Open Fractures Treatment & Management

Virtually all open fractures must be considered for operative intervention. The introduction of bacteria and soft-tissue compromise associated with even “minor” open fractures mandate appropriate preoperative and operative management to minimize the risk of clinically important complications. ^{[12, 13]}

Perhaps the only absolute contraindication for operative management of an open fracture arises if the patient is in such critical condition that any operative intervention could lead to further deterioration; however, evidence from randomized controlled trials to support this concept is lacking. Even the patient in extremis may benefit from wound irrigation and sterile application of traction or external fixation in the trauma bay or trauma care unit until a formal irrigation and debridement can be undertaken in the operating room.

Special considerations in children

The principles for preoperative and intraoperative management of open fractures in the pediatric population are similar to those for adults, but there are a few differences that are largely related to the overall greater healing potential in this population.

In a review article, Stewart et al summarized each aspect of open fracture care for children. ^[14]  They noted that initial evaluation and classification of the injury should follow the modified Gustilo-Anderson system, as in adults. The primary antibiotic choices are the same as in the adult population, but the authors cautioned against alternative regimens involving fluoroquinolones because of issues related to bone healing and chondropathy in children.

Retrospective studies of the timing of operative debridement have called into question the dogma related to emergency management of open fractures in this population. ^[15]  In one study, no difference in acute infection rate was found to be associated with operative care within 6 hours after injury as compared with operative care more than 7 hours after injury.

Further controversy stems from studies related to nonoperative management of type I open fractures, ^[16] but the authors caution strongly against this practice without definitive study. Soft-tissue care generally follows that used in adults, and the use of vacuum-assisted closure (VAC) has been shown to be safe and effective in the pediatric population. ^[17]  Fixation choices should account for the greater healing potential in children and, therefore, often do not require the same degree of stability as in adults. ^[14]

Special considerations in the elderly

The incidence of open fractures in elderly patients has been shown to be equal to or greater than that in younger patients. In one study, the incidence of open fractures in women older than 90 years was similar to that in males between the ages of 15 and 19 years. ^[18] This is partially due to longer life expectancies and to bone and skin changes associated with aging.

Open fractures in elderly patients are most likely to occur in subcutaneous bones (eg, distal radius, hand, tibia, and ankle), ^[19] and even low-energy mechanisms can result in substantial soft-tissue injuries, despite a less severe underlying bony injury. Furthermore, age has been shown to be a risk factor for infection and wound complications, nonunion, and even mortality after open fracture. ^{[20, 21, 22]}

Whereas the general principles of open fracture management in elderly patients remain largely the same, careful evaluation of patient factors such as diabetes, obesity, smoking status, bone density, and nutrition must be addressed to optimize patient outcomes. Furthermore, multidisciplinary teams that include medicine or geriatrics specialties are recommended for operative optimization.

Parenteral antibiotic administration

Patzakis et al described the value of acute systemic antibiotic use for open fractures. ^[23]  In a later review article, Patzakis and Zalavras pointed out that the administration of antibiotics is best considered therapeutic, rather than prophylactic, because of the high risk of infection in the absence of antibiotics. ^[24]

Although debate still surrounds some aspects of antibiotic administration for open fractures, ^[25] the following generalizations can be made:

• All patients with open fractures should receive cefazolin or equivalent gram-positive coverage; this may be sufficient for type I injuries
• Type II or type III injuries likely benefit from the addition of adequate gram-negative coverage, typically with an aminoglycoside or a fourth-generation cephalosporin; a retrospective study by Takahara et al suggested that ampicillin-sulbactam may be an acceptable alternative for type IIIa fractures ^[26]
• Injuries at risk for anaerobic infections (eg, farm injuries, severe tissue necrosis) probably benefit from the addition of penicillin or clindamycin

A 2020 article retrospectively examined infections after open fractures and found an increase in gram-negative, polymicrobial, and methicillin-resistant Staphylococcus aureus (MRSA) infections in comparison with historical cohorts. ^[27] However, the emergence of various antibiotic-resistant organisms and the development of alternative regimens of antibiotics for use in open fractures have not yet been sufficiently well studied.

