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The debridement and copious irrigation necessary for the treatment of open fractures can present a technical challenge to the clinician. We have devised an irrigation system, using materials readily available in the operating room, that allows open fractures to be irrigated at pressures greater than gravity.
A retrospective analysis was conducted of 37 open fracture cases sustained by U.S. military personnel during the recent low-intensity conflict in Panama (Operation Just Cause). The etiology, location, classification, and management of open fractures sustained in combat is presented. A significant difference was noted in the infection rate for type III open fractures that were debrided in Panama (22%) as compared to those that were debrided only after transport to CONUS (66%). This study supports the critical importance of adequate battlefield surgical support in low-intensity conflicts, and reemphasizes the crucial role of early surgical debridement for the prevention of wound infection.
Cooperation between orthopaedic and plastic surgeons is an important factor in the treatment of open fractures. In this article a report is made on a retrospective study of a 5-year series of open fractures of the shaft of the tibia treated at the University Hospital in Uppsala between 1972 and 1976. The study proves that the change to external fixation of these fractures and 'open' treatment of the wounds has meant that to a large extent the previous use of pedicle flaps to cover skin defects has been replaced by split skin grafts. The results in the reported series were good, with adequate function in most cases. The final results may, however, be less good than they appeared at this early review time.
Four hundred four compound fractures were reviewed in 339 patients treated between August 1983 and November 1987. The 252 males and 87 females had a mean age of 33 years (range, 14-86). One hundred twenty-seven (31.4%) fractures were classified as Grade I, 153 (38.9%) as Grade II, and 124 (30.7%) as Grade III by Gustilo's classification. The mean Injury Severity Score was 15 (range, 9-57). Three hundred thirty-four of the open fractures (82.7%) were managed with antibiotic-impregnated bead chains (tobramycin) and systemic antibiotic prophylaxis (cefazolin, tobramycin, and penicillin). Seventy open fractures (17.3%) received systemic antibiotic prophylaxis (cefazolin, tobramycin, and penicillin) without supplemental use of the antibiotic beads. All open fractures underwent acute irrigation and debridement. In the 404 fractures 46.5% of wounds were closed primarily, 12.9% underwent delayed primary closure, 7.9% were left open, and 32.7% were temporized by the antibiotic bead pouch technique until definitive flap coverage and skin grafting were performed. Of the 404 fractures evaluated, 17 (4.2%) developed an acute wound infection. Of these wound infections, eight (11.4%) were in the group managed with systemic antibiotics alone. By comparison, nine (2.7%) of open fractures treated with combined systemic antibiotics and antibiotic-impregnated beads developed an infection. Chronic osteomyelitis developed in 18 of 404 open fractures (4.5%). Ten (14.3%) open fractures which developed osteomyelitis were managed with systemic antibiotics whereas eight (2.4%) fractures managed with systemic antibiotics and antibiotic-impregnated beads developed a chronic infection.(ABSTRACT TRUNCATED AT 250 WORDS)
In 1992, 15 of 152 patients with open fractures were treated with vacuum sealing. Drainage tubes are inserted into polyvinyl foam, which is used to fill in the wound or tissue defect. Polyvinyl foam and adjacent skin are covered with a transparent polyurethane dressing which is impermeable to bacteria. The connection of the drainage tubes to a suction device, such as vacuum bottles, produces negative pressure in the polyvinyl foam, which means a high-contact zone of the foam-wound interface. This results in efficient cleaning and conditioning of the wound, with marked proliferation of granulation tissue. Bone infection did not occur in any of our 15 patients; 1 patient sustained a soft tissue infection due to an insufficient sealing technique. When the correct technique was applied the infection cleared up.
This article reviews current concepts in treating open fractures along with case studies to illustrate specific treatment procedures. It should be used as a basis for care and provide the fundamentals to successfully treat patients in a trauma setting. The practitioner will find this a challenging and exciting area for professional practice.
The history of intramedullary nailing leads us to assume that septic complications arising from the treatment of open fractures through marrow nailing are largely due to reaming and need no longer to a full extent be put down to treatment by locking nailing. Locking nailing of an open fracture (all three degrees) of the femur can be recommended as long as the periosteum is not exposed over large segments, and coverage with soft tissue is possible. Locking nailing of the lower leg can only be recommended with open fractures of the first degree. With fractures of the second and third degrees the fixateur externe is the treatment of choice.
