With high-energy trauma on the rise, open
fractures are a common occurrence. An understanding of fracture
pathology and classification is fundamental to deciding the
appropriate management. While final management depends on
various factors such as locally available resources and
facilities/ financial constraints/ technical expertise etc,
review of literature helps us arrive at a consensus as to what
treatment is best in the given situation. We review here, the
available literature and discuss the preferred lines of
management. While each method has its merits and demerits, this
article attempts to briefly outline the general prevalent
Tscherne1 described 4 major eras in the
treatment of open fractures:
the era of life preservation
the era of limb preservation.
the era of avoidance of infection.
the era of preservation of function.
In spite of the advances made in fracture care and
management of infection, open fractures remain a serious
surgical problem. The annual incidence of open fractures of long
bones has been estimated to be 11.5 per 100000 persons with 40%
occurring in the lower limb, most commonly at the tibial
An open fracture is one in which a break in the skin
and underlying soft tissues communicates with the fracture and
Open fractures are becoming common due to high
energy trauma, as in road traffic accidents. Broadly, the
circumstances of injury fall into 3 main categories:
the body is stationary and is struck by a moving object.
the body is in motion and strikes a stationary object.
the body is in motion and strikes another moving object.
Depending on the extent of trauma, 4 consequences may
- contamination of the area of injury by bacteria from the
- crushing and devascularization of soft tissues render
this area of injury more susceptible to infection.
- the loss of normal soft tissue cover may affect the
methods by which the fracture is usually immobilized and may
deny the fracture site the usual contribution from overlying
soft tissues in the bone healing process.
- direct loss of function owing to damaged muscles, tendons,
nerves and vessels
Several classification systems have been proposed
for open fractures- Allgower3, Tscherne1.
The Gustilo-Anderson system4 is probably the most
widely accepted. It was modified in 1984 and groups open
fractures into the following categories:
Type I: Clean wound less than 1 cm long.
Type II: Laceration more than 1 cm long but without
extensive soft tissue damage, skin flaps or avulsions.
Type IIIA: Extensive soft tissue laceration but
maintain adequate soft tissue coverage of bone.
Type IIIB: Extensive soft tissue loss with periosteal
stripping and bony exposure.
Type IIIC: Open fractures with arterial injury
requiring repair, regardless of wound size.
Higher the velocity of trauma, higher the type, more the
soft tissue injury, more the chances of wound contamination.
When combined with an assessment of the surgeon’s
capabilities, facility and resources, classification of fracture
and associated soft tissue injuries allows determination of the
best treatment. Analysis of fracture pattern reveals the amount
of energy imparted to the extremity and stability of the
fracture after reduction. The AO alphanumeric classification
published by Muller et al5 is based on the
morphological characteristics and location of the fracture.
Taylor and Martin6 proposed a classification of
fractures (SUD) in which the main fracture is characterized as
stable (S), unstable (U) or with diaphyseal extension (D). These
are further divided into 3 subgroups: 0- extra articular, 1-
intra articular with displacement less than 2mm and 2- intra
articular with displacement more than 2mm. According to Taylor
and Martin, with progression from type S to type D, treatment
shifts towards external fixation and away from open reduction.
Conversely, with progression from subgroup 0 to subgroup 2, open
reduction is indicated.
Prognosis of limb salvage
Helfet et al7 reported the
Mangled Extremity Severity Score (MESS) based on 4 criteria:
skeletal and soft tissue injuries, shock, ischemia and age. In
their study, limbs with scores of 7 to 12 ultimately required
amputation, whereas scores of 3 to 6 resulted in viable limbs.
The LEAP (Lower Extremity Assessment Project) study8,
a multicentre prospective study, found that reconstruction and
limb salvage typically result in two year outcomes equivalent to
those of amputation for high energy injuries (Gustilo type IIIB
and IIIC and some IIIA fractures) below the distal femur.
Initial evaluation of a patient with an open
fracture should always follow the principles of the Advanced
Trauma Life Support System9. The ‘ABC’s of
initial management (A- airway, B- breathing, C- circulation) are
addressed first. This is followed by assessing consciousness,
cervical spine, CNS function, thorax, abdomen, pelvis and spine.
