An open fracture, also called a compound fracture, is a type of
bone fracture
A bone fracture (abbreviated FRX or Fx, Fx, or #) is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a '' ...
in
orthopedic
Orthopedic surgery or orthopedics ( alternatively spelt orthopaedics), is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal ...
s that is frequently caused by high energy trauma. It is a bone fracture, also known as a broken bone, associated with a break in the skin continuity which can cause complications such as infection,
malunion
A malunion is when a fractured bone does not heal properly. Some ways that it shows is by having the bone being twisted, shorter, or bent. Malunions can occur by having the bones improperly aligned when immobilized, having the cast taken off to ...
, and
nonunion
Nonunion is permanent failure of healing following a broken bone unless intervention (such as surgery) is performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint, and is therefore often called a "false j ...
.
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.
Cephalosporin
The cephalosporins (sg. ) are a class of β-lactam antibiotics originally derived from the fungus ''Acremonium'', which was previously known as ''Cephalosporium''.
Together with cephamycins, they constitute a subgroup of β-lactam antibiotics ...
s are generally the first line of antibiotics. The antibiotics are continued for 24 hours to minimize the risk of infections.
Therapeutic irrigation
In medicine, therapeutic irrigation or lavage ( or ) is cleaning or rinsing. Types
Specific types include:
* Antiseptic lavage
* Bronchoalveolar lavage
* Gastric lavage
* Peritoneal lavage
* Arthroscopic lavage
* Ductal lavage
* Nasal irrigati ...
, wound
debridement
Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy.
In p ...
, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections.
Classification
There are a number of classification systems attempting to categorise open fractures such as
Gustilo open fracture classification,
Tscherne classification The Tscherne classification is a system of categorization of soft tissue injuries.
Classification
Reliability
The intraobserver (observations at two different times by the same person) agreement for Tscherne classification is 85%; while for int ...
, and
Müller AO Classification of fractures
The Müller AO Classification of fractures is a system for classifying bone fractures initially published in 1987 by the AO Foundation
The AO Foundation is a nonprofit organization dedicated to improving the care of patients with musculoskeletal i ...
. 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.
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.
Characteristics
There are a range of characteristics of open fractures. There can be an obvious broken bone that is sticking out of the skin, but there can also be a broken bone that is associated with a very small "poke-hole" skin wound. Both of these situations are classified as open fractures.
Complications
When a bone is broken and allowed to communicate with the outside environment, the probability of infection increases. Both the surrounding soft tissues can become infected, as well as the bone itself, which is called
osteomyelitis
Osteomyelitis (OM) is an infection of bone. Symptoms may include pain in a specific bone with overlying redness, fever, and weakness. The long bones of the arms and legs are most commonly involved in children e.g. the femur and humerus, while the ...
. Additional complications include the broken bone ends not healing, called non-union, and the broken bone ends healing in an incorrect orientation, called malunion. Lastly, open fractures commonly occur in the setting of traumatic experiences, and the co-occurrence of these events may lead to chronic pain and mental health disorders.
Causes
Open fractures can occur due to direct impacts such as high-energy physical forces (
trauma
Trauma most often refers to:
* Major trauma, in physical medicine, severe physical injury caused by an external source
* Psychological trauma, a type of damage to the psyche that occurs as a result of a severely distressing event
*Traumatic i ...
), motor vehicular accidents, firearms, and falls from height.
Indirect mechanisms include twisting (
torsional
In the field of solid mechanics, torsion is the twisting of an object due to an applied torque. Torsion is expressed in either the pascal (Pa), an SI unit for newtons per square metre, or in pounds per square inch (psi) while torque is expressed ...
injuries) and falling from a standing position.
These mechanisms are usually associated with substantial
degloving
A degloving injury is a type of avulsion in which an extensive section of skin is completely torn off the underlying tissue, severing its blood supply. It is named by analogy to the process of removing a glove.
The causes of degloving can vary ...
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:
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.
Fracture-dislocations
Severe injury in which both fracture and dislocation take place simultaneously.
Gunshot wounds
Caused by high-speed projectiles, they cause damage as they go through the tissue, through secondary shock wave and cavitation.
