This document discusses the evaluation and management of open fractures. The key points are: 1. Open fractures involve both bone and soft tissue injuries and managing them aims to prevent infection, achieve fracture union and restore function. 2. Open fractures are classified based on the type of fracture, soft tissue injury and bacterial contamination. This helps determine treatment and prognosis. 3. Immediate antibiotics and tetanus prophylaxis should be given. Wound irrigation and debridement are also important to prevent infection. 4. Controversies exist regarding wound closure timing and irrigation techniques. Extensive soft tissue damage may require muscle flaps. Fracture stabilization depends on location and injury characteristics.

1. Open Fractures: Evaluation and Management
Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
Abstract
Open fractures are complex injuries that involve both the bone and surrounding Veliskakis2 proposed a classifica-
soft tissues. Management goals are prevention of infection, union of the fracture, tion system for open fractures that
and restoration of function. Achievement of these goals requires a careful approach included three types based on in-
based on detailed assessment of the patient and injury. The classification of open creasing severity. This concept was
fractures is based on type of fracture, associated soft-tissue injury, and bacterial con- refined by Gustilo and Anderson,3
tamination present. Tetanus prophylaxis and intravenous antibiotics should be ad- and their classification system, sub-
ministered immediately. Local antibiotic administration is a useful adjunct. The sequently modified by Gustilo et al,4
open fracture wound should be thoroughly irrigated and débrided, although the op- has found widespread application.
timal method of irrigation remains uncertain. Controversy also exists regarding the Type I includes puncture wounds ≤1
optimal timing and technique of wound closure. Extensive soft-tissue damage may cm, with minimal contamination
necessitate the use of local or free muscle flaps. Techniques of fracture stabilization and muscle damage. Type II in-
depend on the anatomic location of the fracture and characteristics of the injury. cludes lacerations >1 cm, with mod-
J Am Acad Orthop Surg 2003;11:212-219 erate soft-tissue injury. Bone cover-
age is adequate and comminution is
minimal. Type III includes three sub-
types. Type IIIA involves extensive
Open fractures often result from Assessment and soft-tissue damage with adequate
high-energy trauma and are charac- Classification of Open bone coverage. Usually it is the re-
terized by variable degrees of soft- Fractures sult of a high-velocity injury with a
tissue and skeletal injury, both of severe crushing component. Type
which impair local tissue vasculari- Patients who present with associated IIIA also includes heavily contami-
ty. Open fractures communicate life-threatening injuries should be nated wounds with severe commu-
with the outside environment, and initially evaluated and resuscitated nition and segmental fractures. Type
the resulting contamination of the according to Advanced Trauma Life IIIB involves extensive soft-tissue
wound with microorganisms, cou- Support protocols. Injured extremities damage, with stripping of the peri-
pled with the compromised vascular then should be assessed for neurovas- osteum and exposure of the bone.
supply to the region, leads to an in- cular injury and compartment syn-
creased risk of infection as well as to drome. The presence of an open frac-
complications in healing. In addi- ture wound does not exclude the
Dr. Zalavras is Assistant Professor, Department
tion, bone, tendons, nerves, and ar- extremity from the complication of of Orthopaedic Surgery, University of Southern
ticular cartilage may be exposed and compartment syndrome.1 In addition, California Keck School of Medicine, Los Angeles,
subject to damage. complete assessment of the open frac- CA. Dr. Patzakis is Professor and Chairman, The
The principles that govern open ture includes reviewing the mecha- Vincent and Julia Meyer Chair, Chief of Ortho-
paedic Surgery Service, University of Southern
fracture management include as- nism of injury, condition of the soft
California University Hospital and Los Angeles
sessment of the patient and classifi- tissues, degree of bacterial contami- County+University of Southern California Med-
cation of the injury, prevention of in- nation, and characteristics of the frac- ical Center, Department of Orthopaedic Surgery,
fection, wound management, and ture. The evaluation of these factors University of Southern California Keck School of
fracture stabilization, including ear- will help to classify the fracture, de- Medicine.
