Open fracture

Open fracture is a type of bone fracture in orthopedics, frequently caused by high energy trauma. It is a bone fracture associated with a break in the skin continuity which can cause complications such as infection, malunion, and nonunion. Gustilo open fracture classification is the most commonly used method to classify open fractures, to guide treatment and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. Cephalosporins are generally the first line of antibiotics. The antibiotics are continued for 24 hours to minimize the risk of infections. Therapeutic irrigation, wound debridement, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections.

Open fracture
Gustilo Type 2 fracture
Specialty	Orthopedics

Causes

Open fractures can occur due to direct impacts such as high-energy physical forces (trauma), motor vehicular accidents, firearms, and falls from height.[1] Indirect mechanisms include twisting (torsional injuries) and falling from a standing position.[1] These mechanisms are usually associated with substantial degloving of the soft-tissues, but can also have a subtler appearance with a small poke hole and accumulation of clotted blood in the tissues. Depending on the nature of the trauma, it can cause different types of fractures:[2][3]

Common fractures

Result from significant trauma to the bone. This trauma can come from a variety of forces – a direct blow, axial loading, angular forces, torque, or a mixture of these.

Pathological fractures

Result from minor trauma to diseased bone. These preexisting processes include metastatic lesions, bone cysts, advanced osteoporosis, etc.[3]

Fracture-dislocations

Severe injury in which both fracture and dislocation take place simultaneously.[2]

Gunshot wounds

Caused by high-speed projectiles, they cause damage as they go through the tissue, through secondary shock wave and cavitation.[3]

Diagnosis

The initial evaluation for open fractures is to rule out any other life-threatening injuries. Advanced Trauma Life Support (ATLS) is the initial protocol to rule out such injuries. Once the patient is stabilised, orthopedic injuries can be evaluated. Mechanism of injury is important to know the amount energy that is transferred to the patient and the level of contamination. Every limb should be exposed to evaluate any other hidden injuries. Characteristics of the wound should be noted in detail. Neurology and the vascular status of the affected limb is important to rule our any nerve or blood vessels injuries. High index of suspicion of compartment syndrome should be maintained for leg and forearm fractures.[4]

There are a number of classification system attempting to categorise open fractures such as Gustilo open fracture classification, Tscherne classification, and Müller AO Classification of fractures. However, Gustilo open fracture classification is the most commonly used classification system. Gustilo system grades the fracture according to energy of injury, soft tissue damage, level of contamination, and comminution of fractures. The higher the grade, the worse the outcome of the fracture.[4]

Gustilo open fracture Classification

Gustilo Grade	Definition
I	Open fracture, clean wound, wound <1 cm in length
II	Open fracture, wound > 1 cm but < 10 cm in length[5] without extensive soft-tissue damage, flaps, avulsions
IIIA	Open fracture with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma (gunshot and farm injuries) regardless of the size of the wound[5][6]
IIIB	Open fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination.[5][6] Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)
IIIC	Open fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury.

However, Gustilo system is not without its limitations. The system has limited interobserver reliability at 50% to 60%. The size of injury on the skin surface does not necessarily reflect the extent of deep underlying soft tissue injury. Therefore, the true grading of Gustilo can only be done in operating theatre.[4]

Management

Acute Management

Urgent interventions, including therapeutic irrigation and wound debridement, are often necessary to clean the area of injury and minimize the risk of infection.[7] Other risks of delayed intervention include long-term complications, such as deep infection, vascular compromise and complete limb loss.[7] After wound irrigation, dry or wet gauze should be applied to the wound to prevent bacterial contamination. Taking photographs of the wound can help to reduce the need of multiple examinations by different doctors, which could be painful. Limb should be reduced and placed in a well-padded splint for immobilization of fractures. Pulses should be documented before and after reduction.[4]