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 are important to rule out any nerve or blood vessels injuries. High index of suspicion of
compartment syndrome
Compartment syndrome is a condition in which increased pressure within one of the body's anatomical compartments results in insufficient blood supply to tissue within that space. There are two main types: acute and chronic. Compartments of the ...
should be maintained for leg and forearm fractures.
Management
Acute management
Urgent interventions, including
therapeutic irrigation
In medicine, therapeutic irrigation or lavage ( or ) is cleaning or rinsing. Types
Specific types include:
* Antiseptic lavage
* Bronchoalveolar lavage
* Gastric lavage
* Peritoneal lavage
* Arthroscopic lavage
* Ductal lavage
* Nasal irrigati ...
and wound
debridement
Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy.
In p ...
, are often necessary to clean the area of injury and minimize the risk of infection.
Other risks of delayed intervention include long-term complications, such as deep infection, vascular compromise and complete limb loss.
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.
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
''Clostridium tetani'' is a common soil bacterium and the causative agent of tetanus. Vegetative cells of ''Clostridium tetani'' are usually rod-shaped and up to 2.5 μm long, but they become enlarged and tennis racket- or drumstick-shaped wh ...
''.
Anti-tetanus immunoglobulin
Anti-tetanus immunoglobulin, also known as tetanus immune globulin (TIG) and tetanus antitoxin, is a medication made up of antibodies against the tetanus toxin. It is used to prevent tetanus in those who have a wound that is at high risk, have ...
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.
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.
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.
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
Velocity is the directional speed of an object in motion as an indication of its rate of change in position as observed from a particular frame of reference and as measured by a particular standard of time (e.g. northbound). Velocity is a ...
firearms injury. First generation
cephalosporin
The cephalosporins (sg. ) are a class of β-lactam antibiotics originally derived from the fungus ''Acremonium'', which was previously known as ''Cephalosporium''.
Together with cephamycins, they constitute a subgroup of β-lactam antibiotics ...
(
cefazolin
Cefazolin, also known as cefazoline and cephazolin, is a first-generation cephalosporin antibiotic used for the treatment of a number of bacterial infections. Specifically it is used to treat cellulitis, urinary tract infections, pneumonia, e ...
) is recommended as first line antibiotics for the treatment of open fractures. The antibiotic is useful against
gram positive
In bacteriology, gram-positive bacteria are bacteria that give a positive result in the Gram stain test, which is traditionally used to quickly classify bacteria into two broad categories according to their type of cell wall.
Gram-positive bact ...
cocci and
gram negative
The gram (originally gramme; SI unit symbol g) is a unit of mass in the International System of Units (SI) equal to one one thousandth of a kilogram.
Originally defined as of 1795 as "the absolute weight of a volume of pure water equal to th ...
rods such as ''
Escherichia coli
''Escherichia coli'' (),Wells, J. C. (2000) Longman Pronunciation Dictionary. Harlow ngland Pearson Education Ltd. also known as ''E. coli'' (), is a Gram-negative, facultative anaerobic, rod-shaped, coliform bacterium of the genus ''Escher ...
'', ''
Proteus mirabilis
''Proteus mirabilis'' is a Gram-negative, facultatively anaerobic, rod-shaped bacterium. It shows swarming motility and urease activity. ''P. mirabilis'' causes 90% of all ''Proteus'' infections in humans. It is widely distributed in soil and ...
'', and ''
Klebsiella pneumoniae
''Klebsiella pneumoniae'' is a Gram-negative, non-motile, encapsulated, lactose- fermenting, facultative anaerobic, rod-shaped bacterium. It appears as a mucoid lactose fermenter on MacConkey agar.
Although found in the normal flora of the mo ...
''. To extend the coverage of antibiotics against more bacteria in Type III Gustilo fractures, combination of first generation cephalosporin and
aminoglycoside
Aminoglycoside is a medicinal and bacteriologic category of traditional Gram-negative antibacterial medications that inhibit protein synthesis and contain as a portion of the molecule an amino-modified glycoside (sugar). The term can also refer ...