ly bone grafting. Management of termine the treatment regimen, and
Reprint requests: Dr. Patzakis, GNH 3900, 2025
open fractures can be challenging, establish the prognosis and potential Zonal Avenue, Los Angeles, CA 90089-9312.
and multiple surgical procedures clinical outcome. In particular, the de-
frequently are needed to achieve gree of bacterial contamination and Copyright 2003 by the American Academy of
soft-tissue coverage and fracture soft-tissue damage is important in Orthopaedic Surgeons.
union. classifying an open fracture.
212 Journal of the American Academy of Orthopaedic Surgeons

2. Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
Usually it is associated with heavy ity and soft-tissue damage. The risk tered (2.4% [2/84 fractures]) com-
contamination and severe comminu- of infection is related to severity of pared with no antibiotics (13.9%
tion of the bone. Coverage using free injury. Infection rates range from 0% [11/79]) or with penicillin and strep-
muscle flaps is necessary. Type IIIC to 2% for type I, 2% to 10% for type tomycin (9.8% [9/92]). The antibiot-
involves any open fracture with ar- II, and 10% to 50% for type III.3,8 Pre- ics were administered before wound
terial injury requiring repair, regard- vention of infection is based on im- débridement. However, further
less of the degree of soft-tissue inju- mediate antibiotic administration questions regarding administration
ry. Gustilo et al5 later classified open and wound débridement. Tetanus involve selection of antibiotics, in-
fractures more than 8 hours old at prophylaxis should be administered cluding choice of single or combina-
presentation as a special category of based on the patient’s immunization tion therapy; duration of therapy;
type III fracture. Despite its wide status. and usefulness of local administra-
acceptance, however, the reliability tion. It is important that, in the set-
of this classification has been ques- Wound Cultures ting of an open fracture, antibiotics
tioned. Brumback and Jones6 report- In the early postfracture period, not be considered prophylactic. This
ed that the average agreement results of wound cultures may indi- term can be confusing because anti-
among orthopaedic surgeons on the cate the most probable infecting or- biotics routinely administered in or-
classification of open tibial fractures ganism and determine the patho- thopaedic elective procedures are
was 60% overall, which was deemed gen’s sensitivity to antibiotics. prophylactic. But because infection
to be moderate to poor. However, the usefulness of initial commonly occurs in open fractures
Classification systems have the cultures (obtained either at patient not treated with antibiotics, their ad-
inherent limitation of attempting to presentation or intraoperatively be- ministration is better viewed as ther-
classify a continuous variable, such fore and after débridement of open apeutic.
as severity of injury, into distinct cat- fracture wounds) has been contro-
egories. Nevertheless, the classifica- versial because they often fail to Selection
tion of open fractures is important identify the causative organism.9,10 The antibiotics used in the man-
because it directs the attention of the In one prospective randomized agement of open fractures should be
treating surgeon to the presence and double-blind trial, only 3 (18%) of 17 selected based on the wound micro-
extent of injury variables. Misclassi- infections that developed in a series biology. Wound contamination with
fication of an open fracture can oc- of 171 open fracture wounds were both gram-positive and gram-
cur, especially in a patient with a caused by an organism identified by negative microorganisms occurs;
relatively small skin wound. To im- the initial cultures.11 therefore, the antimicrobial regimen
prove the accuracy of the classifica- The predictive value of wound cul- should be effective against both
tion of open fractures, the extent and tures obtained before wound débri- types of pathogens. Currently, sys-
severity of the injury should be as- dement is especially low. This may be temic combination therapy using a
sessed only during surgery, after attributed to early wide-spectrum an- first-generation cephalosporin (eg,
wound exploration and débride- tibiotic coverage, multiple wound dé- cefazolin), which is active against
ment, and not at presentation in the bridements, and late contamination gram-positive organisms, and an
emergency department. with nosocomial pathogens.10 Thus, aminoglycoside (eg, gentamicin or
multiple initial cultures are not rec- tobramycin), which is active against
ommended. Only postdébridement gram-negative organisms, appears
Prevention of Infection cultures should be obtained, which to be optimal, although other
can be useful in the management of combinations also may be effective.
