Open Fractures

By admin On Dec 23, 2022

Ovid: Handbook of Fractures

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.

Title: Handbook of Fractures, 3rd Edition

> Table of Contents > I – General Considerations > 3 – Open Fractures

Open Fractures

An open fracture
refers to osseous disruption in which a break in the skin and
underlying soft tissue communicates directly with the fracture and its
hematoma. A compound fracture refers to the same injury, but this term is archaic.
One-third of patients with open fractures are multiply injured.
Any wound occurring on the same limb
segment as a fracture must be suspected to be a consequence of an open
fracture until proven otherwise.
Soft tissue injuries in an open fracture may have three important consequences:
- Contamination of the wound and fracture by exposure to the external environment.
- Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection.
- Destruction or loss of the soft tissue
  envelope may affect the method of fracture immobilization, compromise
  the contribution of the overlying soft tissues to fracture healing
  (e.g., contribution of osteoprogenitor cells), and result in loss of
  function from muscle, tendon, nerve, vascular, ligament, or skin damage.

MECHANISM OF INJURY

Open fractures result from the application of a violent force. The applied kinetic energy (.5 mv²) is dissipated by the soft tissue and osseous structures (Table 3.1)
The amount of osseous displacement and
comminution is suggestive of the degree of soft issue injury and is
proportional to the applied force.

CLINICAL EVALUATION

Patient assessment involves ABCDE: airway, breathing, circulation, disability, and exposure.
Initiate resuscitation and address life-threatening injuries.
Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
Identify all injuries to the extremities.
Assess the neurovascular status of injured limb(s).

Assess skin and soft tissue damage:
exploration of the wound in the emergency setting is not indicated if
operative intervention is planned because it risks further
contamination with limited capacity to provide useful information and
may precipitate further hemorrhage.

Obvious foreign bodies that are easily accessible may be removed in the emergency room under sterile conditions.
Irrigation of wounds with sterile normal saline may be performed in the emergency room if a surgical delay is expected.

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Sterile injection of joints with saline may be undertaken to determine egress from wound sites to evaluate possible continuity.

Table 3.1. Energy transmitted by injury mechanism

Injury	Energy (Foot-Pounds)
Fall from curb	100
Skiing injury	300–500
High-velocity gunshot wound (single missile)	2,000
20-mph bumper injury (assumes bumper strikes fixed target)	100,000
From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

Identify skeletal injury; obtain necessary radiographs.

COMPARTMENT SYNDROME

Open fractures are not immune to the
potentially disastrous consequences of compartment syndrome,
particularly with severe blunt trauma or crush injuries.
Severe pain, decreased sensation, pain to
passive stretch of fingers or toes, and a tense extremity are all clues
to the diagnosis. A strong suspicion or an unconscious patient in the
appropriate clinical setting warrants monitoring of compartment
pressures.
Compartment pressures >30 mm Hg raise
concern and within 30 mm Hg of the diastolic blood pressure indicate
compartment syndrome; immediate fasciotomies should be performed.
Distal pulses may remain present long after muscle and nerve ischemia and damage are irreversible.

VASCULAR INJURY

An angiogram should be obtained if a vascular injury is suspected.
Indications for angiogram include the following:
- Knee dislocation with ankle-brachial index (ABI) <0.9
- Cool, pale foot with poor distal capillary refill
- High-energy injury in an area of compromise (e.g., trifurcation of the popliteal artery)
- Documented ABI <0.9 associated with a
  lower extremity injury (note: preexisting peripheral vascular disease
  may result in abnormal ABIs; comparison with the contralateral
  extremity may reveal underlying vascular disease)

RADIOGRAPHIC EVALUATION

Trauma survey includes a lateral cervical spine film and AP views of the chest, abdomen, and pelvis.
Extremity radiographs are obtained as
indicated by clinical setting, injury pattern, and patient complaints.
It is important to include the joint above and below an apparent limb
injury.

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Additional studies include CT with or
without intravenous or oral contrast, cystograms, urethrograms,
intravenous pyelograms, angiography, and others as indicated clinically.

