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Open Fractures
MOHAMED ELGEBEILY, MD
LECTURER OF ORTHOPAEDIC SURGERY
AIN SHAMS UNIVERSITY
Definition
It is a fracture with a Break
in the skin and underlying
soft tissue leading directly
into or communicating with
the fracture and its
hematoma
Epidemiology
3% of all limb fractures
21.3 per 100,000 per year
Incidence
Open fractures of the tibia are
more common than in any
other long bone
Tibial diaphysis fractures:
2 per 1000 population to 2 per
10,000
and of these approximately
one fourth are open tibia
fractures*
Mechanism of Injury
Can occur in lower energy, torsional type injury (e.g., skiing)
More common with higher energy direct force (e.g. car
bumper)
Priorities
 ABC’S
 Assoc Injuries
 Tetanus
 Antibiotics
 Soft Tissue
Management
 Fixation
 Long term issues
Physical Examination
Circumferential inspection of
soft tissue envelope, noting
any
Lacerations
deformity
Ecchymosis
Swelling
tissue integrity
Neurovascular
Physical Exam
Neurologic and vascular exam of extremity including ABI’s if indicated
Johansen K, J Trauma April 1991
Wounds should be assessed once in ER, then covered with sterile
gauze dressing until treated in OR- digital camera / cell phone
True classification of wound best done after surgical debridement
completed
Radiographic Evaluation
Full length AP and lateral
views from knee to ankle
required for all tibia fractures
Arteriography indicated if
vascular compromise present
after reduction
Associated Injuries
Approximately 30% of patients have
multiple injuries
Fibula commonly fractured and its
degree of comminution correlates
with severity of injury
Ligamentous knee injury and/or
ipsilateral femur (‘floating knee’)
more common in high energy
fractures
Associated Injuries
Neurovascular structures
require repeated assessment
Foot fractures also common
Compartment syndrome
must be looked for
Antibiotics
First Generation Cephalosporin
+/- Aminoglycoside
+/- Pen G or Clindamycin if Pen allergic
No Cipro alone Patzakis MJ, J Orthop Trauma Nov 2000
24-72hr course
Classification of Open Tibia
Fractures
Gustilo and Anderson open fracture classification first published in
1976 and later modified in 1984
In one study interobserver agreement on classification only 60%
Open fractures
Open fractures
Type 1 Open Fractures
Inside-out injury
Clean wound
Minimal soft tissue damage
No significant periosteal stripping
Type 2 Open Fractures
Moderate soft tissue damage
Outside-in
Higher energy
Some necrotic muscle
Some periosteal stripping
Type 3a Open Fractures
High energy
Outside-in
Extensive muscle devitalization
Bone coverage with existing soft tissue
Type 3b Open Fractures
High energy
Outside in
Extensive muscle devitalization
Requires a flap for
bone coverage and
soft tissue closure
Periosteal stripping
Type 3c Open Fractures
High energy
Increased risk of amputation
and infection
Any grade 3 with
major vascular injury
requiring repair
Why use this classification?
Grades of soft tissue injury correlates with infection and
fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates
0-2% 2-7% 10-25% 10-50% 25-50%
Fracture
Healing
(weeks)
21-28 28-28 30-35 30-35
Amputation
Rate
50%
Objectives of Surgical Treatment
 Prevent Sepsis
 Achieve Union
 Restore Function
Treatment of Soft Tissue Injury
After initial evaluation wound
covered with sterile dressing
and leg splinted
Appropriate tetanus prophylaxis
and antibiotics begun
Thorough debridement and
irrigation undertaken in OR
within 6 hours if possible
Photo documentation
Treatment of Soft Tissue Injury
Careful planning of skin incisions
Longitudinal incisions / “Z” plasty
Essential to fully explore wound as even Type 1 fractures
can pull dirt/debris back into wound and on fracture ends
All foreign material, necrotic muscle, unattached bone
fragments, exposed fat and fascia are debrided
Irrigation
Saline +/- surfactants (soap) Anglen J, Removal of
surface bacteria by irrigation. J Orthop Res 1996
Pressure – avoid high pressure / pulse
lavage Polzin B, Removal of surface bacteria by irrigation. J Orthop
Res 1996
Timing > 6 hrs Crowley DJ, Debridement and wound closure
of open fractures: The impact of the time factor on infection rates.