The ideal duration of antibiotic administration has been controversial. ^[28] A 2017 systematic review by Messner et al could not substantiate more than 72 hours of antibiotic administration after open long-bone fracture. ^[29] A 2019 study found an association with extended antibiotic prophylaxis (>72 hours after definitive wound closure) and increased surgical-site infections (SSIs) in mildly contaminated wounds but a substantial decrease in SSIs in severely contaminated wounds. ^[30] A 2020 review article also could not support antibiotic administration beyond 24 hours after either debridement with sterile dressings or definitive coverage. ^[31]

A 2022 systematic review by Vanvelk et al concluded that prolonged perioperative antibiotic prophylaxis did not appear to be helpful in preventing fracture-related infection but noted that in view of the various limitations of all six of the studies included, the review findings should be interpreted with caution. ^[32] Future randomized trials would be necessary to answer this research question definitively.

Generally, antibiotics should be administered as soon as possible upon presentation and continued for a minimum of 24 hours. 

Tetanus immunization and prophylaxis

Immunization and prophylaxis against tetanus deserve specific consideration. Tetanus is caused by infection from Clostridium tetani, which is an anaerobic bacterium commonly found in soil, and the toxins produced by the bacteria lead to severe and potentially life-threatening muscular spasm. Immunization of civilians became widespread after successful use of heat-inactivated toxin during World War II. ^[33]

On the basis of a review of various sources, Rhee et al made the following recommendations regarding tetanus vaccine in cases of traumatic wounds ^[33] :

• Perform appropriate irrigation and debridement as indicated
• Obtain patient’s immunization history
• Administer tetanus toxoid if the last booster was given more than 10 years previously or if history is not reliable or available
• Give tetanus immunoglobulin to patients with incomplete primary immunization or to patients for whom it has been longer than 10 years since their last booster dose

The authors point out that the severity of the wound should not be a factor in determining the need for tetanus immunization or prophylaxis.

Bone morphogenetic protein

An area of current interest involves the use of bone morphogenic protein (BMP). Although BMP may have many applications related to orthopedic fracture care, it has not been widely studied in relation to open fractures. A multicenter prospective randomized trial that examined the use of recombinant human BMP-2 (rhBMP-2) in open tibia fractures found that patients who received BMP at the time of their wound closure had lower infection rates and less frequently required secondary intervention to obtain union. ^[34]

Certainly, cost is a concern with BMP therapy, but Jones et al showed that the use of BMP in open tibia fractures could result in a situation where the cost of the agent is offset, or even surpassed, by cost savings resulting from decreased secondary procedures and complications. ^[35] Further research is needed to define the proper patient and fracture populations in which BMPs are safe and effective adjuncts to open fracture care.

Surgical management of open fractures involves adhering to a series of principles that have evolved over time and that are largely based on the care of war-wounded military personnel by military surgeons. A leading example is the work by Trueta, which described the successful use of debridement with splinting of injured extremities. ^[36]  Introduction of invasive skeletal stabilization and continued focus on wound management led to increasing success. A modern protocol from Operation Enduring Freedom, by Lin et al, was not associated with any infections in 14 open fractures. ^[37]

Preparation for surgery

It is critical to follow Advanced Trauma Life Support (ATLS) and institutional protocols to properly evaluate a trauma patient. ^[10]  The preoperative evaluation must accurately document neurologic and vascular status. Digital photos are helpful for documenting the initial appearance of the extremity and can be a valuable addition to the medical record. Digital imaging allows other members of the treatment team to see the wound preoperatively without repeated manipulations of the wound. Various mobile smartphone applications are available for this purpose. ^[38]

Open fracture wounds can then be dressed with sterile, moist gauze, and clinical realignment of the limb can be accomplished with a temporary splint or traction. Patients who are appropriate for operative management should be urgently brought to the operating room.