CLASSIFICATION

Gustilo and Anderson (Open Fractures) (Tables 3.2 and 3.3)

Table 3.2. Classification of open fractures

Type	Wound	Level of Contamination	Soft Tissue Injury	Bone Injury
I	<1 cm long	Clean	Minimal	Simple, minimal comminution
II	>1 cm long	Moderate	Moderate, some muscle damage	Moderate comminution
III^a
A	Usually >10 cm long	High	Severe with crushing	Usually comminuted; soft tissue coverage of bone possible
B	Usually >10 cm long	High	Very severe loss of coverage; usually requires soft tissue reconstructive surgery	Bone coverage poor; variable, may be moderate to severe comminution
C	Usually >10 cm long	High	Very severe loss of coverage plus vascular injury requiring repair; may require soft tissue reconstructive surgery	Bone coverage poor; variable, may be moderate to severe comminution
^aSegmental fractures, farmyard injuries, fractures occurring in a highly contaminated environment, shotgun wounds, or high-velocity gunshot wounds automatically result in classification as type III open fractures. From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

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This was originally designed to classify
soft tissue injuries associated with open tibial shaft fractures and
was later extended to all open fractures.
It is useful for communicative purposes despite variability in interobserver reproducibility.

Grade I:	Clean skin opening of <1 cm, usually from inside to outside; minimal muscle contusion; simple transverse or short oblique fractures
Grade II:	Laceration >1 cm long, with extensive soft tissue damage; minimal to moderate crushing component; simple transverse or short oblique fractures with minimal comminution
Grade III:	Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-energy injury with a severe crushing component
IIIA:	Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries, minimal periosteal stripping
IIIB:	Extensive soft tissue injury with periosteal stripping and bone exposure requiring soft tissue flap closure; usually associated with massive contamination
IIIC:	Vascular injury requiring repair

Tscherne Classification of Open Fractures

This takes into account wound size, level of contamination, and fracture mechanism.

Grade I:	Small puncture wound without associated contusion, negligible bacterial contamination, low-energy mechanism of fracture
Grade II:	Small laceration, skin and soft tissue contusions, moderate bacterial contamination, variable mechanisms of injury
Grade III:	Large laceration with heavy bacterial contamination, extensive soft tissue damage, with frequent associated arterial or neural injury
Grade IV:	Incomplete or complete amputation with variable prognosis based on location of and nature of injury (e.g., cleanly amputated middle phalanx versus crushed leg at the proximal femoral level)

Tscherne Classification of Closed Fractures

This classifies soft tissue injury in closed fractures and takes into account indirect versus direct injury mechanisms.

Grade 0:	Injury from indirect forces with negligible soft tissue damage
Grade I:	Closed fracture caused by low to moderate energy mechanisms, with superficial abrasions or contusions of soft tissues overlying the fracture
Grade II:	Closed fracture with significant muscle contusion, with possible deep, contaminated skin abrasions associated with moderate to severe energy mechanisms and skeletal injury; high risk for compartment syndrome
Grade III:	Extensive crushing of soft tissues, with subcutaneous degloving or avulsion, and arterial disruption or established compartment syndrome

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TREATMENT

Emergency Room Management

Table 3.3. Factors that modify open fracture classification regardless of initial skin defect

Contamination

Exposure to soil
Exposure to water (pools, lakes/streams)
Exposure to fecal matter (barnyard)
Exposure to oral flora (bite)
Gross contamination on inspection
Delay in treatment >12 hours

Signs of high-energy mechanism

Segmental fracture
Bone loss
Compartment syndrome
Crush mechanism
Extensive degloving of subcutaneous fat and skin
Requires flap coverage (any size defect)

From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

After initial trauma survey and resuscitation for life-threatening injuries (see Chapter 2):

Perform a careful clinical and radiographic evaluation as outlined earlier.
Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clamping.
Initiate parenteral antibiosis (see later).
Assess skin and soft tissue damage; place a saline-soaked sterile dressing on the wound.
Perform provisional reduction of fracture and place a splint.
Operative intervention: open fractures
constitute orthopaedic emergencies, because intervention less than 8
hours after injury has been reported to result in a lower incidence of
wound infection and osteomyelitis. In certain centers, there has been a
move to delay operating on lower-energy open fractures in the middle of
the night and to treat the injury as the first case of the morning. The
patient should undergo formal wound exploration, irrigation, and
debridement before definitive

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fracture fixation, with the understanding that the wound may require multiple debridements.