A clean pressure dressing with splintage should be applied
to the injured limb. An amputated part should be transported by
wrapping it in a clean moist cloth and placing it in a plastic
bag and then ice in an insulated container. The stump should be
wrapped and bleeding controlled with pressure dressing or a
tourniquet. Incompletely severed parts are covered with sterile
non constricting bandages and cooled with ice packs for
transportation. Cooling of the amputated part to about 4° C
prolongs its viability.
X—rays critical to the care of a severely injured patient
include a lateral view of the cervical spine and A—P view of
chest and pelvis. X—rays of the injured extremities can usually
be deferred till the patient’s general condition has been
As soon as possible, a careful examination of the wound is
performed. Obvious foreign bodies are removed and the wound is
flushed with copious amount of Normal Saline. Remember, “the
solution to pollution is dilution”.
Alongwith tetanus prophylaxis,
bactericidal IV antibiotics should be started as soon as
possible. The chosen antibiotics should be active against both
gram positive and gram negative organisms. Recommended
antibiotics for Type I & Type II fracture wounds, without gross
contamination, are cephalosporins. For Type III Open fractures,
aminoglycoside is added alongwith the cephalosporins. In cases with significant
contamination, the addition of penicillin to cover anaerobic
organisms (specifically clostridium perfringens) is advised. If
cultures are positive, the therapy needs to be tailored to the
Management of open fractures can be discussed under the
Initial Surgical Debridement
The critical aspect is the removal of all nonviable and
Margins of the skin wound are excised to provide adequate
visualization for effective debridement. One must be
conservative in the excision of skin, particularly where it is
at a premium (e.g. over the tibia, hand or foot).
Non viable or contaminated fascia should be excised. Fasciotomy maybe needed in high
Necrotic muscle is a major pabulum for bacterial growth and
poses great danger in anaerobic infections. Every effort should
be made to remove all non—viable muscle tissue. Muscle viability
is judged by red (or robust pink) colour, firm consistency,
contractility and capacity to bleed.
Tendons, unless obviously damaged or contaminated, should
be preserved, especially if they are essential to function.
Cortical bone pieces, free of any soft tissue attachment,
are generally removed. As a rule, bone debridement initially can
be conservative. However, if infection supervenes, early
aggressive redebridement of nonviable bone is essential.
Remember, a delayed union or non union is a far less challenging
complication than an infected non union.
Small vessels and bleeders are ligated or coagulated, while
major vessel injuries need immediate end—to—end anastomosis or
After thorough debridement, the wound should again be
lavaged with copious amount of
Stabilization of bone
Once irrigation & debridement have been done, stabilization
of bone is the next concern.
The options available are:
Type I and low velocity type II fractures with small
wounds, where manipulative reduction produces a stable and
acceptable fracture configuration, particularly in children can
be managed with plaster cast immobilization with appropriately
sized windows for wound inspection and management.
Pins incorporated in plaster casts are occasionally used as a
simple, inexpensive method where cost of external fixators
precludes their use, most commonly in type I and some type II
open tibia fractures.
Skeletal traction and suspensions are generally used as
temporary means of fracture stabilization until definitive, more
invasive methods are indicated or possible, as in open fractures
of femur or pelvis.
External fixation started gaining popularity for treatment
of open fractures during World War II. Today external fixation
is most often indicated for type III B and III C open fractures.
The use of Ilizarov ring fixators and hybrid fixators have
expanded the usefulness of external fixators. External fixators
offer the following advantages - they are relatively easily and
rapidly applied; excellent stability is achieved; and reasonably
anatomical reduction is achieved with minimal additional soft
tissue trauma. Disadvantages include – frequent need for
secondary definitive procedures; occasional interference with
soft tissue reconstructive surgery and pintract infection or
For infection prone injuries with severe soft tissue
contamination, the desire to avoid internal fixation has led to
the popularity of stabilization by external fixation remote
from the zone of injury. Severe open fractures of the tibial
diaphysis are the most common injuries stabilized with external
fixation. Early teaching prescribed only temporary stabilization
with fixators and prompt removal of the device was recommended
to avoid pintract problems. Typically, fixators were removed
soon after wound healing. More recently, authors have stressed
the need to maintain the fixation until the fracture has healed
sufficiently to allow for removal of the device without loss of
reduction. If initial
reduction is adequate enough to establish a stable construct,
partial weight bearing should be initiated as soon as possible.
