The principles that govern open fracture management include as-sessment of the patient and classifi-cation of the injury, prevention of in-fection, wound management, and fracture stabili
Trang 1Charalampos G Zalavras, MD, and Michael J Patzakis, MD
Abstract
Open fractures often result from
high-energy trauma and are
charac-terized by variable degrees of
soft-tissue and skeletal injury, both of
which impair local tissue
vasculari-ty Open fractures communicate
with the outside environment, and
the resulting contamination of the
wound with microorganisms,
cou-pled with the compromised vascular
supply to the region, leads to an
in-creased risk of infection as well as to
complications in healing In
addi-tion, bone, tendons, nerves, and
ar-ticular cartilage may be exposed and
subject to damage
The principles that govern open
fracture management include
as-sessment of the patient and
classifi-cation of the injury, prevention of
in-fection, wound management, and
fracture stabilization, including
ear-ly bone grafting Management of
open fractures can be challenging,
and multiple surgical procedures
frequently are needed to achieve
soft-tissue coverage and fracture
union
Assessment and Classification of Open Fractures
Patients who present with associated life-threatening injuries should be initially evaluated and resuscitated according to Advanced Trauma Life Support protocols Injured extremities then should be assessed for neurovas-cular injury and compartment syn-drome The presence of an open frac-ture wound does not exclude the extremity from the complication of compartment syndrome.1In addition, complete assessment of the open frac-ture includes reviewing the mecha-nism of injury, condition of the soft tissues, degree of bacterial contami-nation, and characteristics of the frac-ture The evaluation of these factors will help to classify the fracture, de-termine the treatment regimen, and establish the prognosis and potential clinical outcome In particular, the de-gree of bacterial contamination and soft-tissue damage is important in classifying an open fracture
Veliskakis2proposed a classifica-tion system for open fractures that included three types based on in-creasing severity This concept was refined by Gustilo and Anderson,3 and their classification system, sub-sequently modified by Gustilo et al,4 has found widespread application Type I includes puncture wounds≤1
cm, with minimal contamination and muscle damage Type II in-cludes lacerations >1 cm, with mod-erate soft-tissue injury Bone cover-age is adequate and comminution is minimal Type III includes three sub-types Type IIIA involves extensive soft-tissue damage with adequate bone coverage Usually it is the re-sult of a high-velocity injury with a severe crushing component Type IIIA also includes heavily contami-nated wounds with severe commu-nition and segmental fractures Type IIIB involves extensive soft-tissue damage, with stripping of the peri-osteum and exposure of the bone
Dr Zalavras is Assistant Professor, Department
of Orthopaedic Surgery, University of Southern California Keck School of Medicine, Los Angeles,
CA Dr Patzakis is Professor and Chairman, The Vincent and Julia Meyer Chair, Chief of Ortho-paedic Surgery Service, University of Southern California University Hospital and Los Angeles County+University of Southern California Med-ical Center, Department of Orthopaedic Surgery, University of Southern California Keck School of Medicine.
Reprint requests: Dr Patzakis, GNH 3900, 2025 Zonal Avenue, Los Angeles, CA 90089-9312 Copyright 2003 by the American Academy of Orthopaedic Surgeons.
Open fractures are complex injuries that involve both the bone and surrounding
soft tissues Management goals are prevention of infection, union of the fracture,
and restoration of function Achievement of these goals requires a careful approach
based on detailed assessment of the patient and injury The classification of open
fractures is based on type of fracture, associated soft-tissue injury, and bacterial
con-tamination present Tetanus prophylaxis and intravenous antibiotics should be
ad-ministered immediately Local antibiotic administration is a useful adjunct The
open fracture wound should be thoroughly irrigated and débrided, although the
op-timal method of irrigation remains uncertain Controversy also exists regarding the
optimal timing and technique of wound closure Extensive soft-tissue damage may
necessitate the use of local or free muscle flaps Techniques of fracture stabilization
depend on the anatomic location of the fracture and characteristics of the injury.
