Current Concepts and Ongoing Research in the Prevention and Treatment of Open Fracture Infections

Abstract

Significance: Open fractures are fractures in which the bone has violated the skin and soft tissue. Because of their severity, open fractures are associated with complications that can result in increased lengths of hospital stays, multiple operative interventions, and even amputation. One of the factors thought to influence the extent of these complications is exposure and contamination of the open fracture with environmental microorganisms, potentially those that are pathogenic in nature. Recent Advances: Current open fracture care aims to prevent infection by wound classification, prophylactic antibiotic administration, debridement and irrigation, and stable fracture fixation. Critical Issues: Despite these established treatment paradigms, infections and infection-related complications remain a significant clinical burden. To address this, improvements need to be made in our ability to detect bacterial infections, effectively remove wound contamination, eradicate infections, and treat and prevent biofilm formation associated with fracture fixation hardware. Future Directions: Current research is addressing these critical issues. While culture methods are of limited value, culture-independent molecular techniques are being developed to provide informative detection of bacterial contamination and infection. Other advanced contamination- and infection-detecting techniques are also being investigated. New hardware-coating methods are being developed to minimize the risk of biofilm formation in wounds, and immune stimulation techniques are being developed to prevent open fracture infections.

Samir Mehta, MD

Figure 1.

Open fracture rate, severity, and mechanistic cause statistics. Open fracture rates and statistics, grouped by anatomical site, from a recent report by Court-Brown et al. The information represents a collection of 2386 open fracture cases recorded at the Royal Infirmary of Edinburgh between 1995 and 2009. The data suggest the majority of open fracture cases occurred on the distant extremities (A). The most severe open fractures (GA Type III) occurred on the lower extremities, especially the lower legs and feet (B). The distant extremities were characterized by major open fracture mechanisms, which have been grouped into four categories for easier visualization (C). To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 2.

Examples of Gustilo–Anderson wound severities. An example of a Gustilo–Anderson Type III open fracture that exhibits extensive soft tissue damage with minimal coverage (A). (B) An X-ray image of the wound in (A). (C) A Type II open fracture with minimal soft tissue damage. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 3.

Example of fracture fixation techniques and hardware. An example of an intramedullary nail used to fix an open diaphyseal tibia fracture (A). The fibula was also fractured but it was not fixed because it is not a weight-bearing bone (A). An example of an external fixation device being used to fix an open tibial fracture (B). To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound

Figure 4.

Bacterial communities associated with open fractures at emergency room presentation. The bacterial communities of open fracture wounds (left) and their corresponding adjacent, unaffected skin (right), as reported by Hannigan et al. The communities were grouped into four anatomical categories. The top 10 bacterial families, calculated as median relative abundance across all samples, were calculated for the wound and skin groups. The bacterial communities upon patient presentation to the emergency room are shown. The skin communities are primarily dominated by Corynebacteriaceae and Staphylococcaceae, while the wound communities are less dominated by these or other bacteria. The wound and skin communities differ from each other at the same anatomical locations, and the different anatomically located communities also differ within the wound and skin categories. The bacteria labels are listed in the legend near the figure bottom. To see this illustration in color, the reader is referred to the web version of this article at www.liebertpub.com/wound