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Introduction ⬇

  • An open fracture refers to osseous disruption in which a break in the skin and underlying soft tissue communicates directly with the fracture and its hematoma.
    • The term compound fracture refers to the same injury but is archaic.
  • One-third of patients with open fractures are multiply injured.
  • Any wound occurring on the same limb segment as a fracture must be suspected to be a consequence of an open fracture until proven otherwise.
  • Soft tissue injuries in an open fracture may have three important consequences:
    • Contamination of the wound and fracture by exposure to the external environment
    • Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection
    • Destruction or loss of the soft tissue envelope may affect the method of fracture immobilization; compromise the contribution of the overlying soft tissues to fracture healing (e.g., contribution of osteoprogenitor cells); and result in loss of function from muscle, tendon, nerve, vascular, ligament, or skin damage.

Mechanism of Injury ⬆ ⬇

  • Open fractures result from the application of a violent force. The applied kinetic energy () is dissipated by the soft tissue and osseous structures (Table 3.1).
  • The amount of bony displacement and comminution is suggestive of the degree of soft tissue injury and is proportional to the applied force.

Evaluation ⬆ ⬇

Clinical Evaluation

  1. Patient assessment involves Advanced Trauma Life Support (ATLS), which includes a primary survey (airway, breathing, circulation, disability, and exposure [ABCDE]), secondary survey (history, complete physical, x-rays obtained), and tertiary survey (careful examination in serial assessments).
  2. Initiate resuscitation and address life-threatening injuries.
  3. Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
  4. Identify all injuries to the extremities.
  5. Assess the neurovascular status of injured limb(s).
  6. Assess skin and soft tissue damage: Exploration of the wound in the emergency setting is not indicated if operative intervention is planned because it risks further contamination with limited capacity to provide useful information and may precipitate further hemorrhage.
    • Obvious foreign bodies that are easily accessible may be removed in the emergency room under sterile conditions.
    • Irrigation of wounds with sterile normal saline may be performed in the emergency room if a significant surgical delay is expected.
    • Computed tomography (CT) scan has been shown to be a better modality to assess traumatic arthrotomy. Air on CT in the presence of an open wound is diagnostic for traumatic arthrotomy.
  7. Identify skeletal injury; obtain necessary radiographs.

Compartment Syndrome

  • An open fracture does not preclude the development of compartment syndrome, particularly with severe blunt trauma or crush injuries.
  • Severe pain, decreased sensation, pain to passive stretch of fingers or toes, and a tense extremity are all clues to the diagnosis. A strong suspicion or an unconscious patient in the appropriate clinical setting warrants monitoring of compartment pressures.
  • Compartment pressures >30 mm Hg raise concern and within 30 mm Hg of the diastolic blood pressure (ΔP) indicate compartment syndrome; immediate fasciotomies should be performed.
  • Distal pulses may remain present long after muscle and nerve ischemia and damage are irreversible.

Vascular Injury

  • Ankle brachial indices (ABIs) should be obtained if signs of vascular compromise exist.
    • Obtained by measuring diastolic pressure at the ankle and arm
    • Normal ratio is >0.9.
  • A vascular consultation and an angiogram should be obtained if a vascular injury is suspected.
  • Indications for angiogram include the following:
    • Knee dislocation with ABI <0.9 following reduction
    • Cool, pale foot with poor distal capillary refill
    • High-energy injury in an area of compromise (e.g., trifurcation of the popliteal artery)
    • Documented ABI <0.9 associated with any lower extremity injury (Note: Preexisting peripheral vascular disease may result in abnormal ABIs; comparison with the contralateral extremity may reveal underlying vascular disease.)

Radiographic Evaluation

  • Extremity radiographs are obtained as indicated by clinical setting, injury pattern, and patient complaints. Every attempt should be made to obtain at least two views of the extremity at 90 degrees to one another. It is important to include the joint above and below an apparent limb injury.
  • Additional studies may include a CT if there is intra-articular involvement.