Irrigation

Washing the wound with large volumes of fluid will remove macro contamination and clotting that may obscure the view of deeper levels of contamination or damaged tissue. Once the macro contamination is eliminated, the irrigation serves to diminish the residual bacterial contamination of the remaining healthy tissue. Irrigation is often done in conjunction with surgical debridement (see below).

The use of antibiotics and other bactericidal additives to the irrigant continues to be a controversial treatment topic, but the chemical makeup of many of the additives is similar to that of soap and thus potentially can cause tissue swelling and the creation of surface layers over the damaged tissue. ^[39]

Although it is clear that irrigation is critical in the surgical management of open fractures, the method of irrigation and the choice of irrigant solution have been subjects of debate. An international survey of 984 surgeons described some of the differences in practice: 70.5% preferred normal saline, 16.8% added bacitracin, 6% added iodine-based solution, and 1.3% added a detergent or soap solution. ^[40] Low-pressure modes of irrigation were preferred by 71%. The differences in practice reflect the variability in early and subsequent studies.

The conclusions of Crowley et al with respect to irrigation may be summarized as follows ^[41] :

• Normal saline should be used routinely
• The use of antibiotics and antiseptics should be limited, because of the lack of evidence of efficacy and because of potential risks
• Low-pressure methods should be used routinely; pressures above 50 psi likely damage soft tissue and bone

A multicenter study by the FLOW investigators found that very low pressure (1-2 psi) was an acceptable low-cost alternative for the irrigation of open fractures. Additionally, the authors found that the addition of soap increased the risk of reoperation and therefore should be avoided. ^[42]

Debridement

Debridement of an open fracture must be done in a thorough and systematic manner so as to avoid leaving devitalized tissue or contamination behind. ^[43]  The skin edges of the traumatic wound should be trimmed to a healthy bleeding edge. Loose subcutaneous fat should also be removed, along with any severely contused or noncontractile muscle. To ensure adequate debridement, traumatic wounds must be extended and muscle compartments opened and explored.

Removal of devitalized tissue is not limited to the soft tissues; bone should also be removed if it is free of soft-tissue attachment. Major articular fragments may be an exception to this rule; they should be retained whenever possible to allow for attempts at fixation and restoration of joint stability and motion. In general, the goal is to remove damaged tissue that would serve as a breeding ground for bacteria, without creating extensive additional surgical trauma through unnecessary periosteal stripping or undermining of the skin flaps.

In high-energy cases, it is often necessary to perform multiple debridements so as to adequately remove tissue that may evolve after the time of the initial operative inspection. In principle, it is best to avoid infection by removing devitalized bone and muscle and then to deal with later reconstruction by using bone grafting and soft-tissue flaps in an aseptic environment.

The timing of surgical intervention became controversial as a result of reevaluation of the literature upon which orthopedic dogma was founded—that is, that all open fractures must be operatively debrided and stabilized within 6 hours after the injury.

In 2006, Pollak authored a review of previous and more recent literature and concluded that "[the concept of] mandatory debridement within 6 hours of injury is minimally supported by the literature.” ^[44]  Many studies that have utilized modern fixation strategies and immediate use of antibiotics have not shown a time-related difference in infection rate. As Pollak pointed out, a randomized trial in this area is not feasible, but additional study is needed to further illuminate the role that timing of initial surgical intervention plays on important outcome variables. ^[44]

Schenker et al published a systematic review and also concluded that the so-called 6-hour rule is not well supported by the existing literature. This was based upon the authors' close evaluation of 16 studies that included over 3500 open fractures. ^[45]

Similarly, in a retrospective review of 642 patients with open fractures, Mener et al found that prolonged time to debridement (even >24 hr) was not associated with increased infection rates ^[46] ; however, debridement performed between 7:00 PM and 7:00 AM was a significant risk factor for infection. Delayed initial operative intervention was most often due to hemodynamic instability and neurologic clearance, refuting the theory that only the least complex injuries were delayed. It can be inferred that proper medical optimization and knowledgeable support staff may contribute to improved patient outcomes.

