Acute Management of Open Fractures: An Evidence-Based Review

Acute Management of Open Fractures :
An Evidence-Based Review
Mohamad J. Halawi, MD; Michael P. Morwood, MD
Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North
Carolina.
NOVEMBER 2015 | VOLUME 38 • NUMBER 11

Background
 Open fractures are often the result of high-energy trauma and can lead to
significant long-term morbidity and disability.1
 An open fracture is defined as one with an associated break in the skin that is
capable of communicating with the fracture and/or its hematoma.2
 Communication with the outside environment  higher rates of infection, malunion,
and nonunion if not recognized and treated appropriately.1,3,4
 1850s  open fractures  early amputation because sepsis and gangrene
 On the 20th century  aseptic technique by English Surgeon, Joseph Lister 
mortality rate drop from the historic 50% down to 9%.5,6
Epidemiology
 Crush injuries (the most common), falls from a standing height and road traffic
accidents.
 Males : Females = 7:3 , mean age of 40.8 and 56 years
 Type of fractures :
 fractures of ﬁnger phalanges (incidence 14/10 per year),
 fractures of the tibia (3.4/10 per year)
 and distal radius (2.4/10 per year) in the general population
Etiology
 Direct mechanisms  high-energy trauma

(motor vehicle accidents, firearms, and falls
from a height)
 Indirect mechanisms  low-energy torsional
injuries, (those sustained during sports and falls
from a standing height)
Classification
 Gustilo : First published in 1976 and modified in 1984,10,11 

worsening prognosis according to the mechanism of injury, level of
contamination, soft tissue damage, and fracture complexity (Table
2).
 In a follow-up study, Gustilo et al3 demonstrated that the risk of
infection directly correlated with the fracture grade.
 Kim and Leopold12 concluded that the size of the injury at the skin
surface did not always reflect the true extent of deep soft tissue
injury.  the true Gustilo classification of an open fracture is best
made in the operating room.12,15-18
Initial Evaluation
 The most critical first goal is saving life Advanced Trauma Life Support
(ATLS) protocol.
 Knowing the mechanism of injury
 A systematic inspection of each limb is critical; the dimensions, locations,
and degree of soft tissue involvement of open wounds should be noted
prior to reduction and/ or splinting.
 A complete neurovascular examination should be performed, and, if
necessary, vascular studies should be obtained for those injuries with a
questionable vascular examination.
Initial Management
 Removing immediately accessible contaminants, such as leaves and

clothes,
 Obtaining photographs of the wound(s) to minimize multiple
examinations,
 Following irrigation, wet-to-dry saline dressing should be applied to aid
in healing, comfort, and prevention of infection.
 The limb should then be reduced and placed in a well-padded splint.
Pulses should be documented before and after reduction.
Tetanus Prophylaxis
 Tetanus prophylaxis a routine practice following open fractures,

although there are no studies evaluating the benefits of tetanus
prophylaxis after open fractures
 The tetanus immune globulin is reserved for highly contaminated
wounds with incomplete/ uncertain vaccination history. This is a
single intramuscular dose of 3000 to 5000 units of tetanus immune
globulin that provides immediate immunity.25
Antibiotic Indication
 Gustilo and Anderson10  70% of open wounds were contaminated with bacteria and argued
that the routine use of antibiotics was a therapeutic
 The authors recommended a combination of a first-generation cephalosporin and
anaminoglycoside, or a third-generation cephalosporin for type III open fractures.11
 Johnson et al32 , in a prospective, randomized study comparing the first- and third-generation
cephalosporins in types II and III open fractures, found no statistical difference in the rate of
infection between the 2 treatment groups.
Surgical Debridement
 The goal is to debride all contaminated and nonviable tissue, including

skin, subcutaneous fat, muscle, and bone.
 Edwards et al36 found that removal of necrotic bone significantly

lowered the infection rate in open fractures.
 Although bone and skin viability are assessed by their capacity to bleed,
muscle viability is assessed by the criteria outlined by Artz et al,37 which
consist of the 4 Cs: color, contractility, consistency, and capacity to
bleed.
Timing of Surgery
 The optimal timing of surgical debridement is debated.