Injury 2007
Treatment of Soft Tissue Injury
After debridement thorough irrigation with
Ringer’s lactate or normal saline
Fasciotomies performed if indicated even in open
fractures
After I+D new gowns, gloves, drapes and sterile
instruments used for fracture fixation
Bone Defects
PMMA –aminoglycoside +/- vancomycin
Bead pouch
Solid spacer
Bone Defects: PMMA Spacer
Masquelet AC, Reconstruction of the long bones by the induced membrane
and spongy autograft [French]. Ann Chir Plast Esthet 2000
Large Fragments: What to do?
• Infection Rates with retained - 21%
• Infection Rates with removed- 9%
Edwards CC, Severe open tibial fractures. Results treating 202 injuries
with external fixation. CORR, 1998
• Use to assist in determining length, rotation
and alignment
Soft Tissue Coverage
Definitive coverage should be performed within 7-
10 days if possible
Most type 1 wounds will heal by secondary intent
or can be closed primarily Hohmann E, Comparison of delayed
and primary wound closure in the treatment of open tibial fractures. Arch
Orthop Trauma Surg 2007
Delayed primary closure usually feasible for type 2
and type 3a fractures
Soft Tissue Coverage
Type 3b fractures require either local
advancement or rotation flap, split-
thickness skin graft, or free flap
STSG suitable for coverage of large
defects with underlying viable muscle
Soft Tissue Coverage
Proximal third tibia fractures
can be covered with
gastrocnemius rotation flap
Middle third tibia fractures
can be covered with soleus
rotation flap
Distal third fractures usually
require free flap for coverage
Stabilization of Open Tibia
Fractures
Multiple options depending on fracture pattern
and soft tissue injury:
IM nail- reamed vs. unreamed
External fixation
ORIF
IM Nail
Excellent results with
type 1 open fractures
Unreamed IM Nail
Time to union with unreamed
nails can be prolonged- in one
study of 143 open tibia fractures
53% were united at 6 months
Vast majority of fractures
united, but 11% required at least
one secondary procedure to
achieve union*
*Tornetta and McConnell 16th annual OTA 2000
Reamed Tibial Nailing
In one study of type 2 and
type 3a fractures good
results- average time to union
24 and 27 weeks respectively;
deep infection rate 3.5%*
Complications increased with
type 3b fractures- average
time to union was 50 weeks
and infection rate 23%*
*Court-Brown JBJS 1991
External Fixation
Compared to IM nails, increased
rate of malunion and need for
secondary procedures
Most common complication
with ex-fix is pin track infection
(21% in one study)*
*Tornetta JBJS 1994
Conversion from Ex-Fix to IM Nail
Bhandari M, Intramedullary nailing following external fixation in femoral and tibialshaftfractures. J
OrthopTrauma2005
Conversion between ex-fix and IM nail
9% infection 90%union
Infection rates decreased with shorter duration of
ex-fix time
Plate Fixation
Traditional plating technique with extensive soft tissue
dissection and devitalization has generally fallen out of
favor for open tibia fractures
Increased incidence of superficial and deep infections
compared to other techniques
In one study 13% patients developed osteomyelitis
after plating compared to 3% of patients after ex-fix*
*Bach and Handsen, Clin Orthop 1989
Percutaneous Plate Fixation
Newer percutaneous
plating techniques using
indirect reduction may be
a more beneficial
alternative
Large prospective studies
yet to be evaluated
Gunshot Wounds
Tibia fractures due to low
energy missiles rarely require
debridement and can often
be treated like closed injuries
Fractures due to high energy
missiles (e.g. assault rifle or
close range shot gun) treated
as standard open injuries
Amputation
In general amputation
performed:
 when limb salvage poses
significant risk to patient
survival,
 when functional result would
be better with a prosthesis,
when duration and course of
treatment would cause
intolerable psychological
disturbance
Mangled Extremity Severity Score
An attempt to help guide
between primary
amputation vs. limb
salvage
In one study a score of 7
or higher was predictive
of amputation*
*Johansen et al. J Trauma 1991
Amputation
Lange proposed two absolute indications for
amputation of tibia fractures with arterial injury:
crush injury with warm ischemia greater than 6
hours, and anatomic division of the tibial nerve*
*Lange et al. J Trauma 1985
Complications
Nonunion
Malunion
Infection- deep and superficial
Compartment syndrome
Fatigue fractures
Hardware failure
Nonunion
Time limits vary from 6 months
to one year
Fracture shows no radiologic
progress toward union over 3
month period
Important to rule out infection
Treatment options for
