1. Open Fractures

2. Definition
Break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its hematoma

3. Trueta J: "Closed" treatment of war fractures, Lacet 1939;1:1452-1455
History
Last century, high mortality with open fractures of long bones
Early amputation in order to prevent death
WWI, mortality of open femur fractures > 70%
1939 Trueta “closed treatment of war fractures”
Included open wound treatment and then enclosure of the extremity in a cast
“Greatest danger of infection lay in muscle, not bone”
Trueta J: "Closed" treatment of war fractures, Lacet 1939;1:

4. History
1943 PCN on the battlefield quickly reduced rate of wound sepsis
Delayed closure of wounds
Hampton: closure btwn 4th and 7th day
Larger defects continued to be left open to heal by secondary intention
Hampton OP Jr: Basic principles in management of open fractures; JAMA 1955; 159:

5. History Advances shifted the focus
Preservation of life and limb  preservation of function and prevention of complications
However, amputation rates still exceed 50% in the most severe open tibial fractures assoc with vascular injury*
Lange RH, Bach AW, Hansen ST et al: Open tibial fractures with associated vascular injuries: prognosis for limb salvage. J Trauma; 25(3):

6. Epidemiology
3% of all limb fractures
21.3 per 100,000 per year

9. Open fracture classification
Allows comparison of results
Provides guidelines on prognosis and treatment
Fracture healing, infection and amputation rate correlate with the degree of soft tissue injury
Gustilo upgraded to Gustilo and Anderson
AO open fracture classification
Host classification of open fractures

10. Gustilo and Anderson Classification
Model is tibia, however applied to all types of open fractures
Emphasis on wound size
Crush injury assoc with small wounds
Sharp injury assoc with large wounds
Better to emphasize
Degree of soft tissue injury
Degree of contamination
Most widely used today

11. Type I open fracture

12. Type 1 Open Fractures Wound less than 1 cm, Inside-out injury
Clean wound
Minimal soft tissue damage
No significant periosteal stripping

13. Type Ii open fracture

14. Type 2 Open Fractures Moderate soft tissue damage Outside-in
Higher energy
Some necrotic muscle
Some periosteal stripping

15. Type Iii-a open fracture

16. Type 3a Open Fractures High energy Outside-in
Extensive muscle devitalization
Bone coverage with existing soft tissue

17. Type Iii-b open fracture

18. Type 3b Open Fractures
High energy
Outside in
Extensive muscle devitalization
Requires a flap for bone coverage and soft tissue closure
Periosteal stripping

19. Type Iii-c open fracture

20. Type 3c Open Fractures High energy
Increased risk of amputation and infection
Any grade 3 with
major vascular injury requiring repair

21. Why use this classification?
Grades of soft tissue injury correlates with infection and fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2%
2-7%
10-25%
10-50%
25-50%
Fracture Healing (weeks)
21-28
28-28
30-35
Amputation Rate
50%

22. Gustilo and Anderson Bowen and Widmaier*
2005 Host classification predicts infection after open fracture
Gustilo and Anderson classification and the number of comorbidities predict infection risk
174 patients with open fractures of long bones
Sorted into three classes based on 14 immunocompromising factors
Age>80, current nicotine use, DM, malignancy, pulmonary insufficiency, systemic immunodeficiency, etc
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:

23. What they found…
Class
Compromising factors
Infection rates A 4% B
1-2
15% C
3 or more
31%
Patients with any compromising risk factor has increased risk of infection
May benefit from additional therapies that decrease the risk of infection.
Bowen TR, Widmaier JC. Host classification predicts infection after open fracture. Clin Orthop Relat Res. 2005;433:

24. Gustilo Classification: a simple and useful tool, but is it accurate?
1994 Brumback et al.
125 randomized open fractures
245 surgeons of various levels of training
12 cases of open tibia fractures, videos used
Interobserver agreement poor
Range 42-94% for each fracture
Ortho attendings - 59% agreement
Ortho Trauma Fellowship trained attendings - 66% agreement
Brumback RJ, Jones AL (1994) Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone and Joint Am; 76(8):1162–1166.