J Am Acad Orthop Surg 2003;11:212-219
Trang 2Usually it is associated with heavy
contamination and severe
comminu-tion of the bone Coverage using free
muscle flaps is necessary Type IIIC
involves any open fracture with
ar-terial injury requiring repair,
regard-less of the degree of soft-tissue
inju-ry Gustilo et al5later classified open
fractures more than 8 hours old at
presentation as a special category of
type III fracture Despite its wide
acceptance, however, the reliability
of this classification has been
ques-tioned Brumback and Jones6
report-ed that the average agreement
among orthopaedic surgeons on the
classification of open tibial fractures
was 60% overall, which was deemed
to be moderate to poor
Classification systems have the
inherent limitation of attempting to
classify a continuous variable, such
as severity of injury, into distinct
cat-egories Nevertheless, the
classifica-tion of open fractures is important
because it directs the attention of the
treating surgeon to the presence and
extent of injury variables
Misclassi-fication of an open fracture can
oc-cur, especially in a patient with a
relatively small skin wound To
im-prove the accuracy of the
classifica-tion of open fractures, the extent and
severity of the injury should be
as-sessed only during surgery, after
wound exploration and
débride-ment, and not at presentation in the
emergency department
Prevention of Infection
All open fracture wounds should be
considered contaminated because of
the communication of the fracture
site with the outside environment A
contamination rate of approximately
65% has been reported.3,7,8Infection
is promoted by the bacterial
contam-ination and colonization of the
wound, the presence of dead space
with devitalized tissues, foreign
ma-terial, and the compromised host
re-sponse resulting from poor
vascular-ity and soft-tissue damage The risk
of infection is related to severity of injury Infection rates range from 0%
to 2% for type I, 2% to 10% for type
II, and 10% to 50% for type III.3,8 Pre-vention of infection is based on im-mediate antibiotic administration and wound débridement Tetanus prophylaxis should be administered based on the patient’s immunization status
Wound Cultures
In the early postfracture period, results of wound cultures may indi-cate the most probable infecting or-ganism and determine the patho-gen’s sensitivity to antibiotics
However, the usefulness of initial cultures (obtained either at patient presentation or intraoperatively be-fore and after débridement of open fracture wounds) has been contro-versial because they often fail to identify the causative organism.9,10
In one prospective randomized double-blind trial, only 3 (18%) of 17 infections that developed in a series
of 171 open fracture wounds were caused by an organism identified by the initial cultures.11
The predictive value of wound cul-tures obtained before wound débri-dement is especially low This may be attributed to early wide-spectrum an-tibiotic coverage, multiple wound dé-bridements, and late contamination with nosocomial pathogens.10Thus, multiple initial cultures are not rec-ommended Only postdébridement cultures should be obtained, which can be useful in the management of early infections or in wounds with marine or other unusual environmen-tal contamination
Antibiotics
The crucial role of antibiotic ad-ministration in the management of open fractures was established in a prospective randomized study by Patzakis et al,7who demonstrated a marked reduction in the infection rate when cephalothin was
adminis-tered (2.4% [2/84 fractures]) com-pared with no antibiotics (13.9% [11/79]) or with penicillin and strep-tomycin (9.8% [9/92]) The antibiot-ics were administered before wound débridement However, further questions regarding administration involve selection of antibiotics, in-cluding choice of single or combina-tion therapy; duracombina-tion of therapy; and usefulness of local administra-tion It is important that, in the set-ting of an open fracture, antibiotics not be considered prophylactic This term can be confusing because anti-biotics routinely administered in or-thopaedic elective procedures are prophylactic But because infection commonly occurs in open fractures not treated with antibiotics, their ad-ministration is better viewed as ther-apeutic
Selection
The antibiotics used in the man-agement of open fractures should be selected based on the wound micro-biology Wound contamination with both positive and gram-negative microorganisms occurs; therefore, the antimicrobial regimen should be effective against both types of pathogens Currently, sys-temic combination therapy using a first-generation cephalosporin (eg, cefazolin), which is active against gram-positive organisms, and an aminoglycoside (eg, gentamicin or tobramycin), which is active against gram-negative organisms, appears