(
gentamicin
Gentamicin is an antibiotic used to treat several types of bacterial infections. This may include bone infections, endocarditis, pelvic inflammatory disease, meningitis, pneumonia, urinary tract infections, and sepsis among others. It is not e ...
or
tobramycin
Tobramycin is an aminoglycoside antibiotic derived from '' Streptomyces tenebrarius'' that is used to treat various types of bacterial infections, particularly Gram-negative infections. It is especially effective against species of ''Pseudomonas ...
) or a third generation cephalosporin is recommended to cover against nosocomial gram negative bacilli such as ''
Pseudomonas aeruginosa
''Pseudomonas aeruginosa'' is a common encapsulated, gram-negative, aerobic–facultatively anaerobic, rod-shaped bacterium that can cause disease in plants and animals, including humans. A species of considerable medical importance, ''P. aerugi ...
''. Adding
penicillin
Penicillins (P, PCN or PEN) are a group of β-lactam antibiotics originally obtained from ''Penicillium'' moulds, principally '' P. chrysogenum'' and '' P. rubens''. Most penicillins in clinical use are synthesised by P. chrysogenum using ...
to cover for
gas gangrene
Gas gangrene (also known as clostridial myonecrosis and myonecrosis) is a bacterial infection that produces tissue gas in gangrene. This deadly form of gangrene usually is caused by '' Clostridium perfringens'' bacteria. About 1,000 cases of gas ...
caused by anaerobic bacteria ''
Clostridium perfringens
''Clostridium perfringens'' (formerly known as ''C. welchii'', or ''Bacillus welchii'') is a Gram-positive, rod-shaped, anaerobic, spore-forming pathogenic bacterium of the genus ''Clostridium''. ''C. perfringens'' is ever-present in nature an ...
'' 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)
Poly(methyl methacrylate) (PMMA) belongs to a group of materials called engineering plastics. It is a transparent thermoplastic. PMMA is also known as acrylic, acrylic glass, as well as by the trade names and brands Crylux, Plexiglas, Acrylite, ...
(PMMA) beads and antibiotic
bone cement
Bone cements have been used very successfully to anchor artificial joints (hip joints, knee joints, shoulder and elbow joints) for more than half a century. Artificial joints (referred to as prostheses) are anchored with bone cement. The bone ce ...
are helpful in reducing rates of infection.
The use of absorbable carriers with implant coatings at the time of surgical fixation is also an effective means of delivering local antibiotics.
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.
However, at present, there is only low to moderate evidence for this and more research is needed.
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.
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
Saline (also known as saline solution) is a mixture of sodium chloride (salt) and water. It has a number of uses in medicine including cleaning wounds, removal and storage of contact lenses, and help with dry eyes. By injection into a vein i ...
or other various forms of water (distilled, boiled, or tap). 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 have 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.
Wound debridement
The purpose of wound
debridement
Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy.
In p ...
is to remove all contaminated and non-viable tissues including skin,
subcutaneous fat
The subcutaneous tissue (), also called the hypodermis, hypoderm (), subcutis, superficial fascia, is the lowermost layer of the integumentary system in vertebrates. The types of cells found in the layer are fibroblasts, adipose cells, and mac ...
, 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.
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).
There is no difference in infection rates for performing surgery within 6 hours of injury when compared to until 72 hours after injury.
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.
Both techniques have similar rates of postoperative healing, postoperative infection, implant failure and compartment syndrome.
Unreamed intramedullary nailing is advantageous because it has a lower incidence of superficial infection and malunion compared to
external fixation
External fixation is a surgical treatment wherein rods are screwed into bone and exit the body to be attached to a stabilizing structure on the outside of the body. It is an alternative to internal fixation, where the components used to provide ...
.
However, unreamed intramedullary nailing can result in high rates of hardware failure if a person's weight bearing after surgery is not closely controlled.
Compared to external fixation, unreamed intramedullary nailing has similar rates of deep infection, delayed union and nonunion following surgery.
For open tibial fractures in children, there is an increasing trend of using
orthopedic cast
An orthopedic cast, or simply cast, is a shell, frequently made from plaster or fiberglass, that encases a limb (or, in some cases, large portions of the body) to stabilize and hold anatomical structures—most often a broken bone (or bones), in ...
rather than external fixation.