26. So………. Fracture type should not be classified in the ER
Most reliably done in the OR at the completion of primary wound care and debridement

28. Radiological Examination
Usually, only AP and lateral radiographs are required
They should include adjacent joints and any associated injuries.
There are a number of features that the surgeon should look for when examining the radiographs

30. Radiological Examination
MRI and CT scans are rarely required in the acute situation but may be helpful in open pelvic, intra-articular, carpal, and tarsal fractures.
Angiography may be required in Gustilo IIIb or IIIc fractures.
In the polytraumatized patient, the surgeon must decide if a delay for further imaging is appropriate.

31. Microbiology
Most acute infections are caused by pathogens acquired in the hospital
1976 Gustilo and Anderson
most infections in their study of 326 open fxs developed secondarily
When left open for >2wks, wounds were prone to nocosomial contaminants such as Pseudomonas and other GN bacteria
Currently most open fracture infections are caused by GNR and GP staph
Gustilo RB, Anderson JT: Prevention of Infection in the Treatment of One Thousand and Twenty-five Open Fractures of Long Bones; JBJS, 58(4): , June 1976

32. Cover the wounds quickly
Nocosomial infection?!!!!
Cover the wounds quickly
Only 18% of infections were caused by the same organism initially isolated in the perioperative cultures*
Carsenti-Etesse et al. 1999
92% of open fracture infections were caused by bacteria acquired while the patient was in the hospital**
*Patzakis MJ, Wilkins J, Moore TM: Considerations in reducing the infection rate in open tibial fractures. Clin Orthop Relat Res Sep;(178):36-41.
*Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P: Prospective, randomized, double-blind study comparing single antibiotic therapy, ciprofloxacin, to combo antibiotic therapy in open fracture wounds. J Orthop Trauma Nov;14(8):
**Carsenti-Etesse H, Doyon F, Desplaces N, Gagey O, Tancrede C, Pradier C, Dunais B, Dellamonica P. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:

33. Common bacteria encountered with open fractures
Blunt Trauma, Low Energy GSW
Staph, Strept
Farm Wounds
Clostridia
Fresh Water
Pseudomonas, Aeromonas
Sea Water
Aeromonas, Vibrios
War Wounds, High Energy GSW
Gram Negative
1] Review the common bacteria encountered with open fractures.
2] Note the distinction between the primary infections which occur due to inoculation of bacteria (above) at the time of injury and secondary infections acquired after hospitalization.

34. What systemic antibiotic?
1st Gen Ceph
Gent
PCN
Grade 1 
Grade 2
+/-
Grade 3
Farm/War Wounds
Give IV antibiotics as early as possible. The two most important factors in reducing infection is early antibiotic use with early surgery (Patzakis, JBJS 1974).
Review recommended prophylactic antibiotic treatment based upon severity of soft tissue injury. Note that there are some variations in clinical practice; limited definitive literature.
(Gustilo, et al; JBJS 72A 1990)

35. Antibiotic comparisons
No difference btwn clindamycin and cefazolin*
Patzakis et al. **
For type 1&2, cipro = cefamandole+gentamicin
For type 3, cipro worse (31% vs 7.7% infection)
Cipro and other fluoroquinolones inhibit osteoblast activity and fracture healing***
*Benson DR, Riggins RS, Lawrence RM, Hoeprich PD, Huston AC, Harrison JA. Treatment of open fractures: a prospective study. J Trauma. 1983;23:25-30.
**Patzakis MJ, Bains RS, Lee J, Shepherd L, Singer G, Ressler R, Harvey F, Holtom P. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000;14:
***Holtom PD, Pavkovic SA, Bravos PD, Patzakis MJ, Shepherd LE, Frenkel B. Inhibitory effects of the quinolone antibiotics trovafloxacin, ciprofloxacin, and levofloxacin on osteoblastic cells in vitro. J Orthop Res. 2000;18:721-7.
***Huddleston PM, Steckelberg JM, Hanssen AD, Rouse MS, Bolander ME, Patel R. Ciprofloxacin inhibition of experimental fracture healing. J Bone Joint Surg Am. 2000;82:

36. When and for how long? Start abx as soon as possible*
Less than 3 hours  4.7 % infection rate
Greater than 3 hours  7.4%
No difference btwn 1 and 5 days of post op abx treatment**
Mass Gen recommended treatment:***
Cefazolin Q 8 until 24 hours after wound closed
Gentamicin or levofloxacin added for type 3
*Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res. 1989;243:36-40.
**Dellinger EP, Caplan ES, Weaver LD, Wertz MJ, Brumback R, Burgess A, Poka A, Benirschke SK, Lennard S, Lou MA. Duration of preventive antibiotic administration for open extremity fractures. Arch Surg. 1988;123:333-9.
***Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Dec;88(12):

37. Local antibiotic therapy
High abx conc within the wound and low systemic conc
Reduces risk of systemic side effect
Vancomycin or aminoglycosides
Heat stable
Available in powder form
Active against suspected pathogens
Eckman JB Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988; 237:213-5.

38. Antibiotics - locally
Antibiotic
Infection Rate
IV Abx
12%
IV Abx + local aminoglycoside impregnated PMMA beads
3.7%
Prevents secondary contamination by nocosomial pathogens
Useful adjunct to systemic abx
Potential for abx impregnated bone graft, bone graft substitute, and abx coated IMN
Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases; J Bone Joint Surg Br Jan;77(1):93-7.

39. Antibiotic Beads Cons Pros Requires removal
Limited to heat stable antibiotics
Increased drainage from wound
Pros
Very high levels of antibiotics locally
Dead space management
Review Pros & Cons of antibiotic bead use:
Requires bead removal.
Requires heat stable powdered antibiotics: tobramycin, vancomycin, cefazolin, oxacillin.
Wound closed over beads drain more.

40. Goals of treatment 1. preserve life 2. preserve limb
3. preserve function
Also….
Prevent infection
Fracture stabilization
Soft tissue coverage

42. Stages of care for open fractures

43. Initial assessment & management
ABC’s
Assess entire patient
Careful PE, neurovasc
Abx and tetanus
Local irrigation 1-2 liters
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.

44. Initial assessment & management
Sterile compressive dressings
Realign fracture and splint
Do not culture wound in the ED*
8% of bugs grown caused deep infection
cultures were of no value and not to be done
Recheck pulse, motor and sensation
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71-5.

45. Primary surgery Objectives of initial surgical management
Preservation of life and limb
Wound debridement
Definitive injury assessment
Fracture stabilization
Stages of open fracture management in the OR

46. Surgical emergency! 1898 Friedrich guinea pigs 1973 Robson:
Take to the OR within 6-8 hours*
1973 Robson:
bacteria multiply in contaminated wounds **
105 organisms/gram of tissue is the infection threshold
Reached at 5.17 hours
1995 Kindsfater et al:
47 G2/3 fxs at 4.8 months out….
Less than 5 hrs  7% infection
Greater than 5 hrs  38% infection
However G3 fxs were treated later
*Friedrich PL. Die aseptische Versorgung frischer Wundern. Arch Klin Chir. 1898;57:
**Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:

47. Or not?.... Calling the “6 hour rule” into question
No significant difference before or after 6 hours!!!
1993 Bednar and Parikh…. No significant difference *
3.4% vs 9%; 82 open femoral/tibial fxs
2004 Ashford et al…. No significant difference **
11% vs 17%; pts from the austrailian outback
2004 Spencer et al.... No significant difference ***
10.1% vs 10.9%; 142 open long bone fxs from UK
2003 Pollack and the LEAP investigators…. No correlation****
315 open long bone fxs
2005 Skaggs et al….No significant difference *****
children with all types of open fractures; 554 open fractures
*Bednar DA, Parikh J. Effect of time delay from injury to primary management on the incidence of deep infection after open fractures of the lower extremities caused by blunt trauma in adults. J Orthop Trauma. 1993;7:532-5.
**Ashford RU, Mehta JA, Cripps R. Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures. Injury. 2004;35:411-6.
***Spencer J, Smith A, Woods D. The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital. Ann R Coll Surg Engl. 2004;86:
****Pollack AN, Castillo RC, Jones AL, Bosse MJ, MacKenzie EJ, and the LEAP Study Group. Time to definitive treatment significantly influences incidence of infection after open high-energy lower-extremity trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; 2003 Oct 9-11; Salt Lake City, UT.
*****Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, Kay RM, Flynn JM. “The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.” JBJS-A :8-12

48. Do we even need to do operative debridement?
Do we even need to debride low grade open fractures?
Orcutt et al... No significant difference, BUT…*
50 type 1 &2 open fractures
less infection in nonoperative group (3% vs 6%)
Less delayed union in nonop group (10% vs 16%)
Yang et al….0% infections **
91 type 1 open fractures treated without I&D
*Orcutt S, Kilgus D, Ziner D. The treatment of low-grade open fractures without operative debridement. Read at the Annual Meeting of the Orthopaedic Trauma Association; 1988 Oct 28; Dallas, TX.
**Yang EC, Eisler J. “Treatment of Isolated Type 1 Open Fractures: Is Emergent Operative Debridement Necessary?” Clin Orthop Relat Res :

49. However, after review of all literature….….
Operative debridement is the standard of care!!!!
Okike et al. states….
“Thorough operative debridement is the standard of care for all open fractures.”
“Even if the benefits of formal I&D were insignificant for low grade fractures, operative debridement is still required for proper wound classification.”
“Open fractures graded on the basis of superficial characteristics are often misclassified.”
Huge risk not to explore and debride!
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am Dec;88(12):

51. URGENTLY debride, not EMERGENTLY
Within 24 hours
Time to OR is probably less important than:*
Adequacy of debridement
Time to soft tissue coverage
Timing depends on….**
Is patient stable?
Is the OR prepared?
Is appropriate assistance available?
Ortho trained scrub techs, assistant surgeons, xray techs, and other OR staff
2005 Skaggs et al:***
If after 10pm, keep until the morning! Or at least within 24 hours.
Unless….
neurovasc compromise
horrible soft tissue contamination
compartment syndrome
Within
6 hours
*Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Dec;88(12):
**Werner CM, Pierpont Y, Pollak AN: The urgency of surgical débridement in the management of open fractures. J Am Acad Orthop Surg Jul;16(7):
***Stewart DJ, Kay RM, Skaggs DL: Open Fractures in Children. Principles of Evaluation and Management. JBJS-A. 2005;87:

52. I&D in the OR Trauma scrub “Zone of injury” Extend the traumatic wound
Soap and saline to remove gross debris
“Zone of injury”
Skin wound is the window through which the true wound communicates with the exterior
Extend the traumatic wound
Excise margins
Resect muscle and skin to healthy tissue
color, consistency, capacity to bleed and contractility

53. I&D in the OR Bone ends are exposed and debrided Irrigate
Serial debridements?
If needed, 2nd or 3rd debridement after hours should be planned

54. The Irrigation Amount No good data, copious is better
Animal studies show improved removal of particulate matter and bacteria but effect plateaus
Irrigation bags typically contain 3 L of fluid
Anglen recommends:*
3L (one bag) for type 1
6L (two bags) for type 2
9L (three bags) for type 3
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS :

55. How to deliver the irrigation? (what animal studies show)
Bulb Syringe vs Pulsatile Lavage
Pulsatile lavage
Detrimental for early bone healing
this is no longer present at 2 wks*
More soft tissue destruction**
More effective in removing particulate matter and bacteria***
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on Fracture Healing.” JOT (7):
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR :
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT :

56. How to deliver the irrigation? (what animal studies show)
High or low pressure?
Higher pressure
Better bone cleaning
Worse soft tissue cleaning
Slows bone healing
*Dirschl DR, Duff GP, Dahners LE, Edin M, Rahn BA, Miclau T. “High Pressure Pulsatile Lavage Irrigation of Intraarticular Fractures: Effects on Fracture Healing.” JOT (7):
**Boyd JI, Wongworawat MD. “High-Pressure Pulsatile Lavage Causes Soft Tissue Damage.” CORR :
***Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. “High and Low Pressure Pulsatile Lavage of Contaminated Tibial Fractures: An in vitro Study of Bacterial Adherence and Bone Damage.” JOT :

57. Antibiotics in the irrigation?
No proven benefit!
Antibiotics (bacitracin and/or neomycin)
Mixed results, controversial
Costly
bacitracin alone around $500/washout
?? Causing resistance
Wound healing problems?
Few reported cases of anaphylaxis
Anglen: “No proven value in the care of open fracture wounds…some risk, albeit small.”
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS :

58. Soaps in the irrigation?
Surfactants (i.e. Soaps)
Less bacteria adhesion
Emulsify and remove debris
No significant difference in infection or bone healing compared to bacitracin solution, but more wound healing problems in bacitracin group
Anglen JO. “Comparison of Soap and Antibiotic Solutions for Irrigation of Lower-Limb Open Fracture Wounds: A Prospective, Randomized Study.” JBJS-A (7):

59. Level 4 evidence based recommendations
1st washout, highly contaminated
 Soap solution
Repeat washout of clean wounds
 Saline
Infected wounds
 Soap, then antibiotic
*Anglen JO. “Wound Irrigation in Musculoskeletal Injury.” JAAOS :

60. Wound closure after contaminated fracture
Dubunked!
Wound closure after contaminated fracture
Timing and technique is controversial
OPEN WOUND should be left OPEN!
Prevents anaerobic conditions in wound: Clostridium
Facilitates drainage
Allows repeat debridement
Zalavras CG, Patzakis MJ:Open fractures: evaluation and management. J Am Acad Orthop Surg May-Jun;11(3):212-9.

61. Percent of primary closures
To close or not to close?
Recently, renewed interest in primary closure
Collinge, OTA 2004
Moola, OTA 2005
Russell, OTA 2005
DeLong, J Trauma 2004/
Bosse, JAAOS 2002
Improved abx management
Better stabilization
Less morbidity
Shorter hospital stay, lower cost
NO increase in wound infection
These wounds are at higher risk of clostridia perfringens if they do get infected.
1999 Delong et al: 119 open fxs
No significant difference
delayed/nonunion and infection rates btwn immediate and delayed closure
Immediate closure is a “viable option”
Grade
Percent of primary closures 1
88% 2
86% 3a
75% 3b
33% 3c 0%
infection rate 7%
Overall delayed/nonunion rate
16%
DeLong WG Jr, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW: Aggressive treatment of 119 open fracture wounds. J Trauma Jun;46(6):

62. Contraindications to primary closure
Inadequate debridement
Gross contamination
Farm related or freshwater immersion injuries
Delay in treatment >12 hours
Delay in giving abx
Compromised host or tissue viability

63. When to cover the wound? “Fix and Flap”**
ASAP after wound adequately debrided
Only 18% of infections are caused by the same organism isolated in initial perioperative culture*
Suggests hospital acquired etiology of infection
“Fix and Flap”**
For Type IIIB & IIIC open tibia fractures
Early if not immediate flap coverage
Timing of flap placement
Infection rate
< 72 hours 6%
> 72 hours
30%
Patzakis MJ, Bains RS, Lee J, et al. “Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds.” JOT :
**Gopal S, Majumder S, Batchelor A, Knight S, De Boer P, Smith RM. “Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia.” JBJS-B (7): 959 – 966.