to be optimal, although other combinations also may be effective Substitutes for aminoglycosides in-clude quinolones, aztreonam, third-generation cephalosporins, or other antibiotics with coverage for gram-negative organisms Ampicillin or penicillin should be added to the an-tibiotic regimen when conditions fa-voring development of anaerobic infections, such as clostridial myo-necrosis (gas gangrene), are present,
as in farm injuries and vascular in-juries (ischemia, low-oxygen
Trang 3ten-sion, and necrotic tissues) The
re-sults of cultures obtained after
débridement and of
antibiotic-sensitivity testing may help in
select-ing the best agents for a subsequent
surgical procedure or in case of an
early infection
The lowest reported infection rate
with various systemic antibiotic
regimens occurred with
combina-tion therapy with a cephalosporin
and an aminoglycoside Patzakis
and Wilkins8reported that the
com-bination therapy was associated
with a 4.6% infection rate (5/109
open tibial fractures), whereas
ad-ministration of only cephalosporin
was associated with a 13% infection
rate (25/192) Type I and II open
fractures were not analyzed
sepa-rately, but the distribution of
frac-ture types was comparable between
the two groups Templeman et al12
proposed administration of a
ceph-alosporin as a single agent in type I
and II open fractures However,
cephalosporin does not provide
cov-erage against contaminating
gram-negative organisms Moreover, a
po-tential misclassification of an open
fracture because of its small wound
size could result in a type IIIA
frac-ture being treated with a single
agent
Quinolones are a promising
alter-native to intravenous antibiotics
because they offer broad-spectrum
antimicrobial coverage, are
bacteri-cidal, can be administered orally
with less frequent dosing than
intra-venous antibiotics, and are well
tol-erated clinically Ciprofloxacin as
single-agent therapy is effective in
the management of type I and II
open fractures In a randomized
pro-spective study, ciprofloxacin was
compared with combination therapy
(cefamandole and gentamicin)
In-fection rates were similar (6%) in the
type I and II fractures; however, in
type III open fractures, the
ciproflox-acin group had an infection rate
of 31% (8/26) compared with 7.7%
(2/26) in the combination therapy
group.11Therefore, in type III open fractures, ciprofloxacin should be used only in combination with a cephalosporin as a substitute for an aminoglycoside Oral ciprofloxacin can be used for open fracture wounds secondary to low-velocity gunshot injuries because it is as ef-fective as intravenous administra-tion of cephapirin and gentamicin.13 However, further studies are war-ranted to elucidate the clinical ben-efits of quinolones because their use has been associated with the inhibi-tion of experimental fracture healing and of osteoblasts.14,15
Duration of Therapy
Antibiotics should be started as soon as possible after the injury oc-curs because a delay >3 hours in-creases the risk of infection.8The du-ration of antibiotic administdu-ration is controversial Dellinger et al16 dem-onstrated that a prolonged course of 5-day antibiotic administration was not superior to a 1-day course for prevention of fracture site infections
The duration of therapy should be limited to 3 days, with repeated 3-day administration of antibiotics
at wound closure, bone grafting, or any major surgical procedure.8,12
Local Administration
In a series of 1,085 open fractures, Ostermann et al17demonstrated that the additional use of local amino-glycoside-impregnated polymethyl-methacrylate (PMMA) beads
signif-icantly (P < 0.001) reduced the
overall infection rate to 3.7%, com-pared with 12% when only intrave-nous antibiotics were used When the types of open fractures were an-alyzed separately, the reduction of infection was statistically significant
(P < 0.001) in only the type III
frac-tures (6.5% versus 20%, respectively, for PMMA beads and intravenous antibiotics)
Antibiotic-impregnated PMMA beads are inserted into the open fracture wound, which is
subse-quently sealed with a film dressing
or similar semipermeable barrier Commercially available antibiotic-impregnated PMMA beads have not been approved by the Food and Drug Administration for use in the United States, so they must be made
by the physician Forty grams of PMMA beads are mixed with the an-tibiotic in powder form and are po-lymerized; the beads then are strung onto or incorporated with a bead mold onto a 24-gauge wire The an-tibiotic selected should be heat sta-ble, water solusta-ble, and available in powder form and have wide-spectrum antimicrobial activity (for example, 3.6 g of tobramycin mixed with 40 g of PMMA) Vancomycin is not recommended as an initial agent because of concerns regarding resis-tant enterococci
The bead pouch technique is most often used for select type II or type III open fractures If the