Wound cultures are positive in 22% of pre-debridement cultures and 60% of post-debridement cultures of infected cases. Therefore, pre-operative cultures no longer recommended. The value of post-operative cultures is unknown. Tetanus prophylaxis is routinely given to enhance immune response against Clostridium tetani. Anti-tetanus immunoglobulin is only indicated for those with highly contaminated wounds with uncertain vaccination history. Single intramuscular dose of 3000 to 5000 units of tetanus immunoglobulin is given to provide immediate immunity.[4]

Another important clinical decision during acute management of open fractures involves the effort to avoid preventable amputations, where functional salvage of the limb is clearly desirable.[7] Care must be taken to ensure this decision is not solely based on an injury severity tool score, but rather a decision made following a full discussion of options between doctors and the person, along with their family and care team.[7]

Antibiotics

Administration of antibiotics as soon as possible is necessary to reduce the risk of infection. However, antibiotics may not provide necessary benefits in open finger fractures and low velocity firearms injury. First generation cephalosporin (cefazolin) is recommended as first line antibiotics for the treatment of open fractures. The antibiotic is useful against gram positive cocci and gram negative rods such as Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae. To extend the coverage of antibiotics against more bacteria in Type III Gustilo fractures, combination of first generation cephalosporin and aminoglycoside (gentamicin or tobramycin) or a third generation cephalosporin is recommended to cover against nosocomial gram negative bacilli such as Pseudomonas aeruginosa. Adding penicillin to cover for gas gangrene caused by anaerobic bacteria Clostridium perfringens is a controversial practice. Studies has shown that such practice may not be necessary as the standard antibiotic regimen is enough to cover for Clostridial infections. Antibiotic impregnated devices such as tobramycin impregnated Poly(methyl methacrylate) (PMMA) beads and antibiotic bone cement are helpful in reducing rates of infection.[4] The use of absorbable carriers with implant coatings at the time of surgical fixation is also an effective means of delivering local antibiotics.[8]

There has been no agreement on the optimal duration of antibiotics. Studies has shown that there is no additional benefits of risk of infection when giving antibiotics for one day, when compared to giving antibiotics for three days or five days.[4][9] However, at present, there is only low to moderate evidence for this and more research is needed.[9] Some authors recommended that antibiotics to be given for three doses for Gustilo Grade I fractures, for one day after wound closure in Grade II fractures, three days in Grade IIIA fractures, and three days after wound closure for Grade IIIB and IIIC.[4]

Wound irrigation

There has been no agreement for the optimal solution for wound irrigation. Studies found out that there is no difference in infection rates by using normal saline or other various forms of water (distilled, boiled, or tap).[10] There is also no difference in infection rates when using normal saline with castile soap compared with normal saline together with bacitracin in irrigating wounds. Studies also shown that there is no difference in infection rates using low pressure pulse lavage (LPPL) when compared to high pressure pulse lavage (HPPL) in irrigating wounds. Optimal amount of fluid for irrigation also has not been established. It is recommended that the amount of irrigation solution to be determined by the severity of the fracture, with 3 litres for type I fractures, 6 litres for type II fractures, and 9 litres for type III fractures.[4]

Wound debridement

The purpose of wound debridement is to remove all contaminated and non-viable tissues including skin, subcutaneous fat, muscles and bones. Viability of bones and soft tissues are determined by their capacity to bleed. Meanwhile, the viability of muscles is determined by colour, contractility, consistency, and their capacity to bleed. The optimal timing of performing wound debridement and closure is debated and dependent on the severity of the injury, resources and antibiotics available, and individual needs.[11] Debridement time can vary from 6 to 72 hours, and closure time can be immediate (less than 72 hours) or delayed (72 hours to up to 3 months).[11] There is no difference in infection rates for performing surgery within 6 hours of injury when compared to until 72 hours after injury.[4][12]