All open fracture wounds should be early infections or in wounds with Substitutes for aminoglycosides in-
considered contaminated because of marine or other unusual environmen- clude quinolones, aztreonam, third-
the communication of the fracture tal contamination. generation cephalosporins, or other
site with the outside environment. A antibiotics with coverage for gram-
contamination rate of approximately Antibiotics negative organisms. Ampicillin or
65% has been reported.3,7,8 Infection The crucial role of antibiotic ad- penicillin should be added to the an-
is promoted by the bacterial contam- ministration in the management of tibiotic regimen when conditions fa-
ination and colonization of the open fractures was established in a voring development of anaerobic
wound, the presence of dead space prospective randomized study by infections, such as clostridial myo-
with devitalized tissues, foreign ma- Patzakis et al,7 who demonstrated a necrosis (gas gangrene), are present,
terial, and the compromised host re- marked reduction in the infection as in farm injuries and vascular in-
sponse resulting from poor vascular- rate when cephalothin was adminis- juries (ischemia, low-oxygen ten-
Vol 11, No 3, May/June 2003 213

3. Open Fractures: Evaluation and Management
sion, and necrotic tissues). The re- group.11 Therefore, in type III open quently sealed with a film dressing
sults of cultures obtained after fractures, ciprofloxacin should be or similar semipermeable barrier.
débridement and of antibiotic- used only in combination with a Commercially available antibiotic-
sensitivity testing may help in select- cephalosporin as a substitute for an impregnated PMMA beads have not
ing the best agents for a subsequent aminoglycoside. Oral ciprofloxacin been approved by the Food and
surgical procedure or in case of an can be used for open fracture Drug Administration for use in the
early infection. wounds secondary to low-velocity United States, so they must be made
The lowest reported infection rate gunshot injuries because it is as ef- by the physician. Forty grams of
with various systemic antibiotic fective as intravenous administra- PMMA beads are mixed with the an-
regimens occurred with combina- tion of cephapirin and gentamicin.13 tibiotic in powder form and are po-
tion therapy with a cephalosporin However, further studies are war- lymerized; the beads then are strung
and an aminoglycoside. Patzakis ranted to elucidate the clinical ben- onto or incorporated with a bead
and Wilkins8 reported that the com- efits of quinolones because their use mold onto a 24-gauge wire. The an-
bination therapy was associated has been associated with the inhibi- tibiotic selected should be heat sta-
with a 4.6% infection rate (5/109 tion of experimental fracture healing ble, water soluble, and available in
open tibial fractures), whereas ad- and of osteoblasts.14,15 powder form and have wide-
ministration of only cephalosporin spectrum antimicrobial activity (for
was associated with a 13% infection Duration of Therapy example, 3.6 g of tobramycin mixed
rate (25/192). Type I and II open Antibiotics should be started as with 40 g of PMMA). Vancomycin is
fractures were not analyzed sepa- soon as possible after the injury oc- not recommended as an initial agent
rately, but the distribution of frac- curs because a delay >3 hours in- because of concerns regarding resis-
ture types was comparable between creases the risk of infection.8 The du- tant enterococci.