anteromedi-al aspect of the tibia is exposed, re-quiring delayed closure or muscle transfer, the beads are placed inside the bone defect, if present, and on top of the exposed bone If the soft-tissue coverage is delayed, the bead pouch does not need to be changed because the antibiotics have been shown to elute at levels above the minimum inhibitory concentration for at least 1 month.18 However, if the patient undergoes repeat dé-bridement, the bead pouch can be changed
The advantages of the bead pouch technique include (1) a high local concentration of antibiotics, of-ten 10 to 20 times higher than that with systemic administration; (2) a low systemic concentration, which protects from the adverse effects of aminoglycosides (although when a tobramycin bead pouch is used, sys-temic aminoglycoside administra-tion is not needed); (3) a decreased need for the use of systemic ami-noglycosides; and (4) sealing of the wound from the external environ-ment with film dressing This
Trang 4tech-nique prevents secondary bacterial
contamination by nosocomial
patho-gens, which have been shown to be
responsible for many of the
infec-tions in type III open fracture
wounds.8,9 In addition, this
tech-nique allows for the period for
soft-tissue transfers to be safely
extend-ed Also, film dressing establishes an
aerobic wound environment, which
is important for avoiding
cata-strophic anaerobic infections;
main-tains the local antibiotic within the
wound; and promotes patient
com-fort by avoiding painful changes of
wound dressing
Wound Management
Irrigation and Débridement
Irrigation is an essential part of
wound management; however, the
optimal volume, delivery method,
and irrigation solution have not
been determined.19Although
high-pressure irrigation improves the
re-moval of bacteria and debris, it also
may damage the bone.20 Pulsatile
flow per se does not add to the
effec-tiveness of irrigation Antiseptic
so-lutions may be toxic to host cells and
should be avoided Antibiotic
solu-tions have been shown in animal
and in vitro studies to be more
effec-tive than saline alone, but clinical
data on open fracture wounds are
lacking Detergent solutions help
re-move bacteria and appear to be a
promising alternative.21One
proto-col is a 10-L saline solution delivered
to the wound by gravity tubing, with
50,000 U of bacitracin and 1,000,000
U of polymyxin added to the last
li-ter of irrigation fluid
After irrigation of the wound,
surgical débridement is the most
im-portant principle in open fracture
management because nonviable
tis-sues and foreign material enhance
bacterial growth and hinder the
host’s defense mechanisms The goal
is a clean wound with viable tissues
and no infection A sterile tourniquet
is applied to the extremity, to be used only when necessary Débridement without inflating the tourniquet fa-cilitates identification of viable tsues and prevents additional is-chemic damage to the already traumatized tissues The injury wound may be insufficient for thor-ough débridement, as in type I and
II open fractures, so the wound usu-ally is extended Skin and subcuta-neous tissues are sharply débrided back to bleeding edges Viable mus-cle can be identified by its bleeding, color, consistency, and contractility
Cortical bone fragments without any soft-tissue attachments are avascular and should be débrided, even if this will result in a large bone defect Ar-ticular fragments, however, should
be preserved even when they have
no attached blood supply, provided they are large enough and recon-struction of the involved joint is pos-sible If necessary, a repeat débride-ment can be done after 24 to 48 hours based on the degree of contamina-tion and soft-tissue damage In inju-ries requiring muscle flap coverage, débridement also should be
repeat-ed at the time of soft-tissue recon-struction
Wound Closure
Wound closure is possible when the available soft tissues are ade-quate; otherwise, soft-tissue recon-struction will be necessary later The optimal time for wound closure remains controversial Primary wound closure after a thorough débridement is not associated with
an increased rate of infection, may prevent secondary contamination, and may reduce surgical morbidity, hospital stay, and cost.22 Neverthe-less, it carries the potential for clostridial myonecrosis, which can lead not only to loss of the limb but also to loss of life.23Primary wound closure, inadequate débridement, and inadequate antibiotic therapy increase the risk of these complica-tions.7
We recommend leaving all open fracture wounds open initially De-layed wound closure (within 3 to 7 days) prevents anaerobic conditions
in the wound, facilitates drainage, allows for repeat débridements at 24- to 48-hour intervals, offers the opportunity to reexamine tissues of questionable viability, and permits use of the antibiotic bead pouch technique Sealing the wound with film dressing prevents secondary contamination and makes delayed wound closure even more prefera-ble Dressings are not changed in the surgical ward; instead, the wound remains sealed with film dressing Split-thickness skin grafts are ap-plied on well-vascularized granula-tion tissue Small wounds, especially
in type I open fractures, may be al-lowed to heal secondarily