Surgical management

Early fracture immobilisation and fixation helps to prevent further soft tissue injury and promotes wound and bone healing. This is especially important in the treatment of intraarticular fractures where early fixation allows early joint motion to prevent joint stiffness. Fracture management depends on the person's overall well being, fracture pattern and location, and the extent of soft tissue injury. Both reamed and unreamed intramedullary nailing are accepted surgical treatments for open tibial fracture.[13] Both techniques have similar rates of postoperative healing, postoperative infection, implant failure and compartment syndrome.[13] Unreamed intramedullary nailing is advantageous because it has a lower incidence of superficial infection and malunion compared to external fixation.[14]  However, unreamed intramedullary nailing can result in high rates of hardware failure if a person's weight bearing after surgery is not closely controlled.[14]  Compared to external fixation, unreamed intramedullary nailing has similar rates of deep infection, delayed union and nonunion following surgery.[14] For open tibial fractures in children, there is an increasing trend of using orthopedic cast rather than external fixation. Bone grafting is also helpful in fracture repair. However, internal fixation using plates and screws is not recommended as it increase the rate of infection.[4] Amputation is a last resort intervention, and is determined by factors such as tissue viability and coverage, infection, and the extent of damage to the vascular system.[15]

Wound management

Early wound closure is recommended to reduce the rates hospital-acquired infection. For Grade I and II fractures, wound can be healed by secondary intention or through primary closure. There is conflicting evident to suggest the effectiveness of Negative-pressure wound therapy (vacuum dressing), with several sources citing a decreased risk in infection,[15][16] and others suggesting no proven benefit.[17]

Epidemiology

Crush injuries are the most common form of injuries, followed by falls from standing height, and road traffic accidents. Open fractures tend to occur more often in males than females at the ratio of 7 to 3 and the age of onset of 40.8 and 56 years respectively. In terms of anatomy location, fractures of finger phalanges are the most common one at the rate of 14 per 100,000 people per year in the general population, followed by fracture of tibia at 3.4 per 100,000 population per year, and distal radius fracture at 2.4 per 100,000 population per year.[4] Infection rates for Gustilo Grade I fractures is 1.4%, followed by 3.6% for Grade II fractures, 22.7% for Grade IIIA fractures, and 10 to 50% of Grade IIIB and IIIC fractures.[18]

History

Before the 1850s, surgeons usually amputated the limbs for those with open fractures, as it was associated with severe sepsis and gangrene which can be life threatening. It was only until the 20th century, when Joseph Lister adopted the aseptic technique in surgeries, that the rate of death from open fractures reduced from 50% to 9%.[4]