In clinical practice, it is likely to be in the patient’s interest to use a more practical, less dogmatic approach—namely, that open fractures should be treated surgically in an urgent (but not necessarily emergency) fashion, utilizing appropriate timely antibiotic coverage, skilled debridement, and skeletal stabilization.

Stabilization

Fracture stabilization is critical for management of the injured extremity and for the overall benefit of the patient. The stability imparted to the bone helps minimize ongoing trauma to the soft tissues and provides a stable scaffold for tissue healing. Furthermore, bone stability allows for early functional motion of the extremity. Nursing care and mobilizing the patient out of bed are facilitated as well.

The choice of fracture-fixation method is based on many factors, including the quality of local soft tissues, the location and pattern of the fracture, the overall health of the patient, and the presence and nature of any associated injuries. A detailed discussion of all the possible fixation methods for the variety of open fractures is beyond the scope of this article. Generally speaking, the method of fixation must minimize additional surgical trauma to the zone of injury while providing adequate stability for patient mobilization and soft tissue healing.

Local adjuncts

Some open fractures may benefit from the addition of local antibiotics. Antibiotics placed in the zone of injury can achieve high local concentration of the drug, typically without systemic side effects. ^[47]  The technique involves antibiotic-impregnated beads sealed into the wound for gradual elution of drug to the surrounding tissues. The technique is based on the addition of heat-stable antibiotic powder to a batch of polymethylmethacrylate (PMMA) cement, forming beads that are threaded on nonabsorbable suture or wire.

The use of multiple small beads creates a relatively large overall surface area for antibiotic elution. Antibiotic cement spacers may also be used to preserve soft-tissue space in the presence of a significant bone defect; during a subsequent procedure, the cement spacer can be removed and the void filled with bone graft. An interesting aspect of this technique is that the pseudocapsule that forms around the cement has been shown to have some osteogenic properties beneficial for promoting successful union after subsequent procedures. ^[48]

Commercially available preformed antibiotic beads are available and typically take the form of a calcium-based absorbable bead. These beads need not be removed at a subsequent procedure, and studies using these systems in animal models of contaminated open fractures have demosntrated apparently promising outcomes. ^[49]

In a systematic review and meta-analysis of eight studies—six of which investigated PMMA beads containing tobramycin—comparing the effect of local antibiotic prophylaxis with systemic therapy alone, Morgenstern et al found an 11.9% risk reduction in fracture-related infection. ^[50] The authors themselves, however, noted a risk of bias and heterogeneity with the limited-quality evidence in this review. Use of local antibiotic adjuncts should be considered on a case-by-case basis, taking into consideration both patient and injury factors.

Initial wound management

Although the practice has come under scrutiny, the prevailing method for dealing with open fracture wounds has been to perform serial debridements and close wounds in a staged fashion, particularly with type III injuries. Delayed wound closure became the standard on the basis of the experience of military surgeons and the severe consequences faced in dealing with primarily or prematurely closed wounds.

A common practice is to close the surgically created extensions of the traumatic wounds at the time of fixation and initial debridement, followed by a second look at the wound, with further debridement if necessary, in 48-72 hours. This can be repeated as indicated by the presence of any further evolution of tissue necrosis.

Negative-pressure wound therapy (NPWT) is often used in dealing with open fracture wounds and may decrease the need for free tissue transfer or rotational flap coverage in high-energy open fractures. ^{[51, 52]}

A meta-analysis by Liu et al concluded that NPWT could significantly reduce the risk of infection and accelerate wound healing in open fractures ^[53] ; there was also some evidence to suggest that NPWT might help reduce the severity of limb injury and increase the chance of avoiding amputation.

