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Open Versus Closed Extremity Fractures In The Trauma ICU: Current Trends In Morbidity And Mortality

Michael J. Kilbourne*,Grant V. Bochicchio**,Kimberly M. Lumpkins***,Kelly Bochicchio**,Thomas Scalea, MD**

*Department of Surgery, Walter Reed Army Medical Center, Washington, DC
**  Department of Surgery, R. Adams Cowley Shock Trauma Center, Baltimore, MD
***Department of Surgery, University of Maryland, Baltimore, MD

Division of Clinical and Outcomes Research R Adams Cowley Shock Trauma Center

Address for Correspondence:  

Michael Kilbourne MD
R. Adams Cowley Shock Trauma Center,
22 South Greene St.  T1R60
, MD, 21201
Ph:  410-328-5377


Background:  Open fractures are more complicated to manage than closed fractures due to their associated soft tissue disruption, requiring more frequent operative intervention and wound care, with significantly greater risk of infection.  In this study, we sought to evaluate the impact of open fractures on morbidity and mortality in today’s critically injured trauma patient.
Methods:  Prospective data were analyzed on 517 blunt trauma patients admitted to the ICU with extremity fractures. Patients were divided into two groups: open fractures (diagnosis of at least one open long bone fracture) or closed fractures (diagnosis of only closed fractures).  Both univariate analysis and multivariate logistic regression analysis were performed for each group controlling for age, gender and Injury Severity Score (ISS) to evaluate outcomes.
Results:  Univariate analysis revealed no significant difference between the open fracture vs. closed fracture groups for hospital length of stay (HLOS); 22±14 days vs. 21±17 days, p= 0.20, ICU length of stay (ILOS); 14±12 days vs. 14±11 days, p= 0.43, ventilator days; 13±12 days vs. 12±12 days, p= 0.51, or mortality; 12% vs. 13%, p= 0.85.  Multivariate linear regression analysis demonstrated that fracture type (open vs. closed) was not predictive of HLOS (coefficient 1.46, p= 0.33), ILOS (coefficient 0.65, p= 0.52), ventilator days (coefficient 0.65, p= 0.57), or mortality (odds ratio 1.14, 95% CI 0.64-2.01).
Conclusion:  Despite the more complex nature of open versus closed long bone fractures, open fractures do not appear to increase the risk of morbidity or mortality in today’s critically injured blunt trauma patient. 

J.Orthopaedics 2008;5(3)e4


Extremity fracture; open; closed; trauma; ICU; morbidity; mortality


Historically, open extremity fractures have been associated with significant morbidity and mortality.  During the mid-1800’s most open fractures were treated with amputation.   For example, in the American Civil War, over 30,000 amputations were performed for open fractures with an overall mortality of 26%.  In the Franco-Prussian War from 1870-1871, the death rate from an open fracture was 44%.  However, by the end of World War I, early splinting (the Thomas splint), a more progressive understanding of bacteria and cross-contamination spurred by Pasteur and Koch, and the application of open wound treatment following excision/extension techniques as advocated by Paré, had greatly reduced the scourge of open fracture deaths.[i]

In contemporary society, open extremity fractures usually result from high-energy trauma, with motorcycle, motor vehicle and automobile versus pedestrian injuries accounting for the majority of cases.  In 50% of patients with open fractures, there is multisystem trauma including intraabdominal, chest, head, pelvis and major vascular injuries.[ii] 

By definition, the soft tissues surrounding open fractures are disrupted.  Communication of the fracture with the outside environment leads to foreign body introduction and microorganism contamination.  In addition, injury to surrounding soft tissue compromises vascular integrity, decreasing wound healing and immune response potential at the fracture site.  Structural integrity of the injured bone is compromised as trauma strips bone fragments from the soft tissue attachments.  Finally, dessication occurs at sites of exposed bone, cartilage, tendons and even hardware sites, which can lead to much increased rates of infection.[iii] 

Open fractures are not only at risk for soft tissue infection, from pathogens like staphylococcus, gram negative rods, pseudomonas and clostridium, but also for osteomyelitis.  Approximately 65% of patients who have open fractures have wound bacterial contamination.[iv]  Open fractures are therefore classified accordingly as shown below in Table 1.

Table 1:  Classification of open fractures and infection risk.



Risk of Infection

Type 1

< 1 cm tissue wound with minimal contamination or muscle crushing


Type 2

> 1 cm tissue wound with moderate contamination and/or muscle crushing


Type 3

Extensive soft tissue damage, massive contamination and/or associated vascular injury




As briefly illustrated, open fractures are generally more complicated to treat than closed fractures.  In addition, patients with open fractures are frequently victims of severe polytrauma, thus are at risk for developing systemic complications, even multiorgan system failure (MOSF).  Reducing the impact of the “second hit” has become the cornerstone for today’s damage control orthopedics.  The question becomes, have our aggressive approaches to the once deadly open fracture reduced this injury’s morbidity and mortality to the same level as a closed fracture? 

Material and Methods :

Prospective data were analyzed on 517 blunt trauma patients admitted to a high-volume urban trauma ICU (minimum stay of 48 hours) with extremity fractures. The patients were divided into two groups: open fractures (diagnosis of a minimum of one open long bone fracture) or closed fractures (diagnosis of only closed long bone fractures). The outcomes measured in each study group included hospital length of stay (HLOS), intensive care length of stay (ILOS), ventilator days, and mortality. Both univariate analysis and multivariate logistic regression analysis were performed for each fracture group controlling for demographic data (age, gender and Injury Severity Score) to evaluate outcomes.