References

1. Halawi, Mohamad J.; Morwood, Michael P. (November 2015). "Acute Management of Open Fractures: An Evidence-Based Review". Orthopedics. 38 (11): e1025–1033. doi:10.3928/01477447-20151020-12. ISSN 1938-2367. PMID 26558667.
2. Vanderhave, Kelly (2015), Doherty, Gerard M. (ed.), "Orthopedic Surgery", CURRENT Diagnosis & Treatment: Surgery (14 ed.), McGraw-Hill Education, retrieved 2018-11-05
3. Menkes, Jeffrey S. (2016), Tintinalli, Judith E.; Stapczynski, J. Stephan; Ma, O. John; Yealy, Donald M. (eds.), "Initial Evaluation and Management of Orthopedic Injuries", Tintinalli’s Emergency Medicine: A Comprehensive Study Guide (8 ed.), McGraw-Hill Education, retrieved 2018-11-05
4. Mohamad J, Halawi; Michael P, Morwood (8 April 2015). "Acute Management of Open Fractures: An Evidence-Based Review". Orthopaedics. 38 (11): 1026–1033. doi:10.3928/01477447-20151020-12. PMID 26558667.
5. Paul, H Kim; Seth, S Leopold (9 May 2012). "Gustilo-Anderson Classification". Clinical Orthopaedics and Related Research. 470 (11): 3270–3274. doi:10.1007/s11999-012-2376-6. PMC 3462875. PMID 22569719.
6. "Ovid: Externer Link". ovidsp.tx.ovid.com. Retrieved 2017-11-10.
7. National Clinical Guideline Centre (UK) (2016). Fractures (Complex): Assessment and Management. National Institute for Health and Care Excellence: Clinical Guidelines. London: National Institute for Health and Care Excellence (UK). PMID 26913311.
8. Morgenstern, M.; Vallejo, A.; McNally, M. A.; Moriarty, T. F.; Ferguson, J. Y.; Nijs, S.; Metsemakers, W. J. (2018). "The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis". Bone & Joint Research. 7 (7): 447–456. doi:10.1302/2046-3758.77.BJR-2018-0043.R1. ISSN 2046-3758. PMC 6076360. PMID 30123494.
9. Chang, Yaping; Kennedy, Sean Alexander; Bhandari, Mohit; Lopes, Luciane Cruz; Bergamaschi, Cristiane de Cássia; Carolina de Oliveira E Silva, Maria; Bhatnagar, Neera; Mousavi, S. Mohsen; Khurshid, Saqib (2015-06-09). "Effects of Antibiotic Prophylaxis in Patients with Open Fracture of the Extremities: A Systematic Review of Randomized Controlled Trials". JBJS Reviews. 3 (6): 1. doi:10.2106/JBJS.RVW.N.00088. ISSN 2329-9185. PMID 27490013.
10. Olufemi, Olukemi Temiloluwa; Adeyeye, Adeolu Ikechukwu (2017). "Irrigation solutions in open fractures of the lower extremities: evaluation of isotonic saline and distilled water". Sicot-J. 3: 7. doi:10.1051/sicotj/2016031. ISSN 2426-8887. PMC 5278649. PMID 28134091.
11. O'Brien, C.L; Menon, M; Jomha, N.M (2014). "Controversies in the Management of Open Fractures". The Open Orthopaedics Journal. 8 (20): 178–184. doi:10.2174/1874325001408010178. PMC 4110387. PMID 25067972.
12. Davies, James; Roberts, Tobias; Limb, Richard; Mather, David; Thornton, Daniel; Wade, Ryckie G. (2020-02-17). "Time to surgery for open hand injuries and the risk of surgical site infection: a prospective multicentre cohort study". Journal of Hand Surgery (European Volume): 175319342090520. doi:10.1177/1753193420905205. ISSN 1753-1934.
13. Shao, Yinchu; Zou, Hongxing; Chen, Shaobo; Shan, Jichun (2014-08-23). "Meta-analysis of reamed versus unreamed intramedullary nailing for open tibial fractures". Journal of Orthopaedic Surgery and Research. 9: 74. doi:10.1186/s13018-014-0074-7. ISSN 1749-799X. PMC 4145248. PMID 25149501.
14. Fu, Qiang; Zhu, Lei; Lu, Jiajia; Ma, Jun; Chen, Aimin (2018-08-24). "External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials". Scientific Reports. 8 (1): 12753. Bibcode:2018NatSR...812753F. doi:10.1038/s41598-018-30716-y. ISSN 2045-2322. PMC 6109134. PMID 30143702.
15. Manway, Jeffrey; Highlander, Peter (2014-11-14). "Open Fractures of the Foot and Ankle". Foot & Ankle Specialist. 8 (1): 59–64. doi:10.1177/1938640014557072. ISSN 1938-6400. PMID 25398852.
16. Schlatterer, Daniel R.; Hirschfeld, Adam G.; Webb, Lawrence X. (2015-01-17). "Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?". Clinical Orthopaedics and Related Research. 473 (5): 1802–1811. doi:10.1007/s11999-015-4140-1. ISSN 0009-921X. PMC 4385370. PMID 25595096.
17. Iheozor-Ejiofor, Zipporah; Newton, Katy; Dumville, Jo C; Costa, Matthew L; Norman, Gill; Bruce, Julie (2018-07-03). "Negative pressure wound therapy for open traumatic wounds". Cochrane Database of Systematic Reviews. 7: CD012522. doi:10.1002/14651858.cd012522.pub2. ISSN 1465-1858. PMC 6513538. PMID 29969521.
18. William W, Cross; Marc F, Swiontkowski (October 2008). "Treatment principles in the management of open fractures". Indian Journal of Orthopaedics. 42 (4): 377–386. doi:10.4103/0019-5413.43373. PMC 2740354. PMID 19753224.