Important

Do not irrigate, debride, or probe the
wound in the emergency room if immediate operative intervention is
planned: this may further contaminate the tissues and force debris
deeper into the wound. If a surgical delay is anticipated, gentle
irrigation with normal saline may be performed. Only obvious foreign
bodies that are easily accessible should be removed.
Bone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may be.

Antibiotic Coverage for Open Fractures (Table 3.4)

Table 3.4. Intravenous antibiotic therapy for open fractures^a

	Type I	Type II	Type III	Organic Contamination
Cefazolin, 1 g every 8 hours	X	X	X
Aminoglycoside, 3–5 mg/kg/day^b			X
Penicillin, 2,000,000 units every 4 hours (or metronidazole, 500 mg every 6 hours)				X
^aAntibiotic doses for adult patients. ^bVaries with renal function of patient. From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

Grade I, II:	First-generation cephalosporin
Grade III:	Add an aminoglycoside
Farm injuries:	Add penicillin and an aminoglycoside

Tetanus prophylaxis should also be given in the
emergency room (see later). The current dose of toxoid is 0.5 mL
regardless of age; for immune globulin, the dose is 75 U for patients
<5 years of age, 125 U for those 5 to 10 years old, and 250 U for
those >10 years old. Both shots are administered intramuscularly,
each from a different syringe and into a different site.

Requirements for Tetanus Prophylaxis

Immunization history	dT	TIG	dT	TIG
Incomplete (<3 doses) or not known	+	–	+	+
Complete/>10 years since last dose	+	–	+	–
Complete/<10 years since last dose	–	–	–a	–
Key: +, prophylaxis required; -, prophylaxis not required; dT, diphtheria and tetanus toxoids; TIG, tetanus immune globulin; a, required if >5 years since last dose.

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Operative Treatment

Irrigation and Debridement

Adequate irrigation and debridement are the most important steps in open fracture treatment:

The wound should be extended proximally and distally to examine the zone of injury.
The clinical utility of intraoperative cultures has been highly debated and remains controversial.

Meticulous debridement should be performed, starting with the skin and subcutaneous fat (Table 3.5).

Table 3.5. Factors of muscle viability

Color	Normally beefy red; rarely, carbon monoxide exposure can be deceiving
Consistency	Normally firm, not easily disrupted
Capacity to bleed	Can be deceiving because arterioles in necrotic muscle can bleed Typically reliable
Contractility	Responsive to forceps pinch or low cautery setting Typically reliable
From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

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Large skin flaps should not be developed
because this further devitalizes tissues that receive vascular
contributions from vessels arising vertically from fascial attachments.
A traumatic skin flap with a
base-to-length ratio of 1:2 will frequently have a devitalized tip,
particularly if it is distally based.
Tendons, unless severely damaged or contaminated, should be preserved.
Osseous fragments devoid of soft tissue may be discarded.
Extension into adjacent joints mandates exploration, irrigation, and debridement.

The fracture surfaces should be exposed, with recreation of the injury mechanism.
Pulsatile lavage irrigation, with or
without antibiotic solution, should be performed. Some authors have
demonstrated decreased infection rates with >10 L of irrigation
under pulsatile lavage.
Meticulous hemostasis should be
maintained, because blood loss may already be significant and the
generation of clot may contribute to dead space and nonviable tissue.
Fasciotomy should be considered, especially in the forearm or leg.
Historically, it has been advocated that
traumatic wounds should not be closed. One should close the surgically
extended part of the wound only. More recently, certain centers have
been closing the open wound after debridement with close observation
for signs or symptoms of sepsis.
The wound, if left open, should be
dressed with saline-soaked gauze, synthetic dressing, a vacuum assisted
closure (VAC) sponge, or an antibiotic bead pouch.
Serial debridement(s) should be performed
every 24 to 48 hours as necessary until there is no evidence of
necrotic soft tissue or bone.

Foreign Bodies

Foreign bodies, especially organic ones, must be sought
and removed because they can lead to significant morbidity if they are
left in the wound. (Note: Gunshot injuries are discussed separately.)

Wood may become blood soaked and difficult to differentiate from muscle.
Cloth and leather are usually found between tissue planes and may be remote from the site of injury.
The foreign material itself usually
incites an inflammatory response, whereas intrinsic crevices may harbor
pathogenic organisms or spores.