the two groups. Templeman et al12 ration of antibiotic administration is The bead pouch technique is most
proposed administration of a ceph- controversial. Dellinger et al16 dem- often used for select type II or type
alosporin as a single agent in type I onstrated that a prolonged course of III open fractures. If the anteromedi-
and II open fractures. However, 5-day antibiotic administration was al aspect of the tibia is exposed, re-
cephalosporin does not provide cov- not superior to a 1-day course for quiring delayed closure or muscle
erage against contaminating gram- prevention of fracture site infections. transfer, the beads are placed inside
negative organisms. Moreover, a po- The duration of therapy should be the bone defect, if present, and on
tential misclassification of an open limited to 3 days, with repeated top of the exposed bone. If the soft-
fracture because of its small wound 3-day administration of antibiotics tissue coverage is delayed, the bead
size could result in a type IIIA frac- at wound closure, bone grafting, or pouch does not need to be changed
ture being treated with a single any major surgical procedure.8,12 because the antibiotics have been
agent. shown to elute at levels above the
Quinolones are a promising alter- Local Administration minimum inhibitory concentration
native to intravenous antibiotics In a series of 1,085 open fractures, for at least 1 month.18 However, if
because they offer broad-spectrum Ostermann et al17 demonstrated that the patient undergoes repeat dé-
antimicrobial coverage, are bacteri- the additional use of local amino- bridement, the bead pouch can be
cidal, can be administered orally glycoside-impregnated polymethyl- changed.
with less frequent dosing than intra- methacrylate (PMMA) beads signif- The advantages of the bead
venous antibiotics, and are well tol- icantly (P < 0.001) reduced the pouch technique include (1) a high
erated clinically. Ciprofloxacin as overall infection rate to 3.7%, com- local concentration of antibiotics, of-
single-agent therapy is effective in pared with 12% when only intrave- ten 10 to 20 times higher than that
the management of type I and II nous antibiotics were used. When with systemic administration; (2) a
open fractures. In a randomized pro- the types of open fractures were an- low systemic concentration, which
spective study, ciprofloxacin was alyzed separately, the reduction of protects from the adverse effects of
compared with combination therapy infection was statistically significant aminoglycosides (although when a
(cefamandole and gentamicin). In- (P < 0.001) in only the type III frac- tobramycin bead pouch is used, sys-
fection rates were similar (6%) in the tures (6.5% versus 20%, respectively, temic aminoglycoside administra-
type I and II fractures; however, in for PMMA beads and intravenous tion is not needed); (3) a decreased
type III open fractures, the ciproflox- antibiotics). need for the use of systemic ami-
acin group had an infection rate Antibiotic-impregnated PMMA noglycosides; and (4) sealing of the
of 31% (8/26) compared with 7.7% beads are inserted into the open wound from the external environ-
(2/26) in the combination therapy fracture wound, which is subse- ment with film dressing. This tech-
214 Journal of the American Academy of Orthopaedic Surgeons

4. Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
nique prevents secondary bacterial is applied to the extremity, to be used We recommend leaving all open
contamination by nosocomial patho- only when necessary. Débridement fracture wounds open initially. De-
gens, which have been shown to be without inflating the tourniquet fa- layed wound closure (within 3 to 7
responsible for many of the infec- cilitates identification of viable tis- days) prevents anaerobic conditions
tions in type III open fracture sues and prevents additional is- in the wound, facilitates drainage,
wounds. 8,9 In addition, this tech- chemic damage to the already allows for repeat débridements at
nique allows for the period for soft- traumatized tissues. The injury 24- to 48-hour intervals, offers the
tissue transfers to be safely extend- wound may be insufficient for thor- opportunity to reexamine tissues of
ed. Also, film dressing establishes an ough débridement, as in type I and questionable viability, and permits
aerobic wound environment, which II open fractures, so the wound usu- use of the antibiotic bead pouch
is important for avoiding cata- ally is extended. Skin and subcuta- technique. Sealing the wound with
strophic anaerobic infections; main- neous tissues are sharply débrided film dressing prevents secondary
tains the local antibiotic within the back to bleeding edges. Viable mus- contamination and makes delayed
wound; and promotes patient com- cle can be identified by its bleeding, wound closure even more prefera-
fort by avoiding painful changes of color, consistency, and contractility. ble. Dressings are not changed in the
wound dressing. Cortical bone fragments without any surgical ward; instead, the wound
soft-tissue attachments are avascular remains sealed with film dressing.