In a prospective study of 60 open fractures treated with prophylactic antibiotics, 10 developed infection with 2/40 Grades 1 and 2 fractures and 8/20 Grade 3 fractures. Intravenous penicillin was ineffective against Staphylococcus aureus and epidermidis, the most usual organisms causing infection in open fractures, as 62 percent of the organisms cultured from the initial culture and 92 percent of those cultured during infection were resistant to penicillin. For the second generation cephalosporins, the respective figures were 21 and 30 percent.
A retrospective study was performed on 33 patients who sustained isolated open-fracture injuries to the foot and ankle. A wide variety of open-fracture injuries of the foot and ankle are documented. Of the 33 cases, only 2 became clinically infected, translating into an infection rate of 6.06%. A literature review of open-fracture injuries is presented along with the preliminary results of the retrospective study.
This article presents a literature review of the evaluation and management of open fractures. A case report of a patient having sustained a type II open fracture of the hallux is presented. Debridement, tetanus prophylaxis, reduction and stabilization, and intravenous antibiosis are the hallmarks for prompt and appropriate treatment.
OBJECTIVE: To describe the epidemiology, early results of treatment, and complications associated with open fractures of the forearm in children. DESIGN: Retrospective review of patients treated according to protocol. SETTING: Level I trauma center. PATIENTS/PARTICIPANTS: All children with an open fracture of the forearm during a four-year period (n = 76). Fourteen patients were excluded because of inadequate follow-up or incomplete medical records. INTERVENTION: All fractures were treated with irrigation and debridement, and parenteral antibiotics. Twenty-five patients were managed with cast immobilization only, and the remaining thirty-seven, with internal fixation either with transcutaneous pins, intramedullary pins, or plates and screws, followed by immobilization in a cast. MAIN OUTCOME MEASUREMENTS: Time to union, angular alignment at union, and incidence of complications. RESULTS: The average time to union was 8.9 weeks (median, eight weeks; range, 6 to 17 weeks). There were no nonunions, but three of the sixty-two fractures had delayed union. Eight of the sixty-two fractures healed with an angular deformity of more than 10 degrees, and two developed infections, one deep and one superficial. There were three preoperative and four postoperative nerve palsies, which all resolved spontaneously. CONCLUSIONS: Open fractures of the forearm in children, treated with prompt administration of parenteral antibiotics followed by debridement, were associated with a fairly low incidence of complications. Although we found that the use of some form of internal fixation tended to reduce both the need to remanipulate these fractures (p = 0.08), and to minimize the incidence of angular deformity greater than 10 degrees (p = 0.16), these findings did not reach statistical significance.
In open limb fractures, loss of bone fragments of considerable size, including portions of the joint surface, is a frequent finding. Although the authors routinely use common surgical methods of reconstruction, in this paper they present a method for preserving these fragments by storage in the abdominal wall, and using them for autografting once healing of the soft tissues in the site of fracture has occurred. This method, illustrated by an analysis of 3 cases, appears to be simple and effective and, when used in selected cases, may provide a solution for the treatment of severe post-traumatic loss of bone.
Ninety-nine open fractures of the tibial shaft were treated with unilateral external fixation with or without supplemental lag-screw fixation. We compared the results in forty-four fractures in which only external fixation was used (control group) with those in fifty-five fractures that were stabilized with lag-screws and external fixation, and we found no statistically significant differences between the two groups with respect to the time to full weight-bearing, the time to union, or the rates of delayed union, osteomyelitis, malunion, superficial or deep pin-track infection, or loosening of the pins. The limbs in which the fracture was treated with external fixation and supplemental lag-screws had more than twice the rate of refracture of the control limbs (11 compared with 5 per cent), and the percentage of fractures having supplemental lag-screw fixation that needed bone-grafting to achieve union was more than twice that in the group treated with external fixation alone. We concluded that the routine use of supplemental lag-screw fixation is not indicated in patients who have an open fracture of the tibial shaft that has been stabilized with external fixation.