In type I and II open fractures, the extended wound made to facilitate débridement can be safely closed primarily, leaving the original injury wound open.24 Part of the injury wound also can be sutured if it is di-rectly over bone, tendons, nerves, or vessels, but the rest of the wound should be left open
Soft-Tissue Reconstruction
Severe damage to the soft tissues,
as in type IIIB open fractures, pre-cludes adequate bone coverage, and soft-tissue reconstruction is neces-sary A well-vascularized soft-tissue envelope is critically important because it enhances vascularity at the fracture site, promotes fracture healing, allows for delivery of anti-biotics, and enhances action of the host defense mechanisms Soft-tissue coverage prevents secondary wound contamination, desiccation, and damage to bone, articular carti-lage, tendons, and nerves
The location and magnitude of the soft-tissue defect determine the choice of method of coverage Re-construction usually is achieved with local or free muscle transfers.25 Fasciocutaneous flaps are useful
Trang 5when dead space is minimal, when
the flaps are pliable, and when they
facilitate tendon gliding They may
restore sensibility to the affected area
if the flap remains innervated
Local pedicle muscle flaps
in-clude the gastrocnemius for
frac-tures in the proximal third of the
tib-ia and the soleus for fractures in the
middle third However, for fractures
in the distal third of the tibia, free
muscle flaps are necessary;
com-monly used flaps include the rectus
abdominis, gracilis, and latissimus
dorsi muscles In considering local
muscle flaps, the condition of the
muscle to be transferred must be
carefully evaluated Muscle that is
traumatized, crushed, or affected by
a compartment syndrome should
not be transferred; free muscle
trans-fer should be used instead Pollak et
al26reported that in the presence of
severe osseous injury, use of
rota-tional flaps was notably more likely
to lead to wound complications
compared with free flaps
Soft-tissue reconstruction should
be done early, within the first 7 days
Delays beyond this period have
been associated with increased
com-plications related to the flap or
infec-tion under the flap.9Some have
ad-vocated that flap coverage be done
within 72 hours.27,28Godina27
report-ed a failure rate of free muscle flaps
in <1% (1/134) when done within 72
hours compared with a failure rate
of 12% (20/167) when done from 72
hours to 90 days In the same series,
the infection rate was 1.5% (2/134)
in the early surgical group compared
with 17.4% (29/167) in the late
sur-gical group Gopal et al28 showed
that results of an early aggressive
protocol in type IIIB and IIIC open
fractures also were satisfactory In
their series, deep infection
devel-oped in 6% of fractures (4/63) that
were covered with a flap within 72
hours compared with 29% of
frac-tures (6/21) covered after 72 hours
However, in these studies, the
antibiotic-impregnated bead pouch
was not used; therefore, secondary contamination may have played a notable role in contributing to the in-creased infection rate in patients with delayed flap coverage.9,27,28
Fracture Stabilization
Adequate stabilization protects the soft tissues from further injury by fracture fragments and facilitates the host response to bacteria despite the presence of implants In addition, stable fixation improves wound care and mobilization of the patient and allows for early motion of adjacent joints, which contributes to
function-al rehabilitation
The choice of fracture fixation de-pends on the fractured bone, the lo-cation of the fracture (eg, intra-articular, metaphyseal, diaphyseal), and the extent of soft-tissue injury
Available techniques for fracture sta-bilization include intramedullary nailing, external fixation, and plate-and-screw fixation More than one technique may be applicable in a specific injury
Intramedullary Nailing
Intramedullary nailing is an effec-tive method of stabilization of di-aphyseal fractures of the lower extremity.29-32It is a biomechanically advantageous method that does not interfere with soft-tissue manage-ment Static interlocking fixation maintains the length and alignment
of the fractured bone and thus has expanded the applicability of nailing
to unstable, comminuted fracture patterns However, it disrupts the endosteal bone circulation to a vari-able degree, especially when the medullary canal is reamed Open femoral fractures are best treated with reamed intramedullary nailing:
Brumback et al29observed no infec-tions in 62 type I, II, and IIIA open fractures, although infection devel-oped in 3 (11%) of 27 type IIIB open femoral fractures Open tibial
frac-tures have been satisfactorily stabi-lized with unreamed intramedullary nailing,30-33but controversies remain regarding the role of external fixa-tion and reamed intramedullary nailing in the stabilization of these fractures
Intramedullary Nailing Versus External Fixation
