Open Fractures
- Introduction
Classification
Emergency management
Definitive treatment
Timing of surgery
Antibiotic choice
Special cases
- Grade I fractures
Tibial fractures
Calcaneal fractures
Paediatric open fracture
Irrigation
References
Open fractures remain one of the true
orthopaedic emergencies. Current principles of treatment consist of splinting
the fracture and administering antibiotics at the time of initial patient
assessment, followed by expeditious transfer to the operating room for
aggressive debridement, lavage, and stable fixation of the fracture, forty-eight
hours of antibiotic prophylaxis after each procedure or debridement, and delayed
closure of open wounds when appropriate. The desired outcome includes skeletal
union with intact soft tissues and normal function.
Current preference in terminology is
to use open rather than compound to denote a fracture with an overlying wound.
GustilloAnderson \classification (1)
The prevalence of wound infection and
nonunion increases with increasing grade of open fracture.
The Gustillo Anderson classification of open fractures looks at several aspects
of the injury not just the size of the wound.
-
Prescence or absence of
neurovascular injury
-
Degree of contamination (farmyard
injuries are grade III injuries)
-
Energy transfer (Degree of
comminution and periosteal stripping)
-
Wound dimensions
Grade I
The wound is less than 1cm long. It is usually a moderately clean puncture,
through which a spike of bone has pierced the skin. There is little soft-tissue
damage and no sign of crushing injury. The fracture is usually simple,
transverse, or short oblique, with little comminution.
Grade II
The laceration is more than 1 cm long, and there is no extensive soft-tissue
damage, flap, or avulsion. There is slight or moderate crushing injury, moderate
comminution of the fracture, and moderate contamination.
Grade III
These are characterized by extensive damage to soft-tissues, including muscles,
skin, and neurovascular structures, and a high degree of contamination. The
fracture is often caused by high velocity trauma, resulting in a great deal of
comminution and instability.
-
III A – Soft tissue coverage
of the fractured bone is adequate
-
III B – Extensive injury to,
or loss of soft tissue, with periosteal stripping and exposure of bone,
massive contamination, and severe comminution of the fracture. After
debridement and irrigation a local or free flap is needed for coverage.
-
III C – Any open fracture
that is associated with an arterial injury that must be repaired, regardless
of the degree of soft tissue injury.
The definitive grade should be assigned in theatre after thorough debridement.
The risk of infection in an open fracture depends on the amount of
contamination, severity of soft tissue injury, and operative treatment of the
fracture.
| Gustilo Anderson grade |
Risk of infection (Sorger) |
| Grade I |
0-12% |
| Grade II |
2-12% |
| Grade III |
9-55% |
ATLS resuscitation
Photograph
Wound swab
Remove gross contamination and apply moist sterile dressing (Betadine)
Antibiotics (Give ASAP, make sure they are given not just written on the drug
chart)
Splint the limb
Check tetanus prophylaxis (click here)
Arrange for urgent surgical debridement/ washout and stabilization of the
fracture
Conventional treatment advocates debridement and washout within 6-8 hours
Early administration of systemic
antibiotics and timely surgical debridement, skeletal stabilisation and delayed
wound closure are the mainstay principles of treatment in open fractures. In the
era of Gustillo Andersons first publication on open fractures they recommended
strongly against internal fixation of open fractures with plates or
intramedullary nails; instead, they recommended external skeletal fixation of
some sort.
Recently clinical studies have shown that with thorough debridement the use of
biological fracture fixation techniques, and early soft tissue cover, internal
fixation with plates or intramedullary nails are safe and effective.
The restoration of skeletal stability is very important for the treatment of the
soft tissues and prevention of infection.
Conventional timing of definitive debridement and washout is 6-8 hours, with
advances in treatment of the osseous and soft tissue injury the validity of this
dictum has been debated (see below).
Surgical treatment of fractures
complicated by soft-tissue wounds has been described over many centuries.
Hippocrates (460–377 B.C.) used heat cauterization as a primary means of
debridement. Pare in 1579, was the first to advocate “immediate dilatation of
wounds, extraction of all lodged foreign bodies.” Karl Reyher, in 1881,
demonstrated decreased mortality rates with early debridement during the
Franco–Prussian War. This was followed in 1898 by Friedrich's experimental
tissue contamination studies in guinea pig soft-tissue wounds, which delimited
the time interval for effectiveness of operative debridement to ~6 h.