and should be débrided, even if this Split-thickness skin grafts are ap-
Wound Management will result in a large bone defect. Ar- plied on well-vascularized granula-
ticular fragments, however, should tion tissue. Small wounds, especially
Irrigation and Débridement be preserved even when they have in type I open fractures, may be al-
Irrigation is an essential part of no attached blood supply, provided lowed to heal secondarily.
wound management; however, the they are large enough and recon- In type I and II open fractures, the
optimal volume, delivery method, struction of the involved joint is pos- extended wound made to facilitate
and irrigation solution have not sible. If necessary, a repeat débride- débridement can be safely closed
been determined.19 Although high- ment can be done after 24 to 48 hours primarily, leaving the original injury
pressure irrigation improves the re- based on the degree of contamina- wound open. 24 Part of the injury
moval of bacteria and debris, it also tion and soft-tissue damage. In inju- wound also can be sutured if it is di-
may damage the bone.20 Pulsatile ries requiring muscle flap coverage, rectly over bone, tendons, nerves, or
flow per se does not add to the effec- débridement also should be repeat- vessels, but the rest of the wound
tiveness of irrigation. Antiseptic so- ed at the time of soft-tissue recon- should be left open.
lutions may be toxic to host cells and struction.
should be avoided. Antibiotic solu- Soft-Tissue Reconstruction
tions have been shown in animal Wound Closure Severe damage to the soft tissues,
and in vitro studies to be more effec- Wound closure is possible when as in type IIIB open fractures, pre-
tive than saline alone, but clinical the available soft tissues are ade- cludes adequate bone coverage, and
data on open fracture wounds are quate; otherwise, soft-tissue recon- soft-tissue reconstruction is neces-
lacking. Detergent solutions help re- struction will be necessary later. The sary. A well-vascularized soft-tissue
move bacteria and appear to be a optimal time for wound closure envelope is critically important
promising alternative.21 One proto- remains controversial. Primary because it enhances vascularity at
col is a 10-L saline solution delivered wound closure after a thorough the fracture site, promotes fracture
to the wound by gravity tubing, with débridement is not associated with healing, allows for delivery of anti-
50,000 U of bacitracin and 1,000,000 an increased rate of infection, may biotics, and enhances action of the
U of polymyxin added to the last li- prevent secondary contamination, host defense mechanisms. Soft-
ter of irrigation fluid. and may reduce surgical morbidity, tissue coverage prevents secondary
After irrigation of the wound, hospital stay, and cost.22 Neverthe- wound contamination, desiccation,
surgical débridement is the most im- less, it carries the potential for and damage to bone, articular carti-
portant principle in open fracture clostridial myonecrosis, which can lage, tendons, and nerves.
management because nonviable tis- lead not only to loss of the limb but The location and magnitude of
sues and foreign material enhance also to loss of life.23 Primary wound the soft-tissue defect determine the
bacterial growth and hinder the closure, inadequate débridement, choice of method of coverage. Re-
host’s defense mechanisms. The goal and inadequate antibiotic therapy construction usually is achieved
is a clean wound with viable tissues increase the risk of these complica- with local or free muscle transfers.25
and no infection. A sterile tourniquet tions.7 Fasciocutaneous flaps are useful
Vol 11, No 3, May/June 2003 215

5. Open Fractures: Evaluation and Management
when dead space is minimal, when was not used; therefore, secondary tures have been satisfactorily stabi-
the flaps are pliable, and when they contamination may have played a lized with unreamed intramedullary
facilitate tendon gliding. They may notable role in contributing to the in- nailing,30-33 but controversies remain
restore sensibility to the affected area creased infection rate in patients regarding the role of external fixa-
if the flap remains innervated. with delayed flap coverage.9,27,28 tion and reamed intramedullary
Local pedicle muscle flaps in- nailing in the stabilization of these
clude the gastrocnemius for frac- fractures.