uninfected nonunions include
onlay bone grafts, free
vascularized bone grafts,
reamed nailing, compression
plating, or ring fixator
Malunion
In general varus malunion more
of a problem than valgus
In one study deformity up to 15
degrees did not produce ankle
complications*
For symptomatic patients with
significant deformity treatment
is osteotomy
*Kristensen et al. Acta Orthop Scand 1989
Deep Infection
Often presents with
increasing pain, wound
drainage, or sinus formation
Treatment involves
debridement, stabilization
(often with ex-fix), coverage
with healthy tissue including
muscle flap if needed, IV
antibiotics, delayed bone
graft of defect if needed
Deep Infection
 Not the Implant but the Management of the
Soft Tissues
 If IM nail already in place, reamed
exchange nail with appropriate antibiotics
may prove adequate treatment
 Staged reconstruction with the used of
PMMA + antibiotics
Superficial Infection
Most superficial infections respond to elevation of
extremity and appropriate antibiotics (typically
gram + cocci coverage)
If uncertain whether infection extends deeper
and/or it fails to respond to antibiotic treatment ,
then surgical debridement with tissue cultures
necessary
Compartment Syndrome
Diagnosis same as in
closed tibial fractures
Common with high
energy tibia fractures
Release ALL 4
compartments
Hardware Failure
Usually due to delayed union
or nonunion
Important to rule out
infection as cause of delayed
healing
Treatment depends on type
of failure- plate or nail
breakage requires revision,
whereas breakage of locking
screw in nail may not require
operative intervention
Negative Pressure Would
Therapy (NPWT)
Can lower need for free flaps Dedmond BT, The use of negative-pressure
wound therapy (NPWT) in the temporary treatment of soft-tissue injuries
associated with high-energy open tibial shaft fractures. J Orthop Trauma 2007
Cannot lower infection rates for Type IIIB open fractures Bhattacharyya T,
Routine use of wound vacuum-assisted closure does not allow coverage delay
for open tibia fractures. Plast Reconstr Surg 2008
BMPs
BMP-2 (Infuse) FDA approval in subset of open tibia fractures BESTT
study group JBJS 84, 2002
Significant reduction in the incidence of secondary procedures
Accelerated healing
Lower infections
Summary
Different injury in young and old
Important injury in both young and old
Understand goals of treatment
Maximize outcome with least iatrogenic risk

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Open fractures

  • 1. Open Fractures MOHAMED ELGEBEILY, MD LECTURER OF ORTHOPAEDIC SURGERY AIN SHAMS UNIVERSITY
  • 2. Definition It is a fracture with a Break in the skin and underlying soft tissue leading directly into or communicating with the fracture and its hematoma
  • 3. Epidemiology 3% of all limb fractures 21.3 per 100,000 per year
  • 4. Incidence Open fractures of the tibia are more common than in any other long bone Tibial diaphysis fractures: 2 per 1000 population to 2 per 10,000 and of these approximately one fourth are open tibia fractures*
  • 5. Mechanism of Injury Can occur in lower energy, torsional type injury (e.g., skiing) More common with higher energy direct force (e.g. car bumper)
  • 6. Priorities  ABC’S  Assoc Injuries  Tetanus  Antibiotics  Soft Tissue Management  Fixation  Long term issues
  • 7. Physical Examination Circumferential inspection of soft tissue envelope, noting any Lacerations deformity Ecchymosis Swelling tissue integrity Neurovascular
  • 8. Physical Exam Neurologic and vascular exam of extremity including ABI’s if indicated Johansen K, J Trauma April 1991 Wounds should be assessed once in ER, then covered with sterile gauze dressing until treated in OR- digital camera / cell phone True classification of wound best done after surgical debridement completed
  • 9. Radiographic Evaluation Full length AP and lateral views from knee to ankle required for all tibia fractures Arteriography indicated if vascular compromise present after reduction
  • 10. Associated Injuries Approximately 30% of patients have multiple injuries Fibula commonly fractured and its degree of comminution correlates with severity of injury Ligamentous knee injury and/or ipsilateral femur (‘floating knee’) more common in high energy fractures
  • 11. Associated Injuries Neurovascular structures require repeated assessment Foot fractures also common Compartment syndrome must be looked for
  • 12. Antibiotics First Generation Cephalosporin +/- Aminoglycoside +/- Pen G or Clindamycin if Pen allergic No Cipro alone Patzakis MJ, J Orthop Trauma Nov 2000 24-72hr course