Many subsequent studies have used modifications of Friedrich's guinea-pig model
of soft-tissue contamination. Edlich et al. in 1969, used this model to compare
the resistance to infection in open versus closed wounds and to delineate the
benefit of delayed primary wound closure. Burke, in 1961, performed
tissue-contamination studies to determine the effective period of antibiotic
administration. Experimentally created lesions were compared with controls for
animals given antibiotics 1 h before to 6 h after injection of the bacterial
inoculum. There was no increase in bacterial colony formation in those animals
given antibiotics within 3 h from the time of contamination.
Open fractures are generally considered orthopaedic emergencies requiring
immediate surgical debridement. Several studies suggest that the timing of
surgery is less important than the adequacy of debridement and early use of
antibiotics. Patzakis and Wilkins documented infection rates of (6.8%) of 396
for wounds debrided within 12 h, and (7.1%) of 708 for those debrided after 12
h. Bednar and Parikh reviewed 82 adult open fractures and found no statistically
significant difference in deep infection rates for those treated within 6 h
compared with those treated within 24 h.
Gustillo and Anderson's classic article concluded “Open fractures require
emergency treatment, including adequate debridement and copious irrigation.”
There are no data in the article to support this claim, as the relation between
surgical delay and infection rate was not independently addressed. They reported
that the infection rate dropped from 12% to 5% with the advent of four changes
in their approach: (a) type III wounds received delayed primary closure, (b)
internal fixation was no longer used, (c) open fractures were treated as
emergencies, and (d) antibiotics were given before surgery. From their study
design, it is impossible to conclude which factors contributed to the decreased
infection rate.
Since the advent of the antibiotic era, several studies suggested that the
timing of surgical debridement of open fractures may not play such a critical
role in preventing infection. Patzakis and Wilkins reviewed 1,104 open fractures
with respect to factors influencing infection rates. They reported that the
delay from injury to surgery had no effect on the infection rate, with a 7% rate
of infection for both fractures debrided <12 h after injury and for those
debrided >12 h after injury. They also found that infection occurred in 4.7% of
fractures in which antibiotics were started within 3 h of injury compared with
7.4% of fractures in which antibiotics were started >3 h after injury. They
concluded, “the single most important factor in reducing the infection rate was
the early administration of antibiotics.” Merritt reviewed 70 patients with open
fractures and documented that “the time between injury and treatment in the
emergency room was not correlated with infection rate, nor was the time between
treatment in the emergency room and debridement in the operating room.” Bednar
and Parikh examined 82 adult open fractures of the lower extremity caused by
blunt trauma with a 5% infection rate, 76% of which were debrided 7–24 h after
injury without an increase in infection.
Skaggs et al in a review of 104 open fractures in children (1990-1995), 55 were
treated between 6 and 24 h after injury. The infection rate was 2.5% for those
treated within 6 h of injury and 1.6% in those with delays >6 h. This difference
is not statistically significant (p = 0.77). One confounding variable in this
study is that the more severe fractures tended to be treated earlier. In those
fractures treated within 6 h, 33% were Gustillo type III injuries, whereas in
fractures treated with >6 h delay, only 8% were type III fractures. As this
series contained only 18 grade III fractures, the number of grade III fractures
is insufficient to draw meaningful conclusions on the effect of surgical delay
in this group. This series also included only 9 injuries that had >24 h delay to
surgery, making conclusions in this group impossible.
Harley et al reviewed the literature 1966-1999 and found 9 articles dealing with
the issue of timing to definitive treatment.
3 articles dealt with patients who did not uniformly receive antibiotics.
The remaining six varied significantly in their structure as well as their
results.
Three prospective studies and one retrospective review found no significant
difference in infection rates with delayed fracture management.
Two more recent retrospective studies concluded that time was an important
factor in the incidence of adverse outcomes. However in one of these (Kinsfater
and Jonassen) there was a predominance of Grade III open fractures (77%) in the
late treatment group likely biasing the results. In the other Kredar and
Armstrong reviewed 56 open tibia fractures in children and found that a delay of
>6 h was correlated with a 25% infection rate (two of eight), compared with a
12% infection rate (five of 42) for those fractures treated within 6 h of
injury, clearly these numbers are too small to be meaningful. With only eight
patients treated >6 h after injury, one less infection would have made the
infection rates equal.
Harley et al undertook a retrospective review of 227 skeletally mature patients
with 241 open long bone fractures, treated 1996 to 1998. This retrospective
review demonstrated no increase in the incidence of infections or nonunions from
open fractures managed up to 13 hours from the time of injury. This result is
consistent with some of the aforementioned studies.