tures in the proximal third of the tib- Fracture Stabilization
ia and the soleus for fractures in the Intramedullary Nailing Versus
middle third. However, for fractures Adequate stabilization protects the External Fixation
in the distal third of the tibia, free soft tissues from further injury by Both unreamed intramedullary
muscle flaps are necessary; com- fracture fragments and facilitates the nailing and external fixation have
monly used flaps include the rectus host response to bacteria despite the been used widely in the manage-
abdominis, gracilis, and latissimus presence of implants. In addition, ment of open tibial fractures, but few
dorsi muscles. In considering local stable fixation improves wound care prospective randomized studies
muscle flaps, the condition of the and mobilization of the patient and have compared the two techniques.
muscle to be transferred must be allows for early motion of adjacent Tornetta et al30 evaluated the two
carefully evaluated. Muscle that is joints, which contributes to function- methods in 29 type IIIB open tibial
traumatized, crushed, or affected by al rehabilitation. fractures. All fractures healed and no
a compartment syndrome should The choice of fracture fixation de- difference in the infection rate was
not be transferred; free muscle trans- pends on the fractured bone, the lo- found. In a prospective series of 174
fer should be used instead. Pollak et cation of the fracture (eg, intra- open tibial fractures, Henley et al31
al26 reported that in the presence of articular, metaphyseal, diaphyseal), reported no difference between un-
severe osseous injury, use of rota- and the extent of soft-tissue injury. reamed nailing and external fixation
tional flaps was notably more likely Available techniques for fracture sta- regarding infection and bone heal-
to lead to wound complications bilization include intramedullary ing. They observed that the severity
compared with free flaps. nailing, external fixation, and plate- of the soft-tissue injury rather than
Soft-tissue reconstruction should and-screw fixation. More than one the choice of implant appeared to be
be done early, within the first 7 days. technique may be applicable in a the main factor influencing injury
Delays beyond this period have specific injury. site infection and bone healing.
been associated with increased com- However, half-pin external fixators
plications related to the flap or infec- Intramedullary Nailing were associated with malalignment
tion under the flap.9 Some have ad- Intramedullary nailing is an effec- in 31% of cases and with a pin tract
vocated that flap coverage be done tive method of stabilization of di- infection in 50%. A meta-analysis of
within 72 hours.27,28 Godina27 report- aphyseal fractures of the lower the management of open tibial frac-
ed a failure rate of free muscle flaps extremity.29-32 It is a biomechanically tures demonstrated that unreamed
in <1% (1/134) when done within 72 advantageous method that does not intramedullary nails reduced the
hours compared with a failure rate interfere with soft-tissue manage- risk of revision surgery, malunion,
of 12% (20/167) when done from 72 ment. Static interlocking fixation and superficial infection compared
hours to 90 days. In the same series, maintains the length and alignment with external fixators.32
the infection rate was 1.5% (2/134) of the fractured bone and thus has Although no advantages in frac-
in the early surgical group compared expanded the applicability of nailing ture healing and injury site infection
with 17.4% (29/167) in the late sur- to unstable, comminuted fracture have been established, intramedul-
gical group. Gopal et al28 showed patterns. However, it disrupts the lary nailing is considered preferable
that results of an early aggressive endosteal bone circulation to a vari- to external fixation. It does not re-
protocol in type IIIB and IIIC open able degree, especially when the quire the same high level of patient
fractures also were satisfactory. In medullary canal is reamed. Open compliance, and it is aesthetically
their series, deep infection devel- femoral fractures are best treated more acceptable than external fixa-
oped in 6% of fractures (4/63) that with reamed intramedullary nailing: tion. Unreamed intramedullary nail-
were covered with a flap within 72 Brumback et al29 observed no infec- ing can be used for types I to IIIA
hours compared with 29% of frac- tions in 62 type I, II, and IIIA open and for select type IIIB open frac-
tures (6/21) covered after 72 hours. fractures, although infection devel- tures of the tibial diaphysis. An ex-
However, in these studies, the oped in 3 (11%) of 27 type IIIB open ternal fixator may be particularly
antibiotic-impregnated bead pouch femoral fractures. Open tibial frac- useful in cases with heavy bacterial
216 Journal of the American Academy of Orthopaedic Surgeons

6. Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
contamination, extensive soft-tissue fer reamed nailing tend to insert tures without cortical contact and for
damage, or vascular injury (ie, types smaller nails, resulting in little dif- fractures with bone defects treated
IIIB and IIIC). ference between the techniques. with external fixation.
