracture. The wound is covered by a dry sterile dressing and the extremity is splinted. Tetanus is updates or tetanus immunoglobin is given if immunization status is uncertain. Antibiotics are started.
The primary goals of the treatment are to prevent infection of the wound and fracture site, while allowing soft tissue healing, fracture union, and eventual return of optimal function.
Union, restoration of anatomy and early return of normal function is the aim of open fracture management.
Infection is a major risk and the single most important cause of permanent disability in open fractures. Infection should be prevented and is major objective of the treatment in open fractures.
Infection contributes to scarring and to loss of function of the soft tissue envelope, to stiffness of joints, to deformity, and to delayed union and nonunion.
Treatment of open fractures is influenced by
- Age and general condition
- Presence of other injuries
- Severity of the injury
- Time elapsed between injury and definitive treatment
- Vascular injuries.
Acute field care of open fracture involves application of a sterile Betadine dressing, and preliminary alignment, and splinting of the fracture for patient transport. Compression bandage is applied in cases with bleeding.
In emergency room wound is thoroughly inspected. Tetanus prophylaxis is provided, and the initial dose of intravenous antibiotics is given.
Open fracture wounds can then be dressed with sterile, moist gauze, and clinical realignment of the limb can be accomplished with a temporary splint or traction. Patients who are appropriate for operative management should be urgently brought to the operating room.
First cardinal rule is to avoid further soft tissue injury. This is achieved by
- Fractures reduction immediately to alleviate pressure on the injured ischemic soft tissues.
- Cleaning of wound and sterile dressing
- Splinting the part and rapid transport to hospital
- Limiting contamination by maintaining sterility
- IV antibiotics
Initial Care in the Hospital
The detailed examination would reveal if limb could be salvaged [esp in presence of vascular injury]
For non-salvageable limbs, amputation is considered.
For salvageable limbs, the wound is cleaned, debrided and fracture is fixed .
Cleaning and Debriding
Debridement is a surgical procedure which is done under anesthesia. Preferably, cleaning should be done in that anesthesia only.
Simple soap or svalon solution is used to clean the wound. The wound should be thoroughly irrigated with as mush as 10 liters of saline solution or ringer lactate.Liters of normal saline are used to clean fractures of long bones. All foreign material must be removed, including the wadding from gunshot wounds and pieces of clothing driven inward by the force of injury. Necrotic muscle and devitalized bone are excised from the wound.
Next is debridement.
The four Cs—color, contractility, consistency, and capacity to bleed—help the surgeon to decide which muscles to debride. Pale muscle that does not (1) bleed when cut or (2) contract when touched should be excised.
Tissues that are poorly perfused or devitalized offer the best medium for bacterial proliferation.
Debridement involves the removal of all contamination and the meticulous excision of all devitalized tissue.
Severity of the wound would dictate extent of the debridement.
Any tight compartments must be decompressed and the muscle viability assessed by bleeding, contractility, and color.
Anything that appears not viable should be debrided.
High-velocity gunshot wound or close-range shotgun wounds result in more disruption and destruction of soft tissue due to the high energy involved. Multiple debridements may be required to ensure that no nonviable tissue is left behind as a focus of infection. Low-velocity wounds may require only local irrigation, debridement of the entry and exit wounds, and supportive oral antibiotic treatment.
Closure may be accomplished if no necrotic tissue or contamination is present. Local muscle flaps or vascularized free-tissue transfers may be required for larger soft-tissue defects. The flap may provided the additional benefit of improved circulation on the area, which assists healing of the fracture site and protects against infection with increased oxygen tension.
Bony fragments which are not attached to soft tissue need to be removed. A large fragment, especially articular should be preserved though if possible.
A stabilized fracture offers better healing due to following advantages.
- Decreases dead space [created by fragment mobility]
- Controls bleeding
- Decreases local irritation
- Improves the blood supply to the tissues,
- Facilitates wound care
- Facilitates soft tissue envelope reconstruction
- Decreases infection
- Encourages faster rehabilitation and leads to better function.
Immobilization in open fractures is done by external fixation or less commonly, internal fixation in selected cases. For example, in open epiphyseal injuries and intra-articular injuries, internal fixation is preferred.
Plaster immobilization had been done in the past but is considered inferior method and not preferred unless patient is not fit to be operated upon.
Plaster is occlusive and adequate care cannot be provided through the window in the plaster.
Removal of the plaster for proper wound care leads to loss of reduction and thus, repeated soft tissue injury. Plaster immobilization is associated with higher rate of infection and bone nonunion. Moreover, immobilization of adjacent joints leads to joint stiffness and poor function.
There are various external fixation devices available for fracture fixation. They usually serve as temporary fixation. Definitive fixation is done after wound has healed.
Internal fixation devices also vary with type of fracture and site of fracture.
Further Wound Care
After the initial debridement and stabilization, the wound of the injury must always be left open. Part of the surgical incision that was made as an extension of the wound to permit thorough debridement can be closed as long as the edges can be brought together without any tension.
The wound is then dressed with sterile gauze packs. Some authors prefer using antibiotic impregnated methyl methacrylate beads and then covering the wound with an adherent plastic drape. This technique captures the oozing exudates and turns into concentrated antibiotic solution.
With either technique, serial debridements are undertaken as part of wound care till all dead tissue is removed.
Any skin and soft tissue procedure required for coverage is undertaken now. This could be simple secondary closure, simple skin grafting or free flap reconstruction.
Further Fracture Care
After wound healing, the further course depends on the choice of implant.
If external fixator is to be continued , the fracture site is bone grafted now.
In fractures treated by plating or nailing, the indications for bone grafting depend on the severity of the soft tissue wound and the fracture morphology.
If the wound was such that either a rotation myofascial flap or a free muscle flap was necessary, the bone graft is carried out after 5–7 weeks, once a stable soft tissue envelope is secure.
Open Joint Injuries
Anatomic reduction, stable fixation of the articular fracture and its metaphyseal component is mainstay of treatment of joint injuries. Therefore open reduction and stable internal fixation si the treatment of choice, even in the open joint injuries.
The initial care and other principles remain same.
Emergency care, the initial assessment, and the debridement are the same.
At the time of the initial surgery, anatomical reduction of the articular surfaces and their stabilization with the minimum of internal fixation should be done, possibly with lag screws.
The lag screws are supplemented by an external fixation.
Metaphyseal component is not treated at this time to avoid the quantum of implant due to risk of sepsis.
The definitive reconstruction of the metaphyseal defect is undertaken 4-6 weeks later when a stable and healthy soft cover has been achieved.
A buttress or a bridge plate is used for this fixation and any defect if present is packed with autogenous cancellous bone.
If plating cannot be carried out, the external fixation is left on and the metaphysis is bone grafted.
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