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Open Fractures

Open fractures
Objectives
  1. Define open fracture
  2. Describe a system of classification for open fractures
  3. Describe an approach to management of open fractures
  4. Discuss indications for wound closure with open fractures
  5. Discuss methods of fixation for open fractures, including advantages and disadvantages of each method
  6. Describe in what way(s) managing open fractures in children differs from that in adults
Discussion
Chapman and Olson define an open fracture as one in which a break in the skin and underlying soft tissues leads directly into or communicates with the fracture and the hematoma. Such a fracture is suspect to contamination by the environment at the time of injury. It is this condition, contamination of the fracture, that must drive the treatment - the first principle being to clean the fracture and the wound of contamination. This is done mechanically by debridement, and secondarily by administration of appropriate intravenous antibiotics, recognizing that the antibiotics will only be accessible to viable tissue. Once the wound management has been addressed, reduction and stabilization of the fracture become priorities. In general, major advances in wound management and treatment of open fractures have occurred in wartime, when large numbers of open fractures demand a high level of attention to minimizing morbidity and mortality. For some time, it has been taught that debridement within 6 hours was in accord with a "golden period" as wounds would become secondarily contaminated. A convincing recent series of patients by Skaggs casts uncertainty on that concept, proper wound management is probably more important than the delay in operation.

The most commonly used classification in North America is that of Gustillo and Anderson, which is essential knowledge for practicing orthopaedists and residents. A type I open fracture communicates with a clean wound, < 1 cm in length. A type II open fracture communicates with a wound > 1 cm long without extensive soft tissue injury, flaps, or avulsions. A type IIIA open fracture has adequate soft tissue coverage despite extensive lacerations or flaps, or is sustained by high energy trauma regardless of the character and size of the wound. A type IIIB open fracture has extensive soft tissue loss with periosteal stripping and bone exposure, and/or is associated with massive contamination. A type IIIC open fracture is associated with vasular injury needing repair. This classification has been useful for comparison of results and assessment of treatment methods.

The goal of open fracture management is to obtain a viable, clean fracture in an adequate, vascularized soft tissue envelope. In this environment the fracture can heal without complication. Residual contamination, especially likely when devitalized tissue remains in the wound, is associated with increased complications both with the wound and the fracture. Thus adequate debridement is the sine qua non of open fracture management. In young children, fracture fragments of questionable viability may incorporate, a similar fragment in the adult must be debrided. In recent years, primary closure and wound coverage has become more adventuresome. While this does decrease hospital stay and promotes faster union, it is also useful to remember the report of Brown in 1974, describing cases of gas gangrene in Miami. The common denominator for every case was primary wound closure. While there is no doubt that many type I and II open fractures undergo successful primary wound closure., it is worth considering the safety of this procedure every time it is done. Type III injuries by nature defy primary closure at every level. Local or remote flap coverage may be necessary. With severe injuries, consideration must be directed to the possibility of early amputation rather than a series of unsuccessful reconstructive procedures.

Fracture stabilization is the final concern. Most open fractures in children may be managed in the same way as a similar closed injury, in a cast. Small wounds left open in a cast will close by secondary intention. Secondary wound closure is always safer, and can be accomplished at the time of o re-exam of the wound 3-5 days after injury. Complications of open fractures in children increase with age of the patient and complexity of the injury. In the mid 90's, a number of reports of treatment of open tibial fractures in children were published. These themes were consistent, and to a lesser degree, delayed union with external fixation. Fractures of the pelvis carry and extra morbidity from associated genitourinary or gastrointestinal injuries, which may require diversion to obtain a clean fracture.

We are now embarking on era of more aggressive internal fixation for open fractures, including intramedullary rodding for open forearm fractures, and increasing use of flexible intramedullary rods in other long bones. Well documented series of various types of fixation will guide operative stablization. The trend at present is for greater use of intamedullary fixation, less plate fixation, less external fixation, and sadly, less cast fixation. Plate fixation requires additional exposure, external fixation can contribute to fracture distraction, and intramedullary fixation can spread contamination from an imperfectly cleaned fracture site.