64. Dressings Temporary closures – rubber bands Wet to dry dressings
Semi-permeable membranes
Antibiotic bead pouch
VAC

65. VAC Vacuum assisted wound closure
Recommended for temporary management
Mechanically induced negative pressure in a closed system
Removes fluid from extravascular space
Reduced edema
Improves microcirculation
Enhances proliferation of reparative granulation tissue
Open cell polyurethane foam dressing ensures an even distribution of negative pressure
-Webb LX: New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg Sep-Oct;10(5):
-Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta A, Kulp B, Morykwas M, Webb L. “The use of Negative Pressure Wound Therapy in the Temporary Treatment of Soft Tissue Injuries associated with High Energy Open Tibial Shaft Fractures.” JOT

66. Types of fracture stabilization
Splint
Good option if operative fixation not required
Internal fixation
Wound is clean and soft tissue coverage available
External fixation
Dirty wounds or extensive soft tissue injury

67. Fracture stabilization
Gustilo type 1 injury can be treated the same way as a comparable closed fracture
Most cases involve surgical fixation
Outcome is similar to closed counterparts

68. Fracture stabilization
Gustilo type 2&3 usually displaced and unstable
dictate surgical fixation
Restore length, alignment, rotation and provide stability
ideal environment for soft tissue healing and reduces wound infection
reduces dead space and hematoma volume
Inflammatory response dampened
Exudates and edema is reduced
Tissue revascularization is encouraged

69. When to use plates? Open diaphyseal fractures of arm & forearm
Open diaphyseal fractures lower extremity
NOT recommended
Open tibial shaft plating assoc high infection rate*
Open periarticular fractures
Treatment of choice in both upper and lower extremities
Bach AW, Hansen ST Jr.: Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin Orthop Relat Res Apr;(241):89-94.

70. When to use IM nails?
Treatment of choice for most diaphyseal fractures of the lower extremity
Inserted without disrupting the already injured soft tissue envelope
Preserves the remaining extra osseous blood supply to cortical bone
Malunion is uncommon

71. To ream or not to ream?
Does reaming cause additional damage to the endosteal blood supply?
Solid IM nails without reaming has a lower risk of infection that tubular nails with a large dead space*
However reamed IM nails are biomechanically stronger and can reliably maintain fracture reduction if statically locked
2000 Finkemeier et al.
reamed vs unreamed interlocked nails of open tibias
NO statistical difference in outcome and risk of complication**
*Melcher GA, Claudi B, Schlegel U, Perren SM, Printzen G, Munzinger J.Influence of type of medullary nail on the development of local infection. An experimental study of solid and slotted nails in rabbits; .J Bone Joint Surg Br Nov;76(6):955-9.
**Keating JF, O'Brien PJ, Blachut PA, Meek RN, Broekhuyse HM: Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study. J Bone Joint Surg Am Mar;79(3):
**Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka TF: A prospective, randomized study of intramedullary nails inserted with and without reaming for the treatment of open and closed fractures of the tibial shaft. J Orthop Trauma Mar-Apr;14(3):

72. When to use external fixation?
Diaphyseal fractures not amenable to IM nails
Ring fixators for periarticular fractures
Temporary joint spanning ex fix is popular for knee, ankle, elbow and wrist
If temporary, plan for conversion to IM nail within 3 weeks

73. Ex-fix: Weigh the pros and cons!
Historically was definitive treatment
Now, more commonly as temporary fixation
Can be applied almost always and everywhere
Severe soft tissue damage and contamination

74. Advantages Easy and quick Relatively stable fixation
No further damage done
Avoids hardware in the open wound

75. Disadvantages Pin track infections Malalignment Delayed union
Poor patient compliance

76. Skin cover and soft tissue reconstruction
Do these early!
1994 Osterman et al.*
Retrospective 1085 fractures, 115 G2 and 239 G3
All treated with appropriate IV Abx and I&D
No infection if wounds closed at 7.6 days
Yes infection if wounds closed at 17.9 days
Infection risk increases if wound open > 7 days
*Ostermann PA, Seligson D, Henry SL: Local antibiotic therapy for severe open fractures: A review of 1085 consecutive cases. J Bone Joint Surg Br 1995;77:93–97.

