Management of Open Fractures

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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

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References (66)

  • C.M. Court-Brown et al.

    The epidemiology of open long bone fractures

    Injury

    (1998)
  • P. Worlock et al.

    The prevention of infection in open fractures: an experimental study of the effect of fracture stability

    Injury

    (1994)
  • C.G. Zalavras et al.

    Open fractures: evaluation and management

    J Am Acad Orthop Surg

    (2003)
  • D.L. Skaggs et al.

    The effect of surgical delay on acute infection following 554 open fractures in children

    J Bone Joint Surg Am

    (2005)
  • B.J. Harley et al.

    The effect of time to definitive treatment on the rate of nonunion and infection in open fractures

    J Orthop Trauma

    (2002)
  • M.J. Patzakis et al.

    Factors influencing infection rate in open fracture wounds

    Clin Orthop Relat Res

    (1989)
  • R.B. Gustilo

    Management of open fractures. An analysis of 673 cases

    Minn Med

    (1971)
  • S.S. Blick et al.

    Compartment syndrome in open tibial fractures

    J Bone Joint Surg Am

    (1986)
  • R.B. Gustilo 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)
  • M.J. Patzakis et al.

    The role of antibiotics in the management of open fractures

    J Bone Joint Surg Am

    (1974)
  • R.B. Gustilo et al.

    Problems in the management of type III (severe) open fractures: a new classification of type III open fractures

    J Trauma

    (1984)
  • R.J. Brumback et al.

    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

    (1994)
  • G.M. Georgiadis et al.

    Open tibial fractures with severe soft-tissue loss. Limb salvage compared with below-the-knee amputation

    J Bone Joint Surg Am

    (1993)
  • M.J. Bosse et al.

    An analysis of outcomes of reconstruction or amputation after leg-threatening injuries

    N Engl J Med

    (2002)
  • K. Johansen et al.

    Objective criteria accurately predict amputation following lower extremity trauma

    J Trauma

    (1990)
  • P. Tornetta et al.

    Amputation versus limb salvage

    Instr Course Lect

    (1997)
  • J. Lee

    Efficacy of cultures in the management of open fractures

    Clin Orthop Relat Res

    (1997)
  • M.D. Fischer et al.

    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

    (1991)
  • M.J. Patzakis et al.

    Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds

    J Orthop Trauma

    (2000)
  • D.C. Templeman et al.

    Update on the management of open fractures of the tibial shaft

    Clin Orthop Relat Res

    (1998)
  • T.P. Knapp et al.

    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

    (1996)
  • P.M. Huddleston et al.

    Ciprofloxacin inhibition of experimental fracture healing

    J Bone Joint Surg Am

    (2000)
  • P.D. Holtom et al.

    Inhibitory effects of the quinolone antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on osteoblastic cells in vitro

    J Orthop Res

    (2000)
  • E.P. Dellinger et al.

    Duration of preventive antibiotic administration for open extremity fractures

    Arch Surg

    (1988)
  • E.P. Dellinger et al.

    Risk of infection after open fracture of the arm or leg

    Arch Surg

    (1988)
  • K. Kanellakopoulou et al.

    Carrier systems for the local delivery of antibiotics in bone infections

    Drugs

    (2000)
  • J.T. Mader et al.

    Treatment of experimental osteomyelitis with a fibrin sealant antibiotic implant

    Clin Orthop Relat Res

    (2002)
  • M.D. McKee et al.

    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

    (2002)
  • C.G. Zalavras et al.

    Local antibiotic therapy in the treatment of open fractures and osteomyelitis

    Clin Orthop Relat Res

    (2004)
  • P.D. Holtom et al.

    Relation of surface area to in vitro elution characteristics of vancomycin-impregnated polymethylmethacrylate spacers

    Am J Orthop

    (1998)
  • A.S. Baker et al.

    Release of gentamicin from acrylic bone cement. Elution and diffusion studies

    J Bone Joint Surg Am

    (1988)
  • N. Greene et al.

    In vitro elution of tobramycin and vancomycin polymethylmethacrylate beads and spacers from Simplex and Palacos

    Am J Orthop

    (1998)
  • P.D. Holtom et al.

    Newer methods of antimicrobial delivery for bone and joint infections

    Instr Course Lect

    (2003)
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