Bone grafting
Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some small or acute fractures can be cured wit ...
is also helpful in fracture repair. However,
internal fixation
Internal fixation is an operation in orthopedics that involves the surgical implementation of implants for the purpose of repairing a bone, a concept that dates to the mid-nineteenth century and was made applicable for routine treatment in the m ...
using plates and screws is not recommended as it increase the rate of infection.
Amputation
Amputation is the removal of a limb by trauma, medical illness, or surgery. As a surgical measure, it is used to control pain or a disease process in the affected limb, such as malignancy or gangrene. In some cases, it is carried out on indi ...
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
The blood circulatory system is a system of organs that includes the heart, blood vessels, and blood which is circulated throughout the entire body of a human or other vertebrate. It includes the cardiovascular system, or vascular system, tha ...
.
Wound management
Early wound closure is recommended to reduce the rates
hospital-acquired infection
A hospital-acquired infection, also known as a nosocomial infection (from the Greek , meaning "hospital"), is an infection that is acquired in a hospital or other health care facility. To emphasize both hospital and nonhospital settings, it is so ...
. 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
Negative-pressure wound therapy (NPWT), also known as a vacuum assisted closure (VAC), is a therapeutic technique using a suction pump, tubing and a dressing to remove excess exudate and promote healing in acute or chronic wounds and second- ...
(vacuum dressing), with several sources citing a decreased risk in infection,
and others suggesting no proven benefit.
Outcomes
Infection
The infection rate of open fractures depend on characteristics of the injury, type and timing of treatment, and patient factors.
Higher rates of infection are associated with a higher Gustilo classification, where the risk of infection with a grade III fracture are up to 19.2% and a grade I or II fracture can have a 7.2% risk of infection. Deep infection is more likely with increasing amounts of time between injury sustainment and antibiotic administration.
There is an increased risk of infection in patients who smoke or have diabetes.
The most common pathogen implicated in infected open fractures is ''Staphylococcus aureus''.
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
The tibia (; ), also known as the shinbone or shankbone, is the larger, stronger, and anterior (frontal) of the two bones in the leg below the knee in vertebrates (the other being the fibula, behind and to the outside of the tibia); it connects ...
at 3.4 per 100,000 population per year, and
distal radius fracture
A distal radius fracture, also known as wrist fracture, is a break of the part of the radius bone which is close to the wrist. Symptoms include pain, bruising, and rapid-onset swelling. The ulna bone may also be broken.
In younger people, thes ...
at 2.4 per 100,000 population per year.
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.
History
In Ancient Egypt, physicians were diagnosing and treating open fractures. Treatment consisted of manual reduction, where the broken bone is made to be straight again with physical maneuvers, and then application of splints and topical ointments. Splints were constructed using linen and sticks or tree bark. A topical ointment consisting of honey, grease, and lint made from vegetable fiber were then applied daily to the open fracture. However, the Ancient Egyptians noted open fractures to have a poor prognosis, and fifth dynasty graves have been discovered containing people who passed away from open fractures.
During the 19th century Crimean War, the use of
plaster-of-paris
Plaster is a building material used for the protective or decorative coating of walls and ceilings and for moulding and casting decorative elements. In English, "plaster" usually means a material used for the interiors of buildings, while "re ...
for the stabilization of open and closed fractures was pioneered. It has been reported that the pioneering Russian surgeon who introduced the novel technique had been inspired by watching sculptors creating works of art.
Before the 1850s, surgeons usually amputated the limbs for those with open fractures, as it was associated with severe
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
and
gangrene
Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...
which can be life-threatening. It was only until the 20th century, when
Joseph Lister
Joseph Lister, 1st Baron Lister, (5 April 182710 February 1912) was a British surgeon, medical scientist, experimental pathologist and a pioneer of antiseptic surgery and preventative medicine. Joseph Lister revolutionised the craft of s ...
adopted the
aseptic technique
Asepsis is the state of being free from disease-causing micro-organisms (such as pathogenic bacteria, viruses, pathogenic fungi, and parasites). There are two categories of asepsis: medical and surgical. The modern day notion of asepsis is deri ...
in surgeries, that the rate of death from open fractures reduced from 50% to 9%.
References
{{Fractures
Bone fractures
Acute pain