Classification ⬆ ⬇

Gustilo and Anderson (Open Fractures) (Tables 3.2 and 3.3)

  • This was originally designed to classify soft tissue injuries associated with open tibial shaft fractures and was later extended to include all open fractures. Although description includes size of skin wound, the subcutaneous soft tissue injury that is directly related to the energy imparted to the extremity is of more significance. For this reason, final typing of the wound is reserved until after operative debridement.
  • It is quantitative, rather than qualitative, and useful for communicative purposes despite variability in interobserver reproducibility.
    • Type I: Clean skin opening of <1 cm, usually a “poke hole,” usually from inside to outside; minimal muscle contusion; low-energy simple spiral or short oblique fractures
    • Type II: Laceration >1 cm long, with more extensive soft tissue damage; minimal-to-moderate crushing component; simple transverse or short oblique fractures with minimal comminution
    • Type III: Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-energy injury with a severe crushing component
    • IIIA: Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries, minimal periosteal stripping
    • IIIB: Extensive soft tissue injury with periosteal stripping and bone exposure requiring soft tissue flap closure; usually associated with massive contamination
    • IIIC: Vascular injury requiring repair

Tscherne Classification of Open Fractures

  • This takes into account wound size, level of contamination, and fracture mechanism.
    • Grade I: Small puncture wound without associated contusion, negligible bacterial contamination, low-energy mechanism of fracture
    • Grade II: Small laceration, skin and soft tissue contusions, moderate bacterial contamination, variable mechanisms of injury
    • Grade III: Large laceration with heavy bacterial contamination, extensive soft tissue damage, with frequent associated arterial or neural injury
    • Grade IV: Incomplete or complete amputation with variable prognosis based on location and nature of injury (e.g., cleanly amputated middle phalanx vs. crushed leg at the proximal femoral level)

Tscherne Classification of Closed Fractures

  • This classifies soft tissue injury in closed fractures and takes into account indirect versus direct injury mechanisms.
    • Grade 0: Injury from indirect forces with negligible soft tissue damage
    • Grade I: Closed fracture caused by low-to-moderate energy mechanisms, with superficial abrasions or contusions of soft tissues overlying the fracture
    • Grade II: Closed fracture with significant muscle contusion, with possible deep, contaminated skin abrasions associated with moderate-to-severe energy mechanisms and skeletal injury; high risk for compartment syndrome
    • Grade III: Extensive crushing of soft tissues, with subcutaneous degloving or avulsion, and arterial disruption or established compartment syndrome

Treatment ⬆ ⬇

Emergency Room Management

After initial trauma survey (ATLS) and resuscitation for life-threatening injuries (see Chapter 2):

  • Perform a careful clinical and radiographic evaluation as outlined earlier.
  • Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clamping.
  • Initiate parenteral antibiotic (see the following discussion).
  • Assess skin and soft tissue damage; place a moist sterile dressing on the wound.
  • Perform provisional reduction of fracture and place in a splint, brace, or traction.
  • Operative intervention: Open fractures constitute orthopaedic urgencies. The optimal timing of surgical intervention is unclear from the literature. The only intervention that has been shown to diminish the incidence of infection in these cases is the early administration of intravenous antibiotics. There is growing evidence that open fractures in the absence of a non–limb-threatening injury (vascular compromise, compartment syndrome) can be delayed up until 24 hours. The patient should undergo formal wound exploration, irrigation, and debridement before definitive fracture fixation, with the understanding that the wound may require multiple debridements.

Important

  • Do not irrigate, debride, or probe the wound in the emergency room if immediate operative intervention is planned because this may further contaminate the tissues and force debris deeper into the wound. If a significant surgical delay (>24 hours) is anticipated, gentle irrigation with normal saline may be performed. Only obvious foreign bodies that are easily accessible should be removed.
  • Bone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may be.

Antibiotic Coverage for Open Fractures

  • Types I and II: First-generation cephalosporin
  • Type III: Add an aminoglycoside.
  • Farm injuries: Add penicillin and an aminoglycoside.
  • Tetanus prophylaxis should also be given in the emergency department (Table 3.4). The current dose of toxoid is 0.5 mL regardless of age; for immune globulin, the dose is 75 U for patients <5 years of age, 125 U for those 5 to 10 years old, and 250 U for those >10 years old. Both shots are administered intramuscularly, each from a different syringe and into a different site.

Operative Treatment

Irrigation and Debridement

Adequate irrigation and debridement are the most important steps in open fracture treatment:

  • The wound should be extended proximally and distally in line with the extremity to examine the zone of injury.
  • The clinical utility of intraoperative cultures has been highly debated and remains controversial. Cultures at the initial debridement are not currently recommended.
  • Meticulous debridement should be performed, starting with the skin subcutaneous fat and muscle (Table 3.5).
    • Large skin flaps should not be developed because this further devitalizes tissues that receive vascular contributions from vessels arising vertically from fascial attachments.
    • A traumatic skin flap with a base-to-length ratio of 1:2 will frequently have a devitalized tip, particularly if it is distally based.
    • Tendons, unless severely damaged or contaminated, should be preserved.
    • Osseous fragments devoid of soft tissue may be discarded.
  • Extension into adjacent joints mandates exploration, irrigation, and debridement.
  • The fracture surfaces should be exposed fully by recreation of the injury mechanism.
  • Lavage irrigation should be performed. Some authors favor pulsatile lavage. There is growing evidence that low-flow, high-volume irrigation may produce less damage to the surrounding tissues with the same effect. This method may decrease reoperation rates, specifically by reducing infection rates and, nonunion rates and minimizing wound healing issues. The addition of antibiotic to the solution has not been shown to be efficacious.
  • Meticulous hemostasis should be maintained because blood loss may already be significant and the generation of clot may contribute to dead space and nonviable tissue.
  • Fasciotomy should be considered if concern for compartment syndrome exists, especially in the obtunded patient.
  • Historically, it has been advocated that traumatic wounds should not be closed. One should close the surgically extended part of the wound only. More recently, most centers have been closing the traumatic open wound over a drain or vacuum-assisted closure (VAC) system (Fig. 3.1) after debridement with close observation for signs or symptoms of sepsis.
  • If left open, the wound should be dressed with saline-soaked gauze, synthetic dressing, a VAC sponge, or an antibiotic bead pouch.
  • Serial debridement(s) should be performed every 24 to 48 hours as necessary until there is no evidence of necrotic soft tissue or bone. Definitive delayed primary or secondary wound closure should follow.

Foreign Bodies

Foreign bodies, both organic and inorganic ones, must be sought and removed because they can lead to significant morbidity if they are left in the wound. (Note: Gunshot injuries are discussed separately.)

  • Road tar and oil may require special attention. Emulsions such as bisacodyl may be helpful to remove foreign bodies during debridement.
  • The foreign material itself usually incites an inflammatory response, whereas intrinsic crevices may harbor pathogenic organisms or spores.

Fracture Stabilization

  • In open fractures with extensive soft tissue injury, fracture stabilization (internal or external fixation, intramedullary [IM] nails) provides protection from additional soft tissue injury, maximum access for wound management, and maximum limb and patient mobilization (see individual chapters for specific fracture management).

Soft Tissue Coverage and Bone Grafting

  • Wound coverage is performed once there is no further evidence of necrosis.
  • The type of coverage—delayed primary closure, split-thickness skin graft, rotational or free muscle flaps—is dependent on the severity and location of the soft tissue injury.
  • Bone grafting can be performed when the wound is clean, closed, and dry. The timing of bone grafting after free flap coverage is controversial. Some advocate bone grafting at the time of coverage; others wait until the flap has healed (normally 6 weeks).

Limb Salvage

  • Choice of limb salvage versus amputation in Gustilo grade III injuries is controversial. Immediate or early amputation may be indicated if:
    • The limb is nonviable: irreparable vascular injury, warm ischemia time >8 hours, or severe crush with minimal remaining viable tissue.
    • Even after revascularization, the limb remains so severely damaged that function will be less satisfactory than that afforded by a prosthesis.
    • The severely damaged limb may constitute a threat to the patient’s life, especially in patients with severe, debilitating, chronic disease.
    • The severity of the injury would demand multiple operative procedures and prolonged reconstruction time that is incompatible with the personal, sociologic, and economic consequences the patient is willing to withstand.
    • The patient presents with an injury severity score (ISS; see Chapter 2) of >20 in whom salvage of a marginal extremity may result in a high metabolic cost or large necrotic/inflammatory load that could precipitate pulmonary or multiple organ failure.
  • Many of the predictive scores such as the mangled extremity severity score (MESS) have been shown to be poor predictors of successful limb salvage.

Complications ⬆

  • Infection: Open fractures may result in cellulitis or osteomyelitis, despite aggressive, serial debridements, copious lavage, appropriate antibiotic, and meticulous wound care. Certain anatomic areas may be more prone to infection than others. The tibia is more affected by soft tissue stripping at the fracture site than a forearm injury due to relative soft tissue coverage of each. Gross contamination at the time of injury is causative, although retained foreign bodies, amount of soft tissue compromise (wound type), nutritional status, and multisystem injury are risk factors for infection.
  • Compartment syndrome: This devastating complication results in severe loss of function, most commonly in the forearm, foot, and leg. It may be avoided by a high index of suspicion with serial neurovascular examinations accompanied by compartment pressure monitoring, prompt recognition of impending compartment syndrome, and fascial release at the time of surgery.