  • 13. Classification of Open Tibia Fractures Gustilo and Anderson open fracture classification first published in 1976 and later modified in 1984 In one study interobserver agreement on classification only 60%
  • 16. Type 1 Open Fractures Inside-out injury Clean wound Minimal soft tissue damage No significant periosteal stripping
  • 17. Type 2 Open Fractures Moderate soft tissue damage Outside-in Higher energy Some necrotic muscle Some periosteal stripping
  • 18. Type 3a Open Fractures High energy Outside-in Extensive muscle devitalization Bone coverage with existing soft tissue
  • 19. Type 3b Open Fractures High energy Outside in Extensive muscle devitalization Requires a flap for bone coverage and soft tissue closure Periosteal stripping
  • 20. Type 3c Open Fractures High energy Increased risk of amputation and infection Any grade 3 with major vascular injury requiring repair
  • 21. Why use this classification? Grades of soft tissue injury correlates with infection and fracture healing Grade 1 2 3A 3B 3C Infection Rates 0-2% 2-7% 10-25% 10-50% 25-50% Fracture Healing (weeks) 21-28 28-28 30-35 30-35 Amputation Rate 50%
  • 22. Objectives of Surgical Treatment  Prevent Sepsis  Achieve Union  Restore Function
  • 23. Treatment of Soft Tissue Injury After initial evaluation wound covered with sterile dressing and leg splinted Appropriate tetanus prophylaxis and antibiotics begun Thorough debridement and irrigation undertaken in OR within 6 hours if possible Photo documentation
  • 24. Treatment of Soft Tissue Injury Careful planning of skin incisions Longitudinal incisions / “Z” plasty Essential to fully explore wound as even Type 1 fractures can pull dirt/debris back into wound and on fracture ends All foreign material, necrotic muscle, unattached bone fragments, exposed fat and fascia are debrided
  • 25. Irrigation Saline +/- surfactants (soap) Anglen J, Removal of surface bacteria by irrigation. J Orthop Res 1996 Pressure – avoid high pressure / pulse lavage Polzin B, Removal of surface bacteria by irrigation. J Orthop Res 1996 Timing > 6 hrs Crowley DJ, Debridement and wound closure of open fractures: The impact of the time factor on infection rates. Injury 2007
  • 26. Treatment of Soft Tissue Injury After debridement thorough irrigation with Ringer’s lactate or normal saline Fasciotomies performed if indicated even in open fractures After I+D new gowns, gloves, drapes and sterile instruments used for fracture fixation
  • 27. Bone Defects PMMA –aminoglycoside +/- vancomycin Bead pouch Solid spacer
  • 28. Bone Defects: PMMA Spacer Masquelet AC, Reconstruction of the long bones by the induced membrane and spongy autograft [French]. Ann Chir Plast Esthet 2000
  • 29. Large Fragments: What to do? • Infection Rates with retained - 21% • Infection Rates with removed- 9% Edwards CC, Severe open tibial fractures. Results treating 202 injuries with external fixation. CORR, 1998 • Use to assist in determining length, rotation and alignment
  • 30. Soft Tissue Coverage Definitive coverage should be performed within 7- 10 days if possible Most type 1 wounds will heal by secondary intent or can be closed primarily Hohmann E, Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop Trauma Surg 2007 Delayed primary closure usually feasible for type 2 and type 3a fractures
  • 31. Soft Tissue Coverage Type 3b fractures require either local advancement or rotation flap, split- thickness skin graft, or free flap STSG suitable for coverage of large defects with underlying viable muscle
  • 32. Soft Tissue Coverage Proximal third tibia fractures can be covered with gastrocnemius rotation flap Middle third tibia fractures can be covered with soleus rotation flap Distal third fractures usually require free flap for coverage
  • 33. Stabilization of Open Tibia Fractures Multiple options depending on fracture pattern and soft tissue injury: IM nail- reamed vs. unreamed External fixation ORIF
  • 34. IM Nail Excellent results with type 1 open fractures
  • 35. Unreamed IM Nail Time to union with unreamed nails can be prolonged- in one study of 143 open tibia fractures 53% were united at 6 months Vast majority of fractures united, but 11% required at least one secondary procedure to achieve union* *Tornetta and McConnell 16th annual OTA 2000
  • 36. Reamed Tibial Nailing In one study of type 2 and type 3a fractures good results- average time to union 24 and 27 weeks respectively; deep infection rate 3.5%* Complications increased with type 3b fractures- average time to union was 50 weeks and infection rate 23%* *Court-Brown JBJS 1991