If the fracture is transverse or inherently stable, the fixator
can be dynamized early on. With less stable fractures,
dynamization is delayed until early signs of fracture healing
are evident. Conversion of external fixator to intramedullary
nailing is preferably done about 3 weeks after fixator removal
(if possible) to minimize the chances of pintract induced
With early, meticulous and aggressive wound debridement and
use of appropriate parenteral bactericidal antibiotics, the
inclination for immediate internal fixation is increasing. The
development of biological techniques in plate fixation and the
design of implants which cause the least possible interference
with the periosteal blood supply have enhanced the use of plates
and screws for stabilization of even open tibial fractures11.
Today, almost all type I, most type II and some type III A open
fractures (without gross wound contamination) are being treated
with primary internal fixation in form of screws, plates or
nails, with primary (or secondary) wound closure (or coverage
procedure) .Prospective randomized studies comparing non-reamed
interlocking tibial nails with external fixation for open tibial
shaft fractures have reported no significant difference in rates
of infection12, 13. Keating et al14
compared a group of 50 open tibia fractures treated by reamed
nailing with another group of 44 open tibia fractures treated by
undreamed nailing. They found no statistically significant
difference between the two groups with regards to functional
outcome, rate of union or infection.
Since open fractures often involve bone loss and soft
tissue stripping (especially type III open fractures), they
frequently need bone grafting. The options include Autogenousbone grafts/ allografts/ vascularized bone grafts/ bone graft
substitutes. Autogenous cancellous bone grafting may be done (if
required) at the time of primary closure of primary or delayed
primary closure in type I and type II fractures and preferably
deferred to a later stage in type III open fractures (usually 6
to 9 weeks later). Fischer and associates15
demonstrated a decreased incidence of infection when bone
grafting of type III open fractures was done on a delayed basis.
Definitive wound management
After wound debridement and fracture stabilization, the
final decision is how to manage the open fracture wound. The
options available are –
- primary closure by suture (clean type I and some type II;
NEVER in type III) : When in doubt, leave it open.
- primary closure with split thickness or full thickness
- biological dressings.
- delayed primary closure by suture (by 5th
- delayed skin graft or flap.
- secondary closure.
The optimal timing of wound coverage is debatable. The
advent of early microsurgical free flap transfer for complex
trauma of the limbs has been a valuable advance, helped by the
shift from external to internal fixation, which has facilitated
microsurgical soft tissue reconstruction. Thus, a radical ‘very
early fix and flap’ protocol has developed. The main drawback is
the need for a joint orthopaedic and microsurgery service, which
is not easily
available in many centers, and the fact that major microsurgical
reconstructions are not always feasible in patients with
multiple injuries and hypovolaemic shock.
All in all, the recommended steps in the care of open
Evaluate the patient and stabilize all life threatening
Treat all open fractures as an emergency.
Tetanus prophylaxis and appropriate antibiotic therapy
should be institute at the earliest.
Irrigate and debride the wound (redebride, if needed).
Stabilize the fracture.
If in doubt, leave the wound open.
Perform bone grafting, if needed.
Rehabilitate the patient and the involved extremity as
soon as possible.
Although all methods have their proponents, the generally
accepted consensus for fracture stabilization is:
Type I: Plaster immobilization (in undisplaced
fractures and children)/ primary internal fixation.
Type II: Primary internal fixation (if wound reasonably
clean)/ external fixation (if contamination suspected or
Type III: External fixator (preferable)/ internal
fixation (only in adequately clean type IIIA open fractures).
While open fractures will continue to test the decision-making
and technical skills of the orthopaedic surgeon, the most
common, and probably the most serious error is to attempt
definitive care of an open fracture in one step.
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