Management of Open Fractures
Section snippets
Evaluation and classification
Open fractures usually result from high-energy trauma, with motorcycle, motor vehicle, and auto versus pedestrian injuries accounting for most cases [5], [6]. Open fractures can be accompanied by potentially life-threatening trauma of other organ systems, or by musculoskeletal injuries elsewhere. Associated injuries involving intra-abdominal organs, chest, skull, pelvis, and major blood vessels are seen in 50% of open fracture patients [5]. Therefore, detailed evaluation and appropriate
Reconstruction or amputation?
Reconstruction and salvage of a severely traumatized extremity, although possible with advances in microsurgical techniques, are not always indicated. The treating surgeon may be confronted with the dilemma of salvage versus amputation of a nonviable extremity with a type IIIC open fracture or a mangled extremity with a IIIB fracture. Recovery of function in a salvaged but severely injured extremity may be limited or absent, despite multiple reconstructive procedures with associated morbidity
Prevention of infection
Prevention of infection is a main goal of open fracture management. Approximately 65% of patients who have open fractures have wound contamination with microorganisms [4], [8], [9].Therefore, antibiotics are not used for prophylaxis but rather for treatment of wound contamination. The risk for infection depends on the severity of injury and ranges from 0% to 2% for type I open fractures, 2% to 10% for type II, and 10% to 50% for type III fractures [4], [8].
Prevention of infection is based on
Local antibiotic therapy
Local therapy with antibiotic-impregnated delivery vehicles has been used as an adjunct to systemic antibiotic therapy in the treatment of open fractures. The most commonly used delivery vehicle is polymethylmethacrylate (PMMA) cement, which can be molded to bead-resembling spheres with a diameter ranging from 5 to 10 mm, or to spacer blocks of larger size. The spherical shape of the beads increases the surface area, thereby promoting the release of antibiotics and facilitating drainage of
Wound management
Wound management includes debridement, irrigation, and subsequent wound closure if adequate coverage can be achieved with the soft tissues available, or soft tissue reconstruction with local or free muscle flaps.
Soft tissue reconstruction
When extensive damage to the soft tissues is present, as in type IIIB open fractures, adequate coverage may not be possible and soft tissue reconstruction should be performed. The importance of a viable soft tissue envelope cannot be overemphasized. The soft tissue envelope is a source of vascularity at the fracture site, promoting fracture healing, antibiotic delivery, and host defense mechanisms. It provides durable coverage, preventing secondary contamination of the wound and desiccation of
Fracture fixation
Stable fracture fixation is necessary in open fractures, preventing further injury to the soft tissues and enhancing the host response to infectious organisms despite the presence of implants [57]. In addition, stable fixation facilitates wound and patient care and allows early motion and functional rehabilitation of the extremity. Fracture stabilization can be accomplished with intramedullary nailing, external fixation, or plate and screw fixation. The choice of method depends on the fractured
Early secondary procedures to stimulate healing
In the presence of bone defects or delayed healing, the authors advocate early bone grafting. The preferred timing for bone grafting ranges in the literature from 2 to 6 weeks after soft tissue coverage [61], [64]. The authors elect to wait for 6 weeks following a soft tissue transfer to ensure the absence of infection and the restoration of the soft tissue envelope. Then, the existing defect is bone grafted. Early bone grafting is also beneficial when healing is delayed and no callus is
Summary
Open fractures are high-energy injuries that require a principle-based approach, starting with detailed evaluation of patient status and injury severity. Early, systemic, wide-spectrum antibiotic therapy should cover gram-positive and gram-negative organisms, and a common regimen is a 3-day administration of a first-generation cephalosporin and an aminoglycoside, supplemented with ampicillin or penicillin to cover anaerobes in farm or vascular injuries. Local antibiotic delivery with the bead
References (66)
- et al.
The epidemiology of open long bone fractures
Injury
(1998) - et al.
The prevention of infection in open fractures: an experimental study of the effect of fracture stability
Injury
(1994) - et al.
Open fractures: evaluation and management
J Am Acad Orthop Surg
(2003) - et al.