A number of other observations in this study are worthy of further comment.
No infections occurred in upper extremity injuries despite numerous Grade 3
injuries and prolonged treatment times.
Increasing severity of injury in the lower extremity, particularly the tibia,
does result in an increased infection rate.
The time to definitive surgical management did not influence the infection rate
in the lower extremity, however, with similar proportions of patients having
deep infections in both the early and the late treatment groups.
Nonunions in upper extremity injuries are uncommon events, and they do not
appear to be related to delays in time to definitive treatment.
There is a higher complication rate following external fixation. It is likely
that this increased complication rate associated with their use is a reflection
of the severity of the original injury and not the technique itself.
Although the use of plates and screws in open fractures is thought to be
associated with an increased rate of infection, this association was not
observed in this study. The majority of plates were used in the upper extremity,
however, whereas intramedullary fixation was preferred in the lower extremity.
In the setting of a lower extremity fracture with metaphyseal or intraarticular
extension and adequate soft tissue coverage, plates remain a viable option and
do not appear to predispose to increased complications when used in this manner.
The use of antibiotics however should not replace thorough and repeated
debridement if necessary of severe open wounds. Emergent open fracture treatment
remains the standard of care. However, the observations are important and should
not be discounted entirely.
It is important to note that 92% of the study subjects had definitive fracture
management within thirteen hours of injury; thus, these conclusions on the
effect of time are realistically limited to the initial thirteen hours.
The rate of infection after open fracture is strongly associated with increasing
Gustilo grade and lower extremity fractures. Nonunion after open fracture is
strongly associated with the presence of infection and increasing Gustilo grade
of fracture.
Although gram negative and gram
positive organisms are pathogens in open fractures, an increase in gram negative
infections has been seen during the past 15 years. This increase has been
attributed to selection of gram negative pathogens secondary to the extensive
use of first generation cephalosporins in prophylaxis, and the possible rise of
nosocomial infections.
Grade III injuries also have an increased incidence of
gram negative pathogens.
Organisms to cover.
-
Staphylococcus aureus
-
Pseudomonas species
-
Enterococcus
-
Escherichia coli
-
Klebsiella
-
Enterobacter
-
Proteus species
-
Serratia species
Several recommendations for
antibiotic prophylaxis exist, consider local policies. In general:
-
Grade I - first-generation
cephalosporin
-
Grade II - first-generation
cephalosporin +- an aminoglycoside, depending on the level of contamination.
-
Grade III - first-generation
cephalosporin with an aminoglycoside.
-
All farm injuries and heavily
soil contaminated injuries ensure adequate anaerobic cover, add
Metronidazole or Benzyllpenicillin to cover for Clostridium and other anaerobes.
Latest British Orthopaedic
Association recommendations
(Open fractures of lower
limb - Sept 2009).
-
Give antibiotics as soon as
possible (within 3 hours).
-
Agent of choice Co-amoxiclav
(1.2g 8 hourly), or a cephalosporin (eg cefuroxime1.5g 8 hourly), continued
until first debridement (excision).
-
At the time of first debridement,
co-amoxiclav (1.2g) or a cephalosporin (such as cefuroxime 1.5 g) and
gentamicin (1.5 mg/kg) should be administered and co-amoxiclav/cephalosporin
continued until soft tissue closure or for a maximum of 72 hours, whichever
is sooner.
-
Gentamicin 1.5 mg/kg and
either vancomycin 1g or teicoplanin 800mg should be administered on
induction of anaesthesia at the time of skeletal stabilisation and
definitive soft tissue closure. These should not be continued
post-operatively. Ideally start the vancomycin infusion at least 90 minutes
prior to surgery.
-
True penicillin allergy
(anaphylaxis) clindamycin (600mg iv pre-op/qds) in place of
co-amoxiclav/cephalosporin. Lesser allergic reaction to penicillin (rash
etc) a cephalosporin is considered to be safe and is the agent of choice.
Cochrane
review 2004 - Gosselin et al
Suggested no value in adding
gentamycin to antibiotics and advocate short term gram positive cover eg.
cephalosporin.
Personally would go with BOA guidance
and would add some gram negative cover as it is emerging relatively as a problem
as we deal more effectively with the gram positive organisms.
Occasionally, antibiotic bead spacers
may be used for temporary antibiotic delivery and to maintain soft-tissue
tension.
