Open Fractures: Practice Essentials, Pathophysiology

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Overview

Practice Essentials

The procedure for evaluation and management of open fractures is best described as a set of principles that has evolved over time, often in relation to advances in wartime care of military personnel. These principles involve both initial management and subsequent surgical intervention.^{[1, 2, 3, 4]}

The first step is accurate diagnosis and documentation of the mechanism of injury. Appropriate coverage of the wound and splinting of the fracture are performed in conjunction with initiation of appropriate antibiotic therapy and tetanus prophylaxis. Broad coverage for gram-positive organisms with the addition of gram-negative coverage for higher-grade injuries has become the most common choice for initiation of antibiotic therapy after open fracture.

Urgent surgical intervention typically follows and involves both soft-tissue and bone management. Adjuncts to the care of open fractures have evolved and often involve delivery of antibiotics or metabolically important substances to the local fracture environment.

These principles are generally well established and accepted across the orthopedic community, but in some respects, controversy still exists regarding the details.

For more information, see the following topics:

Pathophysiology

The risk of a fracture being open is related to the amount of soft-tissue coverage in that region of the body and to the amount of energy imparted to that region. For example, the tibia has a long medial aspect that is subcutaneous, and therefore, it is “easier” for trauma to the lower leg to expose the bone and fracture site. Conversely, the femur is surrounded by thick muscle layers circumferentially and, therefore, is less likely to be exposed after a similar amount of force to the thigh.

Open fractures pose some unique risks beyond those encountered with similar closed fractures that may occur with similar amounts of force. The greatest problem is the risk of infection. Diaphyseal bone loss in excess of 3 cm presents a complex set of problems as well. If the open fracture was caused by penetrating trauma, direct injury to major neurovascular structures may be more likely, thereby affecting the prognosis for limb function.

Direct inoculation of the tissue is a basic issue in the pathophysiology of open fracture management. Furthermore, bacteria can colonize wounds at later stages of care, being introduced into the wound at subsequent dressing changes or repeat debridements prior to definitive wound closure. Gustilo and Anderson reported that 50.7% of their 158 patients had a positive wound culture upon initial evaluation.^[5] Another 31 patients that were initially culture-negative had a subsequent positive culture at the time of their definitive closure.

Devitalized tissue results from the energy imparted to the body. A crushing injury can impair the local immune response, with local ischemia playing a large role in this process. Ischemia may also occur by direct trauma to the large vessels and/or microcirculation. Important indirect causes of ischemia include increased myofascial compartment pressures, increased vascular permeability, and the use of vasoconstrictive medications during resuscitation.

Clinical Presentation

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Media Gallery

An open tibia fracture with bone loss. A tibial nail was placed and the wound was managed with negative pressure wound therapy, eventually covered with split-thickness skin graft.
Eight weeks later, the defect was approached from a lateral incision to avoid the previous medial open fracture wound. A central bone grafting technique was performed.
The central aspect of the leg was filled with bone graft, and internal fixation of the fibula was performed.
The appearance of the mature synostosis 8 months after the patient's original injury.
An open midfoot fracture with bone loss at the base of the first metatarsal, including approximately 66% of the joint surface.
The foot was cared for with serial debridement and temporary pinning of the midfoot to preserve alignment with minimal additional surgical trauma.
An antibiotic-impregnated cement spacer was placed in the bone void, and 12 weeks later, after the pins had already been removed, a midfoot fusion was performed.
Intraoperative image of the midfoot fusion. The cement spacer has been replaced by autologous bone graft from the iliac crest.

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Author

Erin Pichiotino, MD Resident Physician, Department of Orthopedic Surgery, Prisma Health-Upstate

Erin Pichiotino, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Public Health Association, Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas M Schaller, MD Orthopedic Trauma Surgeon, Steadman Hawkins Clinic of the Carolinas

Thomas M Schaller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, AO Foundation, Orthopaedic Trauma Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Smith-Nephew<br/>Received income in an amount equal to or greater than $250 from: smith nephew.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Steven I Rabin, MD Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Forensic Examiners Institute, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

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