BACKGROUND: Prolonged courses of broad-spectrum antibiotics are often cited as the standard of care for prevention of infective complications of open fractures. The origins of these recommendations are obscure, however, and multi-drug-resistant systemic infections attributable to antibiotic overuse are common life-threatening problems in current intensive care unit practice. OBJECTIVE: To review systematically the effects of prophylactic antibiotic administration on the incidence of infections complicating open fractures. DATA SOURCES: Computerized bibliographic search of published research and citation review of relevant articles. STUDY SELECTION: All published clinical trials claiming to evaluate, or cited elsewhere as being authoritative regarding, the role of antibiotics in open fracture management were identified and then evaluated according to published guidelines for evidence-based medicine. Only small studies (<20 patients), practice surveys, pharmacokinetic studies, and reviews or duplicative publications presenting primary data already considered were excluded from analysis. DATA EXTRACTION: Information on demographics, study dates, fracture grade, antibiotic type, duration and route of administration, surgical interventions, infection-related outcomes, and the methodologic quality of the studies was extracted by the authors. The primary results were submitted to the Therapeutic Agents Committee of the Surgical Infection Society for review prior to creation of the final consensus document. DATA SYNTHESIS: Current antibiotic management of open fractures is based on a small number of studies that generally are more than 30 years old and do not reflect current management priorities in trauma and critical care. With a few noteworthy exceptions, these primary studies suffer from a variety of methodologic problems, including co-mingling of prospective and retrospective data sets, absence of or inappropriate statistical analysis, lack of blinding, or failure of randomization. CONCLUSIONS: The data support the conclusion that a short course of first-generation cephalosporins, begun as soon as possible after injury, significantly lowers the risk of infection when used in combination with prompt, modern orthopedic fracture wound management. There is insufficient evidence to support other common management practices, such as prolonged courses or repeated short courses of antibiotics, the use of antibiotic coverage extending to gram-negative bacilli or clostridial species, or the use of local antibiotic therapies such as beads. Large, randomized, blinded trials are needed to prove or disprove the value of these traditional approaches. Such trials should be performed in patients with high-grade fractures who (1) are well-stratified according to the degree of local injury and (2) undergo standardized fracture and wound management. Trials also must be powered to study the effects of extended antibiotic coverage on nosocomial infections. Antibiotic regimens confirmed to improve local fracture outcomes in such studies could then be used rationally, balancing the risks of local fracture-related infections and of multi-drug-resistant systemic infections to achieve optimal global outcomes.
The results of immediate plate fixation of 97 open fractures of the tibial shaft in 95 patients are reported. Significant joint stiffness occurred in 11.4% and angular malunion of greater than 5 degrees in any plane was seen in 3.1%. The infection rate was 10.3%. However, even in those cases which develop delayed union or other complications, plate fixation of open fractures can produce excellent recovery of limb function.
Twenty children with acute type III open fractures of the tibial metaphyses or diaphysis were retrospectively studied. The average age was 9 years, 1 month (range, 2 years, 11 months to 16 years, 2 months). There were seven type IIIA fractures, 10 type IIIB fractures, and 3 type IIIC fractures. All fractures were irrigated and debrided, and prophylactic antibiotics were given for a minimum of 48 h. Fifteen fractures were initially treated with external fixation, three with casts, one with internal fixation, and one with a combination of external fixation and limited internal fixation. Free muscle flaps were used for soft-tissue coverage in six patients, and a local muscle flap in one patient. The average time to fracture healing was 29 weeks, and the median time to fracture healing was 20 weeks (range, 8-104). Four patients had delayed union, and two additional patients had nonunion. Both patients with nonunion were successfully treated with autologous bone grafting. The time to fracture union was related to the severity of soft-tissue injury, fracture configuration, segmental bone loss, and infection. Osteomyelitis developed in three patients. All were successfully treated. Two patients treated with external fixation had leg-length discrepancies of > 1 cm, with the injured extremity longer in both cases. There were no late amputations. Children with severe open fractures of the tibia have a good prognosis for limb salvage with aggressive wound care and fracture management.
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