Discussion on Open fracture at Asgar Ali Hospital by Orthopedics department.

1. Open Fracture
Presented by,
Dr. Mayedul Hassan Shipon
RMO
Orthopedics & Traumatology
1

2. Open Fracture
• Open fractures are a common presentation to A&E, and require rapid
assessment and management by the orthopaedic team.
• Whilst most of these injuries can be safely managed on next day emergency
lists, there are instances where emergency out-of-hours treatment is required.
• Left untreated, open fractures are associated with high rates of morbidity
and mortality.
• It has been estimated that between 3.5 and 6 million fractures occur in the
United States annually. Extrapolating from European data, we can estimate
that more than 3% of these are open fractures. When adjusting for population
differences, we predict that more than 4.5 million open fractures occur per
year in India.
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3. What Is Open Fracture?
• A fracture is ‘open’ when there is
a direct communication between
the fracture site and the external
environment.
• This is most often through the
skin – however, pelvic fractures
may be internally open, having
penetrated in to the vagina or
rectum.
• This, along with the exposure of
bone and deep tissue to the
environment, leads to increased
risk of infection, wound
complications, and nonunion.
3

4. Pathophysiology
• Open fractures usually are high-energy injuries.
• Fracture may become open by either an “in-to-out” injury,
whereby the sharp bone ends penetrate the skin from beneath,
or an “out-to-in” injury, whereby a high energy injury (e.g.
ballistic injury or a direct blow) penetrates the skin, traumatising
the subtending soft tissues and bone.
• Whilst any fracture can become open, the most common
fractures are tibial, phalangeal, forearm, ankle, and metacarpal.
• These patients will often have additional injuries to other parts
of the body.
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5. Outcome
The outcomes of an open fracture can be considered in the following way:
• Skin – this can range from a very small wound to significant tissue loss, whereby
coverage will not be achieved without the aid of plastics surgery (i.e. skin grafting or a
flap)
• Soft tissues – this can also range from very little tissue devitalisation to significant
muscle/tendon/ligament loss requiring reconstructive surgery
• Neurovascular injury – nerves and vessels may be compressed due to limb deformity
or transected altogether
• Infection – the rate of infection is very high following open fracture, due to direct
contamination, reduced vascularity, systemic compromise (such as following major
trauma), and need for insertion of metalwork for fracture stabilisation.
With the availability of broad-spectrum antibiotics, antibiotic impregnated
polymethylmethacrylate beads, pulse lavage and a choice of improved fracture stabilisation and
proficiency in plastic surgery procedures, the outcome of these injuries has improved.
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6. Sign & Symptoms
• Patients will present with pain, swelling,
and deformity, with an overlying wound or
punctum (in severe cases, the bone end
may be visible protruding from the wound).
• On examination, ensure to
check neurovascular status and overlying
skin for any skin or tissue loss.
• Any evidence of contamination should be
assessed for and documented – marine,
agricultural, and sewage contamination is
of the highest importance.
• The need for plastic surgery input should
be identified early, to allow both specialties
to be present at the first operation and
therefore avoid multiple procedures
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7. Investigations
• All patients with suspected
open fractures require
basic blood tests, including
a clotting screen and Blood
Grouping.
• A plain film radiograph of
the affected area(s) will be
required.
• For very comminuted or
complex fracture patterns, a
CT-scan can often aid
management.
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8. Classification
• Gustilo-Anderson
Classification.
• Tscherne
Classification.
• Müller AO
Classification of
fractures.
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9. Gustilo Open Fracture
Classification
• Gustilo open fracture classification is the most commonly
used classification system.
• Gustilo system grades the fracture according to energy of
injury, soft tissue damage, level of contamination, and
comminution of fractures.
• The higher the grade, the worse the outcome of the
fracture.
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10. Gustilo Type I
• Energy - Low
• Wound size - ≤1 cm
• Soft tissue damage - Minimal
• Contamination - Clean
• Fracture pattern - Simple fracture
with minimal comminution.
• Periosteal striping - No
• Skin coverage - Local coverage
• Neurovascular Injury - Normal
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11. Gustilo Type II
• Energy - Moderate
• Wound size - 1-10 cm
• Soft Tissue Damage - Moderate
• Contamination - Moderate
contamination.