The effect of surgical delay on acute infection following 554 open fractures in children
J Bone Joint Surg Am
(2005) - et al.
The effect of time to definitive treatment on the rate of nonunion and infection in open fractures
J Orthop Trauma
(2002) - et al.
Factors influencing infection rate in open fracture wounds
Clin Orthop Relat Res
(1989) Management of open fractures. An analysis of 673 cases
Minn Med
(1971)- et al.
Compartment syndrome in open tibial fractures
J Bone Joint Surg Am
(1986) - et al.
Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses
J Bone Joint Surg Am
(1976) - et al.
The role of antibiotics in the management of open fractures
J Bone Joint Surg Am
(1974)
Problems in the management of type III (severe) open fractures: a new classification of type III open fractures
J Trauma
Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons
J Bone Joint Surg Am
Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation
J Bone Joint Surg Am
An analysis of outcomes of reconstruction or amputation after leg-threatening injuries
N Engl J Med
Objective criteria accurately predict amputation following lower extremity trauma
J Trauma
Amputation versus limb salvage
Instr Course Lect
Efficacy of cultures in the management of open fractures
Clin Orthop Relat Res
The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury
J Bone Joint Surg Am
Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds
J Orthop Trauma
Update on the management of open fractures of the tibial shaft
Clin Orthop Relat Res
Comparison of intravenous and oral antibiotic therapy in the treatment of fractures caused by low-velocity gunshots. A prospective, randomized study of infection rates
J Bone Joint Surg Am
Ciprofloxacin inhibition of experimental fracture healing
J Bone Joint Surg Am
Inhibitory effects of the quinolone antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on osteoblastic cells in vitro
J Orthop Res
Duration of preventive antibiotic administration for open extremity fractures
Arch Surg
Risk of infection after open fracture of the arm or leg
Arch Surg
Carrier systems for the local delivery of antibiotics in bone infections
Drugs
Treatment of experimental osteomyelitis with a fibrin sealant antibiotic implant
Clin Orthop Relat Res
The use of an antibiotic-impregnated, osteoconductive, bioabsorbable bone substitute in the treatment of infected long bone defects: early results of a prospective trial
J Orthop Trauma
Local antibiotic therapy in the treatment of open fractures and osteomyelitis
Clin Orthop Relat Res
Relation of surface area to in vitro elution characteristics of vancomycin-impregnated polymethylmethacrylate spacers
Am J Orthop
Release of gentamicin from acrylic bone cement. Elution and diffusion studies
J Bone Joint Surg Am
In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos
Am J Orthop
Newer methods of antimicrobial delivery for bone and joint infections
Instr Course Lect
Cited by (57)
Infection Protocols for Implants
2019, Clinics in Podiatric Medicine and SurgeryImportance of dual delivery systems for bone tissue engineering
2016, Journal of Controlled ReleaseAntibiotic Prophylaxis in Adults With Open Tibial Fractures: What Is the Evidence for Duration of Administration? A Systematic Review
2016, Journal of Foot and Ankle SurgeryCitation Excerpt :Despite the enormous body of data on the subject of antibiotic use in open fractures, very few well-designed studies were identified. The computerized database search resulted in 14 citations (1,4,7,8,12–21). Ten additional studies were identified by a manual search through the references of the recovered studies (2,22–30).
A novel murine model of established Staphylococcal bone infection in the presence of a fracture fixation plate to study therapies utilizing antibiotic-laden spacers after revision surgery
2015, BoneCitation Excerpt :Implant-related bone infections (osteomyelitis or OM) occur in 5% of the 2 million fracture fixation cases annually in the United States and cost $15,000–$50,000 per incident [1,2]. Despite aggressive prophylactic strategies, the risk of infection establishment in open fracture cases can be as high as 50% [3]. Implant-associated OM can be extremely challenging and costly to treat considering that it can lead to high patient morbidity due to multiple revision surgeries, which involve aggressive debridement of the bone and soft tissue, possible exchange of the implants, as well as long courses of systemic antibiotics.
Orthopedic Implant-Associated Infections
2014, Mandell, Douglas, and Bennett's Principles and Practice of Infectious Diseases