Fracture Stabilization

In open fractures with extensive soft tissue injury,
fracture stabilization (internal or external fixation) provides
protection from additional soft tissue injury, maximum access for wound
management, and maximum limb and patient mobilization. (See individual
chapters for specific fracture management) (Table 3.6).

Table 3.6. Relative indications for type of skeletal fixation in open fractures

External fixation

Severe contamination: any site
Periarticular fractures
1. Definitive
  - Distal radius
  - Elbow dislocation
  - Selected other sites
2. Temporizing
  - Knee
  - Ankle
  - Elbow
  - Wrist
  - Pelvis
Distraction osteogenesis
In combination with screw fixation for severe soft tissue injury

Internal fixation

Periarticular fractures
1. Distal/proximal tibia
2. Distal/proximal femur
3. Distal/proximal humerus
4. Proximal ulnar radius
5. Selected distal radius/ulna
6. Acetabulum/pelvis
Diaphyseal fractures
1. Femur
2. Tibia
3. Humerus
4. Radius/ulna

From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

Soft Tissue Coverage and Bone Grafting

Wound coverage is performed once there is no further evidence of necrosis.
The type of coverage—delayed primary
closure, split-thickness skin graft, rotational or free muscle flaps—is
dependent on the severity and location of the soft tissue injury.
Bone grafting can be performed when the
wound is clean, closed, and dry. The timing of bone grafting after free
flap coverage is controversial. Some advocate bone grafting at the time
of coverage; others wait until the flap has healed (normally 6 weeks).

Limb Salvage

Choice of limb salvage versus amputation in Gustilo
Grade III injuries is controversial. Immediate or early amputation may
be indicated if:

The limb is nonviable: irreparable
vascular injury, warm ischemia time >8 hours, or severe crush with
minimal remaining viable tissue.
Even after revascularization the limb
remains so severely damaged that function will be less satisfactory
than that afforded by a prosthesis.
The severely damaged limb may constitute
a threat to the patient’s life, especially in patients with severe,
debilitating, chronic disease.

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The severity of the injury would demand
multiple operative procedures and prolonged reconstruction time that is
incompatible with the personal, sociologic, and economic consequences
the patient is willing to withstand.
The patient presents with an injury severity score (ISS; see Chapter 2)
of >20 in whom salvage of a marginal extremity may result in a high
metabolic cost or large necrotic/ inflammatory load that could
precipitate pulmonary or multiple organ failure.
The expected postsalvage function does not justify limb salvage.

The Mangled Extremity Severity Score (MESS) was designed to predict the likelihood of amputation based on four criteria. A

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score of >7 has been reported to predict amputation accurately in both retrospective and prospective studies (Table 3.7).

Table 3.7. Mangled extremity severity score (MESS) for prediction of amputation

A.	Skeletal/soft tissue injury		Points^a
	1.	Low energy (stab, simple fracture, low-velocity gunshot wound)	1
	2.	Medium energy (open/multiple fractures or dislocations)	2
	3.	High energy (close-range shotgun, high-velocity gunshot, crush)	3
	4.	Very high energy (above plus gross contamination, soft tissue avulsion)	4
B.	Limb ischemia
	1.	Pulse reduced or absent but perfusion normal	1^b
	2.	Pulseless, paresthesias, diminished capillary refill	2^b
	3.	Cool, paralyzed, insensate, numb	3^b
C.	Shock
	1.	Systolic blood pressure always >90 mm Hg	0
	2.	Hypotensive transiently	1
	3.	Persistent hypotension	2
D.	Age (Years)
	1.	<30	0
	2.	30–50	1
	3.	>50	2
^aMESS = total points. ^bScore doubles for ischemia >6 hours.

COMPLICATIONS

Infection: Open fractures may result in
cellulitis or osteomyelitis, despite aggressive, serial debridements,
copious lavage, appropriate antibiosis, and meticulous wound care.
Gross contamination at the time of injury is causative, although
retained foreign bodies, soft tissue compromise, and multisystem injury
are risk factors for infection.
Compartment syndrome: This devastating
complication results in severe loss of function, especially in tight
fascial compartments including the forearm and leg. It may be avoided
by a high index of suspicion with serial neurovascular examinations
accompanied by compartment pressure monitoring, prompt recognition of
impending compartment syndrome, and fascial release at the time of
surgery.