77. Reconstructive ladder: options for wound coverage
Type 1 open fx
Primary closure
Secondary intention
Skin graft
Local flap
Regional flap
Distant flap
Free flap
Tissue expansion
Type 2/3A open fx
Type 3B open fx

79. Flap coverage for type 3b

80. Type 3c, a bad injury! Devastating damage to bone and soft tissue
Major arterial injuries that require repair
Poor functional outcome
Consensus btwn ortho, vascular and plastics
Salvage is technically possible in most cases
However it is not always the correct choice esp type 3c tibia fractures

81. We can do both, salvage & amputate.
Vascular surgery can revascularize with bypass graft
Generally before fracture stabilization
Plastics can provide soft tissue coverage
However, in the tibia, the severity to soft tissue envelope and bone may result in infected nonunion
If salvage…. long course of repeated surgical procedures
Painful and psychologically distressing
Functional outcome may be poor and no better than amputation

82. How to decide, salvage or amputate?
Important factors in decision making:*
General condition of the patient (shock)
Warm ischemia time (>6hours)
Age (>30 years)
Cut to crush ratio (blunt injuries has a large zone of crush)
Howe HR Jr, Poole GV Jr, Hansen KJ, Clark T, Plonk GW, Koman LA, Pennell TC: Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg Apr;53(4):205-8.

83. Gunshot injuries Energy dissipated at impact = damage severity
High velocity rifles and close range shotguns
Worst, high energy of impact
Huge secondary cavitation
Secondary effects of shattered bone fragments
Bullets lodged in joints should be removed
avoid lead arthropathy and systemic lead poisoning

84. Low velocity GSW <2000 ft/sec
Low velocity handguns
Less severe, not treated like open fractures
Cavitation is not significant
Secondary missile effects are minimal
Bone fragments rarely stripped of soft tissue attachments and blood supply
Soft tissue injuries not severe and skin wounds are small

85. Low velocity GSW open fractures
Treat open fractures from low velocity GSW as closed fractures without Abx
Geisslar et al. *
If neurovascular status normal, do local debridement
NO formal I&D needed
IV Abx
Approach fx fixation as if closed
Dickey et al.**
No abx vs IV Ancef x 3d
67 low velocity GSW fxs
Not requiring operative fixation
No difference in infection rates
**Dickey et al, J Ortho Trauma, 3;6-10,1989
*Geisslar ett al, J Ortho Trauma, 4;39-41,1990

86. Pitfalls and complications
Infection  delayed union, nonunion, malunion and loss of function
Plan ahead to avoid delayed union and nonunion
Predict nonunion in severe injuries with bone loss
Bone grafting usually delayed 6 weeks when soft tissues have soundly healed
Autogenous bone grafting is usual strategy
Fibular transfer, free composite graft or distraction osteogenesis for complex defects
Recombinant human BMP in open tibia fracture reduces risk of delayed union

87. Advances… BMPs Antibiotic Laden Bone Graft**
40% decreased infection rate with BMP in type 3 open tibia fractures*
Antibiotic Laden Bone Graft**
Tobramycin-impregnated calcium sulfate pellets with demineralized bone matrix
Animal study: successful in preventing infection
*BESTT Study Group, Govender S, Csimma C, Genant H, Valentin-Opran A. “Recombinant Human Bone Morphogenetic Protein-2 for Treatment of Open Tibial Fractures: A prospective, controlled, randomized study of four hundred and fifty patients.” JBJS-A (12):
**Beardmore AA, Brooks DE, Wenke JC, Thomas DB. “Effectiveness of local antibiotic delivery with an osteoinductive and osteoconductive bone-graft substitute.” JBJS-A (1):

88. Summary A = good evidence (level 1 studies)
B = fair evidence (level 2/3 studies)
C = poor quality evidence (level 4/5 studies)
I = insufficient or conflicting evidence
Okike K, Bhattacharyya T: Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Dec;88(12):

89. Thank you