  • 37. External Fixation Compared to IM nails, increased rate of malunion and need for secondary procedures Most common complication with ex-fix is pin track infection (21% in one study)* *Tornetta JBJS 1994
  • 38. Conversion from Ex-Fix to IM Nail Bhandari M, Intramedullary nailing following external fixation in femoral and tibialshaftfractures. J OrthopTrauma2005 Conversion between ex-fix and IM nail 9% infection 90%union Infection rates decreased with shorter duration of ex-fix time
  • 39. Plate Fixation Traditional plating technique with extensive soft tissue dissection and devitalization has generally fallen out of favor for open tibia fractures Increased incidence of superficial and deep infections compared to other techniques In one study 13% patients developed osteomyelitis after plating compared to 3% of patients after ex-fix* *Bach and Handsen, Clin Orthop 1989
  • 40. Percutaneous Plate Fixation Newer percutaneous plating techniques using indirect reduction may be a more beneficial alternative Large prospective studies yet to be evaluated
  • 41. Gunshot Wounds Tibia fractures due to low energy missiles rarely require debridement and can often be treated like closed injuries Fractures due to high energy missiles (e.g. assault rifle or close range shot gun) treated as standard open injuries
  • 42. Amputation In general amputation performed:  when limb salvage poses significant risk to patient survival,  when functional result would be better with a prosthesis, when duration and course of treatment would cause intolerable psychological disturbance
  • 43. Mangled Extremity Severity Score An attempt to help guide between primary amputation vs. limb salvage In one study a score of 7 or higher was predictive of amputation* *Johansen et al. J Trauma 1991
  • 44. Amputation Lange proposed two absolute indications for amputation of tibia fractures with arterial injury: crush injury with warm ischemia greater than 6 hours, and anatomic division of the tibial nerve* *Lange et al. J Trauma 1985
  • 45. Complications Nonunion Malunion Infection- deep and superficial Compartment syndrome Fatigue fractures Hardware failure
  • 46. Nonunion Time limits vary from 6 months to one year Fracture shows no radiologic progress toward union over 3 month period Important to rule out infection Treatment options for uninfected nonunions include onlay bone grafts, free vascularized bone grafts, reamed nailing, compression plating, or ring fixator
  • 47. Malunion In general varus malunion more of a problem than valgus In one study deformity up to 15 degrees did not produce ankle complications* For symptomatic patients with significant deformity treatment is osteotomy *Kristensen et al. Acta Orthop Scand 1989
  • 48. Deep Infection Often presents with increasing pain, wound drainage, or sinus formation Treatment involves debridement, stabilization (often with ex-fix), coverage with healthy tissue including muscle flap if needed, IV antibiotics, delayed bone graft of defect if needed
  • 49. Deep Infection  Not the Implant but the Management of the Soft Tissues  If IM nail already in place, reamed exchange nail with appropriate antibiotics may prove adequate treatment  Staged reconstruction with the used of PMMA + antibiotics
  • 50. Superficial Infection Most superficial infections respond to elevation of extremity and appropriate antibiotics (typically gram + cocci coverage) If uncertain whether infection extends deeper and/or it fails to respond to antibiotic treatment , then surgical debridement with tissue cultures necessary
  • 51. Compartment Syndrome Diagnosis same as in closed tibial fractures Common with high energy tibia fractures Release ALL 4 compartments
  • 52. Hardware Failure Usually due to delayed union or nonunion Important to rule out infection as cause of delayed healing Treatment depends on type of failure- plate or nail breakage requires revision, whereas breakage of locking screw in nail may not require operative intervention
  • 53. Negative Pressure Would Therapy (NPWT) Can lower need for free flaps Dedmond BT, The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma 2007 Cannot lower infection rates for Type IIIB open fractures Bhattacharyya T, Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg 2008
  • 54. BMPs BMP-2 (Infuse) FDA approval in subset of open tibia fractures BESTT study group JBJS 84, 2002 Significant reduction in the incidence of secondary procedures Accelerated healing Lower infections
  • 55. Summary Different injury in young and old Important injury in both young and old Understand goals of treatment Maximize outcome with least iatrogenic risk