However, clinical experience with External fixation may be accom-
Unreamed Versus Reamed reamed nailing is limited, whereas panied by pin tract infections and
Intramedullary Nailing many investigators have document- fracture malalignment. These com-
Unreamed intramedullary nail- ed satisfactory experience with un- plications can be avoided by the se-
ing has been widely used in open reamed nailing, including its use lection of compliant patients; imple-
tibial fractures.30,31,33 Schemitsch et with type IIIB open fractures.30,31,33 mentation of an external fixation
al34 showed in a sheep tibia model The unreamed nailing technique can protocol, which includes the use of
that endosteal blood flow at comple- be used even in type I open tibial half-pins inserted after predrilling to
tion of the procedure was reduced to fractures to reduce damage to bone avoid thermal necrosis of bone; and
18% of the level prior to nailing vascularity. meticulous care of the pin tract. A
when reaming was done whereas it considerable proportion of the com-
was reduced to only 44% with un- External Fixation plications associated with external
reamed nailing. Unreamed nailing External fixation can be helpful in fixation can be attributed to the tran-
preserves endosteal blood supply to wounds with severe soft-tissue dam- sition to another form of fixation. In-
a greater degree than does reamed age and contamination because it fection has been reported at a rate
nailing.34,35 Thus, it may be prefera- avoids hardware implantation and approaching 50% after conversion of
ble in open tibial fractures, in which does not compromise fracture vas- the external fixation to delayed in-
periosteal vascularity may be al- cularity. External fixation is techni- tramedullary nailing.9,41 However,
ready compromised by the traumat- cally expedient and is associated in these series, infection was associ-
ic insult. Reamed nailing, on the with minimal blood loss. It is ap- ated with a prior pin tract infection
other hand, allows insertion of plied at a site distant to the injury in the majority of patients. Blachut et
larger-diameter implants, improves and thus does not interfere with al42 showed that by early (mean, 17
stability at the fracture site, and wound management. External fixa- days) conversion of the fixator to a
helps reduce implant failure. More- tion is suitable for diaphyseal tibial nail in the absence of pin tract infec-
over, the cortical circulation that was fractures because of the subcutane- tions, infection developed in only
disrupted during reaming is gradu- ous location of the bone, and it be- 5% of patients. Loss of alignment fre-
ally reconstituted, although more comes a more attractive option than quently occurs when the fixator is
slowly than unreamed nailing.35 intramedullary nailing moving to prematurely removed and the pa-
Two prospective randomized the proximal or to the distal tibia, if tient is transferred to a brace.38
studies compared reamed with un- the size of the proximal or distal In heavily contaminated open
reamed nailing in open tibial frac- fragment does not allow for stabili- fractures, temporary external fixa-
tures; neither established a signifi- zation with a nail. Ring or transartic- tion can be a useful option. Howev-
cant difference in infection rates.36,37 ular fixators are useful for periartic- er, to minimize the chance of bacte-
Keating et al36 reported an infection ular fractures. Spanning external rial colonization of the pin tracts,
rate of 2.5% (1/40) in fractures treat- fixation is becoming popular and conversion to intramedullary nail-
ed with the unreamed nailing tech- may be safely converted to another ing should be done in the absence of
nique versus 4.4% (2/45) in fractures method when applied away from pin tract infections and when the fix-
treated with the reamed nailing tech- the zone of injury. ator has been present for only a short
nique. Finkemeier et al37 observed Many authors38-40 have reported time.42 Otherwise, the fixator should
infection rates of 3.8% (1/26) in un- on the effectiveness of external fixa- be maintained until fracture healing.