Similarly, a 2020 systematic review and meta-analysis by Grant-Freemantle et al found that NPWT decreased the incidence of deep infection and flap failure as compared with conventional dressings after open fractures that were not amenable to early closure. ^[54]  

A 2022 systematic review and meta-analysis by Qian et al found that in patients with open fractures of the lower limb, NPWT, as compared with traditional gauze dressings, was associated with lower rates of infection overall and of acute wound infection, was well as with a shorter average hospital stay. ^[55] There were no significant differences in functional score or the development of other complications (eg, deep infection, amputation, or bone nonunion).

In many cases, abundant granulation tissue forms after NPWT, and residual soft-tissue defects can be covered effectively with basic skin grafts. (See the images below.)

Timing of wound closure

The timing of wound closure is another area where the traditional dogma has been challenged. Jenkinson et al found that primary closure after Gustilo type I-IIIA fractures yielded lower rates of deep infection than delayed closure. ^[56] Similarly, Scharfenberger et al found lower rates of deep infections and nonunion after primary closure in open fractures than after delayed closure. ^[57]  Again, much of the standard treatment is based on literature published before current standards related to antibiotics, surgical implants, and surgical technique. In short, it seems that in many cases, primary wound closure at the time of operative debridement and fixation can be done safely without additional risk to the patient.

As noted by Weitz-Marshall and Bosse, “Surgical judgment, typically gained with experience, is required to successfully use an immediate wound-closure protocol." ^[58]  In addition, Weitz-Marshall and Bosse made the following comments:

• Gross contamination, stagnant water contamination, and farm injuries or fresh-water boating injuries should not necessitate immediate wound closure
• Delay of 12 hours after injury for delivery of antibiotics, confounding comorbidities, and doubt about the adequacy of the initial debridement are all contraindications for acute closure
• Pending definitive research, the “best clinical practice may be the adoption of a treatment plan that allows for the earliest possible soft-tissue coverage over a clean, stable, viable zone of injury”

Very similar recommendations were made in a review paper published by Crowley et al ^[41]  and included consideration of supporting literature published after the review by Weitz-Marshall and Bosse. ^[58]

The optimal duration of postoperative antibiotic use has not been definitively established by the literature; however, current evidence supports perioperative antibiotics for 24 hours or until complete wound coverage or closure. Often, institutional policies are in place for systemwide antibiotic regimens after open fractures.

Some of the literature strongly questions this practice, and concern has been raised regarding the development of resistant systemic nosocomial infections in the polytrauma patient because of overuse of perioperative antibiotics. ^[59]  A modern study in the setting of current trauma care, fixation techniques, and antibiotic-resistance patterns is needed to clarify this issue.

In situations involving significant bone loss, the postoperative plan may include the use of autologous bone graft. In high-energy open fractures, the timing of subsequent grafting procedures should be based on the presence of a “fully reepithelialized wound with no drainage” and no clinical evidence of infection. ^[60]

Infection is the most obvious complication that may result from an open fracture. ^{[12, 13]}  The risk of infection is related to the severity of the injury (see Classification), as follows ^[24] :

• Gustilo-Anderson type I, 0-2%
• Gustilo-Anderson type II, 2-10%
• Gustilo-Anderson type III, 10-50%

Failure to heal may result with any fracture. For of a variety of reasons, nonunion risk is greater with open fractures than with similar closed fractures. Many of the factors are related to the damaged blood supply at the zone of injury. The impaired circulation can lead to poor formation or loss of the fracture hematoma. The subsequent poor delivery of inflammatory mediators to facilitate callus formation and the presence of necrotic bone exacerbate the risk of nonunion.

Loss of bone or periosteum from the fracture site impairs bone healing as well. Operative technique of debridement and fixation must focus on minimizing further trauma to the bone and surrounding tissues.

Details regarding outcome and prognosis for open fractures are variable, depending on the specifics of the local and associated injuries.

The frequency of follow-up is driven by various factors. The wound may have to be monitored closely in the early phases of healing. The particular fractures and chosen methods of fixation will determine the need for radiographic and clinical reexamination. (See the images below.)