Open Fractures
Open fractures account for around 3% of all broken bones and are classified as such when there is direct communication between the injury site and the external environment, usually because of an overlying laceration. Open fractures are usually classified according to the Gustilo-Anderson scale, which assesses the size of the wound, any associated tissue damage and the energy mechanism of the fracture. The scale ranges from the least severe Type I fractures to Type III-C. A surprising number of open fractures result from simple low-energy mechanisms, such as a fall, and the most common sites of injury are the lower leg (usually the tibia), forearm, ankle, fingers and toes.
Urgent assessment and management are required in order to achieve a good outcome for the patient. If left untreated, these types of injury are associated with high levels of morbidity and mortality. The main aims of open fracture management are to prevent infection, achieve definitive cover over the wound, realign the bones and achieve union in order to restore function. The precise treatment strategy will be determined by the patient’s condition, fracture type and mechanism of injury. Of particular importance is the condition of the soft tissues surrounding the fracture site, as this will often determine the early management of the patient.
The initial treatment of an open fracture is surgical debridement of the injury site. This procedure entails the removal of foreign objects and dead, damaged or infected tissue, which improves the healing potential of the remaining healthy tissue. This procedure commonly takes place as soon as appropriate after the injury, but many factors may influence the timing of surgery. It is vital that the initial debridement is as meticulous as possible; vascularity of the affected tissue needs to be carefully assessed and any compromised tissue removed. Failure to do so may result in the breakdown of non-viable tissue, infection and a delay in healing.
The next step is to achieve wound closure, either through primary closure of the skin, split-thickness skin-grafting or the use of either free or local muscle flaps. There is some debate as to the ideal timing for wound closure but it has been demonstrated that immediate or early closure (within 72 hours) reduces the risk of infection, the rate of reoperations and the time to bony union.
Skeletal stabilisation may be achieved through the use of skeletal traction, external fixation or internal fixation. The first two procedures have the advantage of being quick to use, although skeletal traction can only be used in limited cases and for a short period of time. External fixation has the added advantage that it can be placed so that the injury zone is free of metalwork and is easily accessible for both imaging and any necessary future fixation. Plate fixation is commonly undertaken and is particularly useful in fractures involving joints, where reconstruction of the articular surface is important. A major drawback of plate fixation is the higher risk of infection associated with its use, although improvements in technology and less-invasive techniques are reducing this. Intramedullary nails are also used to treatment fractures when appropriate (in the femur and tibia).
Problems associated with open fractures include infection, flap loss and bony issues. The risk of infection increases with the severity of the injury, and can be up to 50% in Type III cases. The high risk is due partly to direct communication with outside pathogens, along with the reduced vascularity of the injury site, compromised tissues in cases of major trauma and the need for the insertion of metalwork for fracture stabilisation. Therefore, early treatment with antibiotics should almost be viewed as mandatory for these patients, as it can reduce the risk of infection.
Flap loss may be fairly minor, and involve only the tip, or total necrosis may occur. As the tip is the least vascularised area, it is most vulnerable to necrosis. Total necrosis of the flap may occur if a flap is not truly viable at first elevation. Flap necrosis almost always necessitates a return to surgery. It may be possible to rectify tip necrosis by excising the affected tip and reinserting the flap, or alternative flap coverage may have to be considered. The latter will almost certainly be the case for total flap necrosis.
A major risk in open fractures is non-union of the damaged bones. The rate increases with the severity of the original injury and occurs in nearly 40% of Type III cases. This is partly because in an open fracture the haematoma, which contains postinjury healing factors, is released through the fracture site. Options for the prevention of non-union include prophylactic bone grafting and the application of bone morphogenic proteins (BMP) during the initial operation. Medical issues that may delay fracture healing includes diabetics or smokers.
Despite recent advances in both surgical techniques and technology, open fractures remain a challenge to treat and rates of infection and non-union are high. Successful treatment of an open fracture usually involves timely surgical management with input from orthopaedic, plastic and vascular surgeons in order to ensure that the patient returns to full function as soon as possible.
About Mr Vasireddy
Mr Vasireddy is a full-time fellowship-trained Orthopaedic Trauma Surgeon at King’s College Hospital. He specialises in the management of complex open/closed pelvic, acetabular, upper limb and lower limb fractures and amputations. He is also one of a small group of surgeons, and the only contemporary Orthopaedic Surgeon, in the UK who works as a HEMS (Air Ambulance) Pre-hospital Care Doctor. Find out more and download his CV here.
Further reading:
Cross WW 3rd, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop. 2008 Oct-Dec;42(4):377-86.
Nanchahal J, Nayagam S, Khan U, Moran C, Barrett S, Sanderson F, Pallister I. Standards for the management of open fractures of the lower limb [Internet]. [London]: Royal Society of Medicine Press; 2009 [cited 6 Jan 2020]. Available from http://www.bapras.org.uk/docs/default-source/commissioning-and-policy/standards-for-lower-limb.pdf?sfvrsn=0
BOA OPEN FRACTURES – https://www.boa.ac.uk/uploads/assets/3b91ad0a-9081-4253-92f7d90e8df0fb2c/29bf80f1-1cb6-46b7-afc761119341447f/open%20fractures.pdf