Gentamycin dosing (10)
Usual dosing of Gentamycin is 3 to 5
mg per kg of body weight, divided into two or three daily doses have been
recommended. Aminoglycosides, unlike beta lactams, have concentration dependent
killing and postantibiotic effect. The nephrotoxic effects of the
aminoglycosides are related to the trough concentration and not the peak
concentration. The duration of treatment also is important in developing
nephrotoxicity, with an increased incidence when treatment is longer than 7 to
10 days.
Sorger et al showed that once daily dosing with 6mg/kg daily of gentamicin is
safe, effective, and cost efficient in the treatment of open fractures when
combined with a cephalosporin and aggressive operative debridement and
stabilization.
Duration of antibiotics
Continue for 2 to 4 days after each
operative manipulation.
The infection rate following open
grade I fractures is very low.
| |
Gustillo |
Chapman |
Yang |
| Grade I |
0% |
1.9% |
0% |
Yang et al retrospectively reviewed
91 patients with type I open fractures. They questioned the need for debridement
and irrigation of stable type I fractures.
Their protocol is that low-energy Type I open fractures do not require operative
debridement. The decision, however, remains the responsibility of the on-call
surgeon. Initially, Type I open fractures are classified by the size of the soft
tissue wound only. The majority of patients with comminuted open fractures with
Type I wounds are taken to the operating room emergently. These fractures are
reclassified after operative debridement to a higher-grade injury.
Universally accepted principles of
management of open fractures of the tibia include immediate wound debridement
and irrigation, skeletal stabilization, repeated wound debridement, and early
soft tissue coverage.
The method of bony stabilization remains controversial.
-
Cast immobilization and plate
fixation are unacceptable for the management of these injuries, with high
rates of nonunion, malunion, and infection. Bach and Hansen compared ORIF with
external fixation in a randomized trial and observed a threefold difference in
infection rates (ORIF, 35%; external fixation, 13%).
-
External fixation is an excellent
initial method of skeletal stabilization in these injured, often unstable
patients. However, several studies have demonstrated that their value in the
definitive management of these injuries is questionable, with high rates of
pin loosening, sepsis, nonunion, and malunion. Edwards et al. reported a 15%
infection rate in 202 consecutive grade III open injuries, with more aggresive
debridement they reduced it to 9% in the latter half of their study. The
concept of early bone grafting was suggested and has since become part of the
baseline protocol used by most trauma centers when using external fixation in
open tibial fractures. Malunion is certainly more commonly encountered in
patients treated with external fixation with rates of up to 20%
-
Locked reamed and unreamed
intramedullary nails. The URTN has the theoretical advantage of preservation
of the endosteal blood supply and, because it is a solid device, has a lower
chance of harboring infection. However, experience with the solid nail has
shown significant rates of hardware failure, particularly locking screws, and
increased rates of delayed union or nonunion. Several authors have reported
satisfactory results using the reamed technique in open tibia fractures. There
is only one prospective, randomized study comparing the intramedullary nail in
open tibial fractures inserted with or without reaming. Unfortunately, they
excluded grade IIIB and IIIC injuries from their study, and found no increased
risk of complications after reaming in the less severe open tibial fractures.
Grade IIIB and IIIC injuries remains controversial in this respect.
External fixation versus unreamed
intramedullary nail
-
Santoro et al. prospectively
compared the use of external fixation and nonreamed locked nailing in open
tibial fractures. In 65 patients, they reported a higher union rate, shorter
time to union, and fewer malunions in the group treated with the unreamed
nail. There were only 12 grade IIIB injuries in this study.
-
Henley et al. reported on a series
of 174 type II and III open tibial fractures and found a significantly lower
incidence of infection and malunion with URTN compared with external fixation.
Although the external fixation group required significantly more secondary
procedures, time to union was similar in both groups.
-
Tornetta et al. published the early
results of a prospective, randomized study comparing external fixation with
the URTN in grade IIIB injuries. All 29 patients healed within 9 months, with
a similar time to union in both treatment groups. Of interest, 19 of the more
severe injuries were prophylactically bone grafted at 6 weeks.
-
Schandelmaier et al. reviewed 32
patients with grade IIIB injuries treated with either external fixation or the
URTN. Time to bony union, infection, and nonunion rates were not significantly
different between the two groups, but patients treated with the URTN made an
earlier return to full weight bearing and a better functional recovery.
Soft tissue cover
Early soft tissue reconstruction is essential and should be performed within 48
hours, usually timed to coincide with the “second look.” Occasionally, it is not
possible to achieve this, but every attempt should be made to close the wound
within 5 days. Further delay beyond this period leads to increased rates of
infection and nonunion. Plastic and reconstructive surgeons must be involved
early, at the time of admission or within 24 hours. Inappropriate wound
extensions performed by the inexperienced surgeon during the initial debridement
may limit further reconstruction options later.