References
  1. Blasier RD, Barnes CL. Age as a prognostic factor in open tibial fractures in children. Clinical Orthopaedics & Related Research 1996(331):261-4.
  2. Buckley SL, Smith G, Sponseller PD, Thompson JD, Griffin PP. Open fractures of the tibia in children. Journal of Bone & Joint Surgery - American Volume 1990;72(10):1462-9.
  3. Buckley SL, Smith GR, Sponseller PD, Thompson JD, Robertson WW, Jr., Griffin PP. Severe (type III) open fractures of the tibia in children. Journal of Pediatric Orthopedics 1996;16(5):627-34.
  4. Chapman MW, olson SA. Open fractures. In: Rockwood CA, Jr., Green DP, Bucholz RW, Heckman JD, editors. Fractures in adults. Philadelphia: Lippincott-Raven; 1996. p. 305-52.
  5. Cramer KE, Limbird TJ, Green NE. Open fractures of the diaphysis of the lower extremity in children. Treatment, results, and complications. Journal of Bone & Joint Surgery - American Volume 1992;74(2):218-32.
  6. Cullen MC, Roy DR, Crawford AH, Assenmacher J, Levy MS, Wen D. Open fracture of the tibia in children. Journal of Bone & Joint Surgery - American Volume 1996;78(7):1039-47.
  7. Ferrera PC, Hill DA. Good outcomes of open pelvic fractures. Injury 1999;30(3):187-90.
  8. Goldner JL, Hardaker WT, Jr., Mabrey JD. Open fractures of the extremities. The case for open treatment. Postgraduate Medicine 1985;78(5):199-204, 7-11, 14.
  9. Grimard G, Naudie D, Laberge LC, Hamdy RC. Open fractures of the tibia in children. Clinical Orthopaedics & Related Research 1996(332):62-70.
  10. Gustillo R, B,, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: A new classification of type III open fractures. J Trauma 1984;24:742-46.
  11. Haasbeek JF, Cole WG. Open fractures of the arm in children. Journal of Bone & Joint Surgery - British Volume 1995;77(4):576-81.
  12. Hertel R, Lambert SM, Muller S, Ballmer FT, Ganz R. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Archives of Orthopaedic & Trauma Surgery 1999;119(1-2):7-12.
  13. Hutchins CM, Sponseller PD, Sturm P, Mosquero R. Open femur fractures in children: treatment, complications, and results. Journal of Pediatric Orthopedics 2000;20(2):183-8.
  14. Irwin A, Gibson P, Ashcroft P. Open fractures of the tibia in children. Injury 1995;26(1):21-4.
  15. Kreder HJ, Armstrong P. The significance of perioperative cultures in open pediatric lower-extremity fractures. Clinical Orthopaedics & Related Research 1994(302):206-12.
  16. Mosheiff R, Suchar A, Porat S, Shmushkevich A, Segal D, Liebergall M. The "crushed open pelvis" in children. Injury 1999;30(Suppl 2):B14-8.
  17. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clinical Orthopaedics & Related Research 1989(243):36-40.
  18. Porat S, Milgrom C, Nyska M, Whisler JH, Zoltan JD, Mallin BA. Femoral fracture treatment in head-injured children: use of external fixation. Journal of Trauma-Injury Infection & Critical Care 1986;26(1):81-4.
  19. Robertson P, Karol LA, Rab GT. Open fractures of the tibia and femur in children. Journal of Pediatric Orthopedics 1996;16(5):621-6.
  20. Seligson D, Ostermann PA, Henry SL, Wolley T. The management of open fractures associated with arterial injury requiring vascular repair. Journal of Trauma-Injury Infection & Critical Care 1994;37(6):938-40.
  21. Shoemaker SD, Comstock CP, Mubarak SJ, Wenger DR, Chambers HG. Intramedullary Kirschner wire fixation of open or unstable forearm fractures in children. Journal of Pediatric Orthopedics 1999;19(3):329-37.
  22. Skaggs DL, Kautz SM, Kay RM, Tolo VT. Effect of delay of surgical treatment on rate of infection in open fractures in children. Journal of Pediatric Orthopedics 2000;20(1):19-22.
  23. Song KM, Sangeorzan B, Benirschke S, Browne R. Open fractures of the tibia in children. Journal of Pediatric Orthopedics 1996;16(5):635-9.
  24. Stewart KJ, Tytherleigh-Strong G, Bharathwaj S, Quaba AA. The soft tissue management of children's open tibial fractures. Journal of the Royal College of Surgeons of Edinburgh 1999;44(1):24-30.

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