• Fracture pattern - Moderate
comminution
• Periosteal striping - No
• Skin coverage - Local coverage
• Neurovascular Injury - Normal
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12. Gustilo Type IIIA
• Energy - High
• Wound size - Usually >10 cm
• Soft Tissue Damage - Extensive
• Contamination - Extensive
• Fracture pattern - Severe
comminution or segmental
fractures
• Periosteal striping - Yes
• Skin coverage - Local coverage
• Neurovascular Injury - Normal
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13. Gustilo Type IIIB
• Energy - High
• Wound size - Usually >10 cm
• Soft Tissue Damage - Extensive
• Contamination - Extensive
• Fracture pattern - Severe
comminution or segmental fractures
• Periosteal striping - Yes
• Skin coverage - Requires free tissue
flap or rotational flap coverage.
• Neurovascular Injury - Normal
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14. Gustilo Type IIIC
• Energy - High
• Wound size - Usually >10 cm
• Soft Tissue Damage - Extensive
• Contamination - Extensive
• Fracture pattern - Severe comminution
or segmental fractures
• Periosteal striping - Yes
• Skin coverage - Typically requires flap
coverage.
• Neurovascular Injury - Exposed fracture
with arterial damage that requires repair.
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15. Reliability of Gustilo
Classification
• Brumback and Jones & Horn and Rettig have examined the reliability of the Gustilo-
Anderson classification system
• One study of 245 orthopaedic surgeons who were asked to classify 12 different open
fracture wounds of the tibia, using videotape and photographs, found that interobserver
agreement was only 60% representing moderate to poor agreement.
• In another study, 10 patients with open fractures had photographic slides of their wounds
and radiographs taken before and after debridement and stabilization. These slides
subsequently were evaluated by 22 orthopaedic surgeons (eight attending orthopaedic
surgeons and 14 orthopaedic residents). The kappa value in this study was 0.53,
indicating moderate agreement overall with no difference between the ability of either
attending staff or residents to use the Gustilo-Anderson classification system reliably.
• Although this classification system has a fairly good ability to predict fracture outcomes,
it is not perfect. The Gustillo classification does not take into account the viability and
death of soft tissues over time which can affect the outcome of the injury.
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16. Oestern and Tscherne classification
• The Oestern and Tscherne classification for open fractures uses wound
size, level of contamination, and fracture pattern to grade open fractures
Grade I
• Open fractures with a small puncture wound without skin
contusion
• Negligible bacterial contamination
• Low-energy fracture pattern
Grade II
• Open injuries with small skin and soft tissue contusions.
• Moderate contamination
• Variable fracture patterns
Grade III
• Open fractures with heavy contamination
• Extensive soft tissue damage
• Often, associated arterial or neural injuries
Grade IV • Open fractures with incomplete or complete amputations
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17. Müller AO
Classification
of fractures.
•The Orthopaedic Trauma
Association Committee for Coding
and Classification initially
published their classification
system covering the whole
skeleton in 1996.
•In 2006 they published a revision,
unifying the Muller/AO and OTA
systems into a single alphanumeric
classification:
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18. Management
The management of
Open fracture can be
divided into 3 stages;
• ER management
• Acute Management
• Surgical Management.
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19. ER Management
• Fracture management begins after initial trauma survey and resuscitation is complete: airway, breathing,
circulation, disability, and exposure (ABCDE)
• Antibiotics & Analgesics
• Control of bleeding
Direct pressure will control active bleeding
Do not blindly clamp or place tourniquets on damaged extremities
• Assessment
Soft tissue damage
Neurovascular exam - If concern for vascular insult, ankle brachial index (ABI) should be obtained. Normal
ratio is >0.9. Vascular surgery consult and angiogram is warranted if ABI <0.9.
Consider saline load test if concern for traumatic arthrotomy
• Dressing
Remove gross debris from wound, do not remove any bone fragments.
Place sterile saline-soaked dressing on wound
Little evidence to support aggressive irrigation or irrigation with antiseptic solution in the ED, as this can push
debris further into wound
• Stabilize
Splint, brace, or traction for temporary stabilization. It decreases pain, minimizes soft tissue trauma, and
prevents disruption of clots.
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20. Acute Management
• Urgent interventions, including therapeutic irrigation and wound debridement, are often necessary
to clean the area of injury and minimize the risk of infection.
• Other risks of delayed intervention include long-term complications, such as deep infection,
vascular compromise and complete limb loss.
• After wound irrigation, dry or wet gauze should be applied to the wound to prevent bacterial
contamination.