reamed nailing and 5.3% (1/19) in tion as definitive treatment as well as
reamed nailing. In both studies, a re- the value of early bone grafting in se- Plate Fixation
duced incidence of screw failure was vere injuries.38-40 Marsh et al,40 in a Plate fixation is useful in intra-
seen in the group undergoing the prospective study of 101 type II and articular and metaphyseal fractures
reamed nailing technique. III fractures, reported that 96 frac- because it stabilizes an accurate res-
Choice of technique remains con- tures (95%) healed, 95% of them toration of joint congruency and ori-
troversial. Interestingly, surgeons with <10° of angulation in any plane, entation. In diaphyseal fractures of
who prefer unreamed nailing try to and that 6 fracture sites (6%) were in- the upper extremity, plate fixation is
insert a nail of sufficient diameter fected. To avoid healing complica- often the method of choice. Plate fix-
to accommodate larger locking tions, early bone grafting should be ation in open tibial fractures has
bolts, whereas surgeons who pre- considered for comminuted frac- been associated with an increased
Vol 11, No 3, May/June 2003 217

7. Open Fractures: Evaluation and Management
incidence of infection and hardware and restoration of the soft-tissue en- bacterial contamination, soft-tissue
failure.43,44 Bach and Hansen43 re- velope. Then the existing defect is damage, and fracture characteristics.
ported wound infection in 35% (9/ bone grafted. Depending on the frac- To avoid the complication of clos-
26) and fixation failure in 12% (3/26) ture pattern, grafts are applied either tridial myonecrosis, the wound
of type II and III open tibial frac- at the fracture site beneath a flap or should be thoroughly irrigated and
tures. Clifford et al44 observed im- posterolaterally away from the site débrided and not closed primarily.
plant failure in 7 of 97 open tibial of injury. Early bone grafting in the Early, systemic, wide-spectrum anti-
fractures and infection in 4 of 9 type absence of a bone defect also may be biotic therapy is necessary to cover
III fractures. New plating techniques necessary when healing is delayed both gram-positive and gram-
using fixed-angle plate screw devic- and no callus is apparent on radio- negative organisms. A 3-day admin-
es are characterized by minimally in- graphs at 8 to 12 weeks. Autogenous istration of a first-generation cepha-
vasive insertion and preservation of bone graft remains the method of losporin and an aminoglycoside,
bone vascularity, and they may choice. The usefulness of graft sub- supplemented with ampicillin or
prove to be a useful alternative for stitutes in the management of de- penicillin for injuries occurring on a
metaphyseal fractures, especially fects associated with open fractures farm and for vascular injuries, is a
when intra-articular extension is has not been shown to be effective. critically important part of effective
present. However, to date, no pub- Exchange nailing is another op- treatment. Local antibiotic delivery
lished data are available to support tion to stimulate healing in cases of with the bead pouch technique can
their use. delayed union, provided no infec- prevent secondary wound contami-
tion or bone defect is present. Infec- nation. In the presence of extensive
Early Secondary Procedures to tion necessitates additional débride- soft-tissue loss and exposed bone,
Stimulate Healing ment, whereas bone defects should coverage is accomplished with early
In the presence of bone defects or be managed with bone grafting. transfer of local or free muscle flaps.
delayed healing, early bone grafting Stable fracture fixation is important;
can expedite healing. With bone de- the method chosen depends on the
fects, the preferred timing for bone Summary bone and soft-tissue characteristics.
grafting ranges from 2 to 6 weeks af- Early bone grafting is indicated for
ter soft-tissue coverage.38,45 Waiting Assessment and classification of bone defects, unstable fractures
for 6 weeks after a soft-tissue trans- open fractures should be done intra- treated with external fixation, and
fer ensures the absence of infection operatively based on the degree of delayed union.
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