Results :

Five hundred and seventeen patients were evaluated in this study population with a mean age of 43 and ISS of 30. The majority were male (n= 267, 51%). Two hundred and ninety-one patients (56%) sustained only closed fractures, while 226 (44%) had at least one open long bone fracture. Of these open fractures, 148 (65%) involved a lower extremity and 78 (35%) involved an upper extremity. The mean age of the open fracture group was slightly lower than that of the closed fracture group (41±20 vs. 45±18, p< 0.05). There was no significant difference between the open and the closed fracture groups in gender (56% male vs. 49% male, p= 0.09) or ISS (31±12 vs. 30±11, p= 0.30). In univariate analysis, there was no significant difference between the open fracture vs. closed fracture groups for HLOS, ILOS, ventilator days, or mortality, as shown in Table 2 below.

Table 2:  Univariate analysis evaluating outcomes from open versus closed extremity fractures.  Mean ± standard deviation.  HLOS: hospital length of stay; ILOS: intensive care unit length of stay.


Closed Fracture Group


Open Fracture Group

P value

HLOS (days)




ILOS (days)




Ventilator Days








Furthermore, multivariate linear regression analysis demonstrated that fracture type (open vs. closed) was not predictive of any of these same outcomes, as shown in Table 3 below.

Table 3:  Multiple logistic regression analysis evaluating fracture type and outcome.  HLOS: hospital length of stay; ILOS: intensive care unit length of stay; CI: confidence interval.


Odds Ratio

P value







Ventilator Days






*95% CI= 0.64-2.01

Discussion :

Both univariate and multivariate analysis demonstrated no difference in outcomes between open and closed fractures in the trauma ICU, despite the apparent difference in complexity between these injuries. It may be that the playing field has been leveled, so to speak, between closed and open fractures in terms of ICU morbidity and mortality. That is not to say that closed fractures require nearly as much as attention as open fractures, but that open fracture management has improved significantly.

Principles of management of open fractures involve emergent debridement of contaminated, non-viable soft tissue and bone, large volume mechanical irrigation (pulse lavage), fracture stabilization, and prophylactic antibiotic therapy. Many patients with open fractures subsequently require repeat debridements, antibiotic bead placement, soft tissue coverage procedures, and prophylactic bone grafting. Thus, the process for treating open fractures continues to require intensive attention, possibly daily procedures, and a multidisciplinary approach.

The reasons leading to our apparent trauma ICU improvement of open fracture management are likely multifactorial. One of the most significant philosophical changes in the past 20 years, the concept of early fracture fixation, may play a large part. This approach involves fracture fixation as part of the initial resuscitation effort. Early fixation probably reduces the noxious stimuli from the fracture site, leading to a less sustained inflammatory response. Early fracture stabilization allows for patient mobilization, improvement in pulmonary status, decreased incidence of deep venous thrombosis and pressure ulcers, and ease of nursing care. In several important studies, early reduction and fixation has been compared favorably to delayed reduction and stabilization. In 1989, Bone and colleagues demonstrated that early femoral fracture stabilization in 178 patients led to lower incidences of pulmonary complications and shorter ICU and hospital stays. Likewise, Behrman and colleagues (1990) showed in 339 trauma patients that delayed operative fracture fixation increased the incidence of pulmonary shunt, pneumonia, hospital stay, and ICU days.

The second reason for open fracture management improvement could be the development of new techniques and technology. In previous years, the treatment of complex fractures was accomplished by open reduction through large incisions with extensive dissection which frequently resulted in a high incidence of skin sloughing, wound infection, and osteomyelitis. To decrease this secondary trauma, realignment of major articulating fragments through indirect reduction is now frequently achieved with external fixators or distractors, many times with image-guidance or arthroscopy. Periarticular fractures (small fragments), once unable to be fixed, are now frequently stabilized percutaneously by lag screws over guide wires. Currently, hybrid fixation constructs combining cannulated screws and external fixation has reduced the complications that had been previously associated with the more invasive surgical approach to periarticular fractures.

A third important reason for the closing gap between open and closed fracture morbidity is the implementation of early soft tissue coverage. Canine studies by Richards and colleagues in 1987, demonstrated that muscle coverage versus skin coverage or healing by secondary intention greatly increased osteoclastic and osteoblastic activity at the cellular level serving as biological basis for improved fracture healing. From this study we know that the quality of the soft tissue envelope, in terms of blood supply, will profoundly affect the healing process. In addition, muscular flaps have been shown to have a greater resistance to bacterial inoculation than random pattern flaps or secondary healing. Several human studies have given clinical merit to early, robust flap coverage. In 1985, Byrd and colleagues managed 191 open tibial fractures and found that fractures managed with open-wound techniques had much higher complication rates than those closed with flaps. Similarly, Gustilo and colleagues found that flap coverage within two weeks of a type 3B was shown to result in decreased infection rates, hospital stay, and number of secondary procedures compared with flap coverage accomplished after two weeks.

Intensive care, spanning all organ systems, continues to become more sophisticated. From an orthopedic standpoint, damage control fracture fixation, hybrid constructs, and early soft tissue coverage have improved open extremity fracture management significantly. It currently appears that the morbidity and mortality of open fractures are no different to that of closed fractures in the trauma ICU.


Reference :


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This is a peer reviewed paper 

Please cite as : Michael J. Kilbourne: Open Versus Closed Extremity Fractures In The Trauma ICU: Current Trends In Morbidity And Mortality

J.Orthopaedics 2008;5(3)e4





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