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.
Extremity fracture; open; closed; trauma; ICU; morbidity;
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]
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]
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]
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
Open fractures are therefore classified accordingly as shown
below in Table 1.
Table 1: Classification of open fractures and infection
Risk of Infection
< 1 cm
tissue wound with minimal contamination or muscle crushing
> 1 cm
tissue wound with moderate contamination and/or muscle
soft tissue damage, massive contamination and/or associated
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
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
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
Multiple logistic regression analysis evaluating fracture type
and outcome. HLOS: hospital length of stay; ILOS: intensive
care unit length of stay; CI: confidence interval.
*95% CI= 0.64-2.01
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
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
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
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.
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