• Taking photographs of the wound can help to reduce the need of multiple examinations by different
doctors, which could be painful.
• Limb should be reduced and placed in a well-padded splint for immobilization of fractures. Pulses
should be documented before and after reduction.
• Wound cultures are positive in 22% of pre-debridement cultures and 60% of post-debridement
cultures of infected cases. Therefore, pre-operative cultures no longer recommended. The value of
post-operative cultures is unknown.
• Tetanus prophylaxis is routinely given to enhance immune response against Clostridium tetani.
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21. 21

22. Contamination of Open Fracture
and Use of Antibiotics
• All open fractures are by definition contaminated and must
be treated as such. The treatment methods may differ
depending on the type of fracture. Infection risks also differ
by fracture type and have been reported to be ranging
from 0 to 2% for Type I fractures, 2 to 10% for Type II
fractures, and 10 to 50% for Type III fractures.
• More recent studies have shown that the rates of clinical
infection increased to 1.4% (7/497) for Type I fractures,
3.6% (25/695) for Type II fractures, and to 22.7% (45/198)
of Type III fractures.
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23. • Antibiotic treatment with open fracture management should
be automatic with early administration being paramount,
ideally within 3 hours of injury. The risk of infection has been
shown to decrease six-fold with this practice.
• In the treatment of open fractures in the hospital setting, the
surgeon must also be concerned for nosocomial infections,
namely by Staphylococcus aureus and aerobic gram-
negative bacilli such as Pseudomonas. Specific antibiotic
coverage for these organisms may be indicated.
• The duration of antibiotic therapy in the treatment of open
fractures has been suggested to be between 1 and 3 days
without any solid agreement on a firm end point but typically
it is recommended to maintain antibiotic coverage until the
wound is closed. The recommended treatment regimen is,
23

24. Ref: US National Library Of Medicine
National Institutes Of Health
Ref: US National Library Of Medicine
National Institute Of Health24

25. • Gustilo Type I and II
1st generation cephalosporin
Clindamycin or vancomycin can also be used if allergies exist
• Gustilo Type III
1st generation cephalosporin+ aminoglycoside
• Farm injuries, heavy contamination, or possible bowel contamination
Add high dose penicillin for anaerobic coverage (clostridium)
• Special considerations
Fresh water wounds - Fluoroquinolones or 3rd or 4th generation cephalosporin
Saltwater wounds - Doxycycline + ceftazidime or a fluoroquinolone
• Duration
Initiate as soon as possible
Continue for 24 hours after initial injury if wound is able to be closed primarily
Continue for 24 hours after final closure if wound is not closed during initial surgical
debridement (72 hours for Type III wounds)
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26. • Local antibiotic delivery must be considered when
extensive contamination is present.
• This is commonly done with an “antibiotic bead-pouch”
construct formed with antibiotic powder and
polymethylmethacrylate (PMMA) cement.
• This simple technique when used in conjunction with
systemic antibiotics has been shown to decrease infection
rates from 12 to 3.7% in severe open fractures.
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27. Surgical Management
• Perhaps the most important aspect in the treatment of open fractures is the initial
surgical intervention with irrigation and meticulous debridement of the injury
zone.
• In fact, the surgeon should spend as much time for planning and performing the
debridement as for the fixation of the fracture. This initial debridement should
include a sequential evaluation of skin, fat, fascia, muscle, and bone.
• The propensity to excise as little possible should be avoided in open fracture
management given the relatively high contamination rate of these injuries,
especially in Type III injuries.
• Staged debridement and irrigation can be done (Perform every 24 to 48 hours as
needed)
• Overall, there is a lack of evidence-based recommendations to guide surgeons
on the appropriate additives for irrigations.
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28. Irrigation principles in the open fracture management
Gustilo Fracture Type Irrigation volume/additives
Type I
3 L normal saline with liquid castile soap additive only.
Alternatively, no additive may be used
Type II 6 L normal saline with liquid castile soap additive only.
Type IIIA-C
9 L normal saline with liquid castile soap additive. Highly
contaminated wounds may benefit from antibiotic in the irrigation
solution.
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29. Debridement principles in the open fracture management
Tissue Principles
Skin
Excise all devitalized skin and resect edges until dermal bleeding is encountered. Extend
the open wound to evaluate underlying structures. Longitudinal incisions are best.