Both unreamed intramedullary nailing and external fixation have been used widely in the manage-ment of open tibial fractures, but few prospective randomized studies have compared the two techniques Tornetta et al30 evaluated the two methods in 29 type IIIB open tibial fractures All fractures healed and no difference in the infection rate was found In a prospective series of 174 open tibial fractures, Henley et al31 reported no difference between un-reamed nailing and external fixation regarding infection and bone heal-ing They observed that the severity
of the soft-tissue injury rather than the choice of implant appeared to be the main factor influencing injury site infection and bone healing However, half-pin external fixators were associated with malalignment
in 31% of cases and with a pin tract infection in 50% A meta-analysis of the management of open tibial frac-tures demonstrated that unreamed intramedullary nails reduced the risk of revision surgery, malunion, and superficial infection compared with external fixators.32
Although no advantages in frac-ture healing and injury site infection have been established, intramedul-lary nailing is considered preferable
to external fixation It does not re-quire the same high level of patient compliance, and it is aesthetically more acceptable than external fixa-tion Unreamed intramedullary nail-ing can be used for types I to IIIA and for select type IIIB open frac-tures of the tibial diaphysis An ex-ternal fixator may be particularly useful in cases with heavy bacterial
Trang 6contamination, extensive soft-tissue
damage, or vascular injury (ie, types
IIIB and IIIC)
Unreamed Versus Reamed
Intramedullary Nailing
Unreamed intramedullary
nail-ing has been widely used in open
tibial fractures.30,31,33 Schemitsch et
al34showed in a sheep tibia model
that endosteal blood flow at
comple-tion of the procedure was reduced to
18% of the level prior to nailing
when reaming was done whereas it
was reduced to only 44% with
un-reamed nailing Unun-reamed nailing
preserves endosteal blood supply to
a greater degree than does reamed
nailing.34,35Thus, it may be
prefera-ble in open tibial fractures, in which
periosteal vascularity may be
al-ready compromised by the
traumat-ic insult Reamed nailing, on the
other hand, allows insertion of
larger-diameter implants, improves
stability at the fracture site, and
helps reduce implant failure
More-over, the cortical circulation that was
disrupted during reaming is
gradu-ally reconstituted, although more
slowly than unreamed nailing.35
Two prospective randomized
studies compared reamed with
un-reamed nailing in open tibial
frac-tures; neither established a
signifi-cant difference in infection rates.36,37
Keating et al36reported an infection
rate of 2.5% (1/40) in fractures
treat-ed with the unreamtreat-ed nailing
tech-nique versus 4.4% (2/45) in fractures
treated with the reamed nailing
tech-nique Finkemeier et al37 observed
infection rates of 3.8% (1/26) in
un-reamed nailing and 5.3% (1/19) in
reamed nailing In both studies, a
re-duced incidence of screw failure was
seen in the group undergoing the
reamed nailing technique
Choice of technique remains
con-troversial Interestingly, surgeons
who prefer unreamed nailing try to
insert a nail of sufficient diameter
to accommodate larger locking
bolts, whereas surgeons who
pre-fer reamed nailing tend to insert smaller nails, resulting in little dif-ference between the techniques
However, clinical experience with reamed nailing is limited, whereas many investigators have
document-ed satisfactory experience with un-reamed nailing, including its use with type IIIB open fractures.30,31,33 The unreamed nailing technique can
be used even in type I open tibial fractures to reduce damage to bone vascularity
External Fixation
External fixation can be helpful in wounds with severe soft-tissue dam-age and contamination because it avoids hardware implantation and does not compromise fracture vas-cularity External fixation is techni-cally expedient and is associated with minimal blood loss It is ap-plied at a site distant to the injury and thus does not interfere with wound management External fixa-tion is suitable for diaphyseal tibial fractures because of the subcutane-ous location of the bone, and it be-comes a more attractive option than intramedullary nailing moving to the proximal or to the distal tibia, if the size of the proximal or distal fragment does not allow for stabili-zation with a nail Ring or transartic-ular fixators are useful for periartic-ular fractures Spanning external fixation is becoming popular and may be safely converted to another method when applied away from the zone of injury
Many authors38-40 have reported
on the effectiveness of external fixa-tion as definitive treatment as well as the value of early bone grafting in se-vere injuries.38-40 Marsh et al,40in a prospective study of 101 type II and III fractures, reported that 96 frac-tures (95%) healed, 95% of them with <10° of angulation in any plane, and that 6 fracture sites (6%) were in-fected To avoid healing complica-tions, early bone grafting should be considered for comminuted