 Historically, open fractures were treated with emergent debridement within 6 hours of
injury, as reported by Gustilo and Anderson10 in 1976.
 Friedrich in 1898, showed that the contaminating microorganisms reached an infective

load within 6 to 8 hours after inoculation and theorized that simple wound debridement
was ineffective after this time.38
 A meta-analysis on the effect of timing to operative debridement following open long-

bone fractures found no association between higher infection rates and delayed
debridement up to 12 hours.41
Irrigation Solution
 A Cochrane meta-analysis by Fernandez and Griffiths44 found no

difference in infection rates between isotonic saline irrigation and
various forms of water (distilled, boiled, or tap) in open fractures.
 In a review by Crowley et al,45 the authors recommended normal
saline irrigation without additives, citing concerns about toxicity and
adverse healing effects.
Irrigation Volume
 Gustilo et al3 in 1990 recommended irrigation with 5 to 10 L of

normal saline or distilled water followed by 2 L of bacitracin solution
for all open fractures.
 A recent expert opinion by Anglen51 proposed an irrigation protocol
based on the severity of injury fracture, with
 3 L for type I fractures,
 6 L for type II fractures, and
 9 L for type III fractures.
Fracture Management
 Early fracture stabilization reduces pain, facilitates bed transfers and ambulation,
prevents further soft tissue injury, and promotes healing.
 This is particularly important for intra-articular fractures where early joint motion may
be advantageous.3
 There are many different treatment options for open fractures depending on
hemodynamic status, fracture location and pattern, and extent of soft tissue injury.
External Fixation
 External fixation is an effective temporizing measure

in polytrauma patients, particularly in cases of soft
tissue defects.
 Edwards et al36 showed a 93% union rate with
external fixation at a median follow-up of 9 months
in 202 consecutive type III open tibial fractures.
Intramedullary Nailing (IMN)
 Compared with external fixation, IMN

provide the advantage of faster time
to weight bearing, fewer subsequent
procedures, 58 higher level of patient
compliance, 55 and lower incidence
of malalignment. 58
Bone Grafting
 Bone grafting can help in fracture repair and reconstruction of skeletal defects. 32
 It can be performed at the time of closure for types I and II open fractures but should be
delayed until the wound has healed in type III fractures, owing to the extensive periosteal
stripping, soft tissue damage, and possible blood flow compromise associated with these
severe injuries.32
 Bone graft : recombinant human bone morphogenetic protein-2 (rhBMP-2) can also be
used at the time of definitive wound closure to accelerate healing.
 Since the BESTT study, rhBMP-2 has been approved by the US Food and Drug
Administration for use in the primary treatment of open tibial shaft fractures.
Wound Closure
 Delayed wound closure may increase risk of infection with nosocomial gram negative
microorganisms, such as Pseudomonas species, Enterobacter species, and methicillin-resistant S
aureus.3,68
 Benson et al69, in a double-blind, randomized trial examining open fractures with adequate soft
tissue coverage, found no increased risk of infection when wound closure was delayed for 5 days
in highly contaminated fractures provided patients received antibiotic prophylaxis and surgical
debridement.
 For wounds with extensive tissue loss (type IIIB and IIIC injuries), Gopal et al70 favored early internal
fracture fixation and flap coverage (within 72 hours). Their conclusion was supported by a higher
rate of infection when flap coverage was delayed, although they cautioned that this difference
was not statistically significant.
Negative-PressureWound Therapy
 Most wounds associated with type I open fractures will heal by secondary intention or can
be closed primarily without an increased risk of infection.71
 However, higher-energy injuries (type II and III open fractures) may require temporary
coverage between serial debridements or until flap coverage.
 Stannard et al7 ,in a prospective, randomized trial2, showed that the use of negative-
pressure wound therapy (NPWT) between surgical debridements prior to wound closure
resulted in a five fold decrease in infection rate compared with standard gauze dressing. In
contrast, Bhattacharyya et al 73 retrospectively reviewed
Conclusion
 Prophylactic antibiotics (eg, a first generation cephalosporin)  reduce the risk of deep
infection.
 Urgent operative irrigation and debridement is the standard of care.
 The goals of surgery are to achieve thorough debridement, bone stabilization, and
restoration of the soft tissue envelope.
 Multiple fixation techniques are available, each with its advantages and disadvantages.
 The role of adjunctive therapies, such as antibiotic-impregnated devices, rhBMP-2, and
NPWT between serial debridements, is emerging.
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Acute Management of Open Fractures :

NOVEMBER 2015 | VOLUME 38 • NUMBER 11

 Direct mechanisms  high-energy trauma

 Gustilo : First published in 1976 and modified in 1984,10,11 

 Removing immediately accessible contaminants, such as leaves and

 Tetanus prophylaxis a routine practice following open fractures,

 The goal is to debride all contaminated and nonviable tissue, including

 Edwards et al36 found that removal of necrotic bone significantly

 The optimal timing of surgical debridement is debated.

 Friedrich in 1898, showed that the contaminating microorganisms reached an infective

 A meta-analysis on the effect of timing to operative debridement following open long-

 A Cochrane meta-analysis by Fernandez and Griffiths44 found no

 Gustilo et al3 in 1990 recommended irrigation with 5 to 10 L of

 External fixation is an effective temporizing measure

 Compared with external fixation, IMN

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