Subcutaneous tissue
and fat
Excise all devitalized tissue. Affected subcutaneous fat and tissue should be freely
excised. These tissues have a sparse blood supply and on subsequent debridements,
further devitalization may become apparent.
Fascia
Excise all devitalized tissue. As with subcutaneous fat, contaminated fascia should be
freely excised. It is vital to recall that compartment syndromes can still occur in the face
of open fractures and complete compartment releases should be undertaken if
compartment syndrome is suspected.
Muscle
Muscle provides an excellent environment for bacteria to flourish. Thus, extensive
debridement of contaminated and devascularized tissue should be completed. Attention
to the classic “C’s” of muscle viability can assist the decision for excision: color,
consistency, contractility, and capacity to bleed. Caution should be taken with excision of
tendons and ligaments. These should be meticulously cleaned and left for later
debridement if they prove to be devitalized.
Bone
Remove all devitalized bone. The ends of the bone should be delivered into the wound
and cleaned/debrided. Devitalized fragments of bone should be removed. Large portions
of cancellous bone can be cleaned and used as graft material (only if not directly
involved in the open fracture environment and not grossly contaminated. Clinical
judgment is needed in this case).
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30. Skeletal Stabilization
• Early stabilization of open fractures provides many benefits to the
injured patient.
• It protects the soft tissues around the zone of injury by preventing
further damage from mobile fracture fragments.
• It also restores length, alignment, and rotation—all vital principles
of fracture fixation. This restoration of length also helps decrease
soft tissue dead spaces and has been shown in studies to
decrease the rates of infection in open fractures.
• Lastly, early fixation allows improved access to soft tissues
surrounding the injury and facilitates the patient's early return to
normal function.
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31. • The surgeon has many choices when deciding on fixation
constructs: skeletal traction, external fixation, and intramedullary
nails and plates.
• The choice of fixation involves the bone fractured and the
fracture location (intraarticular, metaphyseal, diaphyseal), the
extent of the soft-tissue injury and the degree of contamination,
and the physiologic status of the patient.
• Skeletal traction and external fixation are the quickest fixation
constructs to employ.
• The use of skeletal traction should be reserved only for selected
open fracture types (i.e., pelvis fractures and very proximal femur
fractures) and if used, it should only be for a short selected time.
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32. • External fixation is a valuable tool in the surgeon's arsenal for acute open
fracture management.
• Indications for external fixation are grossly contaminated open fractures
with extensive soft-tissue compromise, the Type IIIA-C injuries, and when
immediate fixation is needed for physiologically unstable patients. This
later indication involves the damage control concept of orthopaedic trauma.
• Plate fixation is generally indicated for open upper extremity fractures and
periarticular fractures where reconstruction of the articular surface is
paramount.
• Higher infections rates have been reported with plate fixation of open
fractures, so diligence is needed when the decision is made to use plates.
• Current plating technology and less-invasive techniques are lowering these
rates and providing patients with good to excellent results.
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33. • Intramedullary nail fixation remains the mainstay of treatment for
most open tibial shaft fractures and for selected femoral fractures.
• A recent study showed that more than 88% of surgeons use an
intramedullary nail for open Type I and II tibial shaft fractures.
Interestingly, this number decreases to 68% for Type IIIA and to 48%
for Type IIIB fractures. The choice in the latter is external fixation.
• Conversion from external fixation to an intramedullary nail has
received considerable attention in some literatures. Original reporting
of this conversion had alarming results with infection and nonunion
rates of 44 and 50%, respectively.
• With open fracture management, adjunctive therapies include
prophylactic bone grafting and the application of bone morphogenic
proteins (BMPs) at the initial operation may be considered.
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34. Wound Closure
• Early soft tissue coverage or wound closure is ideal .
• Timing of flap coverage for open tibial fractures remains
controversial, <5 days is desired.
• Increased risk of infection beyond 7 days.
• Negative-pressure wound therapy may be utilized during
debridement until definitive coverage can be achieved.
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35. Conclusion
• The above review provides a framework that the surgeon
can reference when treating patients with open fractures.
• The management of open fractures involves the
adherence to principles discussed earlier.
• Using a principle-based treatment regimen can help
improve patient outcomes while avoiding complications
and adverse events.
• Ultimately, this is the surgeon's goal, and patients will
benefit from the early return to normal function.
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36. Thanks for your patience
Ref:
US National Library Of Medicine
National Institute Of Health
Indian Journal of orthopaedics
https://www.orthobullets.com
https://www.wikipedia.org36