frac-tures without cortical contact and for fractures with bone defects treated with external fixation
External fixation may be accom-panied by pin tract infections and fracture malalignment These com-plications can be avoided by the se-lection of compliant patients; imple-mentation of an external fixation protocol, which includes the use of half-pins inserted after predrilling to avoid thermal necrosis of bone; and meticulous care of the pin tract A considerable proportion of the com-plications associated with external fixation can be attributed to the tran-sition to another form of fixation In-fection has been reported at a rate approaching 50% after conversion of the external fixation to delayed in-tramedullary nailing.9,41However,
in these series, infection was associ-ated with a prior pin tract infection
in the majority of patients Blachut et
al42showed that by early (mean, 17 days) conversion of the fixator to a nail in the absence of pin tract infec-tions, infection developed in only 5% of patients Loss of alignment fre-quently occurs when the fixator is prematurely removed and the pa-tient is transferred to a brace.38
In heavily contaminated open fractures, temporary external fixa-tion can be a useful opfixa-tion
Howev-er, to minimize the chance of bacte-rial colonization of the pin tracts, conversion to intramedullary nail-ing should be done in the absence of pin tract infections and when the fix-ator has been present for only a short time.42Otherwise, the fixator should
be maintained until fracture healing
Plate Fixation
Plate fixation is useful in intra-articular and metaphyseal fractures because it stabilizes an accurate res-toration of joint congruency and ori-entation In diaphyseal fractures of the upper extremity, plate fixation is often the method of choice Plate fix-ation in open tibial fractures has been associated with an increased
Trang 7incidence of infection and hardware
failure.43,44 Bach and Hansen43
re-ported wound infection in 35% (9/
26) and fixation failure in 12% (3/26)
of type II and III open tibial
frac-tures Clifford et al44 observed
im-plant failure in 7 of 97 open tibial
fractures and infection in 4 of 9 type
III fractures New plating techniques
using fixed-angle plate screw
devic-es are characterized by minimally
in-vasive insertion and preservation of
bone vascularity, and they may
prove to be a useful alternative for
metaphyseal fractures, especially
when intra-articular extension is
present However, to date, no
pub-lished data are available to support
their use
Early Secondary Procedures to
Stimulate Healing
In the presence of bone defects or
delayed healing, early bone grafting
can expedite healing With bone
de-fects, the preferred timing for bone
grafting ranges from 2 to 6 weeks
af-ter soft-tissue coverage.38,45Waiting
for 6 weeks after a soft-tissue
trans-fer ensures the absence of infection
and restoration of the soft-tissue en-velope Then the existing defect is bone grafted Depending on the frac-ture pattern, grafts are applied either
at the fracture site beneath a flap or posterolaterally away from the site
of injury Early bone grafting in the absence of a bone defect also may be necessary when healing is delayed and no callus is apparent on radio-graphs at 8 to 12 weeks Autogenous bone graft remains the method of choice The usefulness of graft sub-stitutes in the management of de-fects associated with open fractures has not been shown to be effective
Exchange nailing is another op-tion to stimulate healing in cases of delayed union, provided no infec-tion or bone defect is present Infec-tion necessitates addiInfec-tional débride-ment, whereas bone defects should
be managed with bone grafting
Summary
Assessment and classification of open fractures should be done intra-operatively based on the degree of
bacterial contamination, soft-tissue damage, and fracture characteristics
To avoid the complication of clos-tridial myonecrosis, the wound should be thoroughly irrigated and débrided and not closed primarily Early, systemic, wide-spectrum anti-biotic therapy is necessary to cover both positive and gram-negative organisms A 3-day admin-istration of a first-generation cepha-losporin and an aminoglycoside, supplemented with ampicillin or penicillin for injuries occurring on a farm and for vascular injuries, is a critically important part of effective treatment Local antibiotic delivery with the bead pouch technique can prevent secondary wound contami-nation In the presence of extensive soft-tissue loss and exposed bone, coverage is accomplished with early transfer of local or free muscle flaps Stable fracture fixation is important; the method chosen depends on the bone and soft-tissue characteristics Early bone grafting is indicated for bone defects, unstable fractures treated with external fixation, and delayed union
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