Open fracture

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

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

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. 

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.

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.

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.

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

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.

8. Classification Gustilo-Anderson Classification. Tscherne Classification. Müller AO Classification of fractures . 

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.

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

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

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

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

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.

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. 

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

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:

18. Management The management of Open fracture can be divided into 3 stages; ER management Acute Management Surgical Management.

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.

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 . 

21. 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.

22. 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. Ref: US National Library Of Medicine National Institutes Of Health Ref: US National Library Of Medicine National Institute Of Health

24. 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)

25. 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. 

26. 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.

27. 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.

28. 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).

29. 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.

30. 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.

31. 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.

32. 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.

33. 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.

34. 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.

35. 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.org