Open fracturesInitial management

Many patients with open fractures have multiple injuries and severe shock; for them, appropriatetreatment at the scene of the accident is essential. After splinting the limb, the wound should becovered with a sterile dressing or clean material and left undisturbed until the patient reaches theaccident department. This will reduce the risk of further contamination and wound desiccation.In hospital a rapid general assessment is the first step, and any life-threatening conditions areaddressed (see Chapter 22). Tetanus prophylaxis is administered: toxoid for those previouslyimmunized, human antiserum if not. Antibiotics should be given once the diagnosis of an openfracture is confirmed the sooner the better. This is usually co-amoxiclav or cefuroxime, butclindamycin if the patient is allergic to penicillin. The wound is carefully inspected; ideally itshould be photographed with a Polaroid or digital camera, so that it can again be kept covered untilthe patient is in the operating theatre. Important features to be noted are the site and size of thewound, whether it is tidy or ragged, clean or dirty, and whether it communicates with the fracture.Other important factors are the condition of the soft tissues and the state of the circulation andnerve supply.

Fractures Principles of Treatment

Classifying the injuryGustilos classification of open fractures is widely used: Type 1 is a low-energy fracture with a small, clean wound and little soft-tissue damage. Type II is a moderate-energy fracture with a clean wound more than 1 cm long, but no skinflap, not much soft-tissue damage and no more than moderate comminution of the fracture. Type III is a high-energy fracture with extensive damage to skin, soft tissue and neurovascularstructures, and contamination of the wound.

In Type III A the fractured bone can be adequately covered by muscle or skin, despitethe laceration; Type III B there is extensive periosteal stripping and fracture cover is not possible without the use of local or distant flaps;the fracture is classified as Type III C if there is an arterial injury which needs to be repaired,regardless of the amount of other soft-tissue damage.

24.9 Management of soft tissues Swelling is minimized by improving venous drainage. This can be accomplishedby elevation and firm support. Stiffness is minimized by movement and exercise. (a) A made-to-measure pressuregarment helps reduce swelling and scarring. (b) A Coban wrap around a limb to control swelling during treatment.(c) An intermittent venous plexus pump for use on the hand or foot. (d) Continuous passive motion provided by amotorized frame.

The incidence of wound infection correlates directly with the extent of soft-tissue damage, risingfrom less than 2% in Type I to over 10% in Type III fractures. The risk of infection also rises withincreasing delay in obtaining soft-tissue coverage of the fracture.

Treatment of open fractures

All open fractures, no matter how trivial they may seem, must be assumed to be contaminated; it isimportant to try to prevent them from becoming infected. The four essentials are: Antibiotic prophylaxis. Prompt wound debridement. Stabilization of the fracture. Early definitive wound cover.

Repeated examination of the limb is important; remember that open fractures also can be associatedwith a compartment syndrome.

Sterility and antibiotic coverThe wound should be kept covered until the patient reaches the operating theatre. At the timeof debridement, gentamicin is added to a second dose of the first antibiotic. Both antibioticsprovide prophylaxis against the majority of Grampositive and Gram-negative bacteria that may haveentered the wound at the time of injury. Only co-amoxiclav or cefuroxime (or clindamycin) iscontinued thereafter; the total period of antibiotic use for these fractures should not be longer than 72hours. This advice is based on evidence that later infections are caused mostly by hospital-acquiredbacteria and not seeded at the time of injury. Protracted use of wide-spectrum antibiotics priorto definitive wound closure only serves to select resistant bacteria from the hospital environmentto contaminate the wound. Correspondingly, gentamicin and vancomycin (or teicoplanin) aregiven as a single dose at the time of definitive wound cover as these antibiotics are effectiveagainst methicillin-resistant Staphylococcus aureus and Pseudomonas, both of which are near the topof the league table of bacteria responsible for deep infection after open fractures.

Debridement and wound excisionThe operation aims to render the wound free of foreign material and dead tissue, leaving aclean surgical field with a good blood supply throughout. Because open fractures are oftenassociated with severe tissue damage, the operation should be performed by someoneskilled in dealing with both skeletal and soft tissues; ideally this should be a joint effort byorthopaedic and plastic surgeons. The following principles must be observed:

Wound excision the wound margins are excised, but only enough to leave healthy skin edges.

Wound extension thorough cleansing necessitates adequate exposure; poking around in a smallwound to remove debris can be dangerous. The safest extensions are to follow the line offasciotomy incisions; these avoid damaging important perforator vessels that can be used to raise skin flaps for eventual fracture cover.

Delivery of the fracture examination of the fracture surfaces cannot be adequatelyperformed without extracting the bone from within the wound. The simplest (and gentlest)method is to bend the limb in the manner in which it was forced at the moment of injury;the fracture surfaces will be exposed through the wound without any additional damage to thesoft tissues.

Removal of devitalized tissue devitalized tissue provides a nutrient medium for bacteria. Alldoubtfully viable tissue, whether soft or bony, should be removed.

Wound cleansing all foreign material and tissue debris is removed by excision or through awash with copious quantities of normal saline. A common mistake is to inject syringefulsof fluid through a small aperture this only serves to push contaminants further in. Addingantibiotics or antiseptics to the solution has no added benefit. As a general rule it is best to leave cut nerves and tendons alone, though if the wound is absolutely clean and no dissection is required and providedthe necessary expertise is available they can be sutured.

Wound closure and stabilizationA small, uncontaminated wound in a Grade I or II fracture may (after debridement) be sutured,provided this can be done without tension. In the more severe grades of injury, fracture stabilizationand wound cover using split-skin grafts, local or distant flaps is ideal, provided both orthopaedicand plastic surgeons are satisfied that the wound is clean and viable after debridement.If a combined plastic-and-orthopaedic approach is not available at the time of debridement, thefracture is stabilized by external fixation and then left open and dressed with an impervious dressing.

Return to surgery for a second look should have definitive fracture cover as an objective. thisshould ideally be performed within 4872 hours, and not later than 57 days. The external fixatorcan be replaced by internal fixation at the time of definitive wound closure, should the surgeon deemthe fracture pattern appropriate and the degree of contamination at the time of injury mild. Openfractures do not fare well if left exposed for long and repeated debridement can be self-defeating. Ifwound cover is delayed, then external fixation is the safest means of definitive fracture stabilization.Skin grafting is most appropriate if the wound cannot be closed without tension and the recipientbed is clean, free of obvious infection and well vascularized; it is not necessary to wait until the bedis covered with granulation tissue. Partial-thickness grafts can, if necessary, be laid on periosteum orparatenon but they should not be applied directly over bare bone or tendons or metal implants.Extensive skin loss over a fracture, or in an open area where the blood supply is suspect,is better dealt with by transposing a local or regional fasciocutaneous or musculocutaneousflap, if this can be fashioned without risk to its blood supply. Occasionally the only option is totransfer a free flap, with its blood vessels, using microsurgical techniques. Where blood vesselsare preserved, they should be sutured outside the zone of injury.