Open calcaneus fractures are
devastating injuries with high complication rates. While the use of open
reduction and internal fixation for the treatment of long bones with open
fractures has been supported by several authors, no such studies exist for the
treatment of open calcaneal fractures. Reports of the treatment of calcaneal
fractures include a few cases of open fractures, but their numbers are small,
and they are not able to separate their results by location of wound, severity
of soft tissue disruption, calcaneal fracture type, and definitive treatment. Heier
et al reviewed 42 patients with open calcaneal fractures and suggested that:
Open calcaneal fractures have a high propensity for deep infection despite the
use of an aggressive treatment protocol to prevent it. It appears that type-I
and type-II open fractures associated with a medial wound can be treated with
open reduction and internal fixation. Type-II fractures associated with a wound
in another location should be treated with limited or no internal fixation.
Type-III open fractures, and especially type-IIIB open fractures, require
extensive debridement and prompt soft-tissue coverage as soon as possible. Early
internal fixation should be avoided in this subgroup because of the high rates
of osteomyelitis and subsequent amputation.
Aldridge et al reviewed open calcaneal fractures and did not find as high a
complication rate they agreed that definitive hardware placement at the time of
initial irrigation and debridement probably is not warranted: Definitive
fracture stabilization can and should wait until soft tissue coverage is
achieved.
Skaggs et al reviewed 104 (1990-1995)
open fractures in children and found a 1.0% rate of infection requiring surgical
drainage, and a 1.0% rate of soft-tissue infection managed with oral antibiotics
alone. The infection rate did not increase with a delay of >6 h between injury
and operative debridement. If surgical delay >6 h is necessary for optimal
management of a child with an open fracture, it does not appear to increase the
rate of infection in children who are started on early intravenous antibiotics.
As this series contained only 18 patients with grade III open fractures and 9
patients whose surgery was delayed >24 h, conclusions should not be drawn in
these groups.
Song et al (1996) suggested an age related healing response to open tibial
fractures with a more benign course in children younger than 11 years.
Wood et al (2001) retrospectively reviewed 87 open tibial fractures in children
treated between 1994 and 1999. All patients underwent debridement under
anaesthesia within 6 to 20 hours of injury and received antibiotics.
Following debridement, 56 children (42 type-I and 13 type-II fractures) were
treated in above-knee plaster casts. All fractures healed in four to eight
weeks. Shortening occurred in two patients and two developed 10° of valgus.
External fixation was used in 19 patients (four type-II and 15 type-III
fractures). Delayed split skin grafts were done in 12 patients and muscle
pedicle flaps in three. To treat compartment syndrome, fasciotomy was performed
in two children. Owing to vascular injuries, it was necessary to amputate the
legs of two children. No deep infections developed but there were three
superficial infections and 12 cases of pin-tract sepsis. Fixators were removed
after three to six weeks, and above-knee casts applied until union occurred at 6
to 10 weeks. Nonunion in two patients was treated by bone graft. Valgus
deformity occurred in two patients and shortening of 1 cm to 2 cm in three.
Open tibial fractures have a more benign outcome in children than in adults.
There were few complications related to vascular injury and nonunion.
Despite a lack of clinical studies,
the efficacy of high-pressure irrigation in decreasing the bacterial load in
soft tissues has been well established in both in vivo and in vitro experimental
models. The advent of pulsatile irrigation has further improved bacterial
removal from soft tissues. Several authors have noted the complications
associated with high-pressure pulsatile irrigation for fracture debridement.
Dirschl and colleagues, in an in vivo study on rabbits, found that high-pressure
pulsatile lavage resulted in visible damage at the fracture site and resulted in
delayed healing. Other investigators examined the effects of high-pressure
pulsatile irrigation on contaminated human tibiae in an in vitro model. They
reported that high-pressure irrigation of tibiae resulted in significant
macroscopic bony damage and carried surface bacteria into the intramedullary
canal. In a subsequent study, these investigators have shown that low-pressure
irrigation results in significantly less macroscopic and microscopic bone damage
and is as efficacious as high-pressure lavage in removing bacteria within 3
hours of contamination. However, after a 3-hour delay in irrigation,
low-pressure lavage was ineffective in removing bacteria.
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Cochrane Database Syst Rev. 2004;1:CD003764.
Last Updated 11/08/2004
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