Open fractures of the lower extremity: Current management and clinical outcomes

Abstract

Open fractures of the lower extremity are the most common open long bone injuries, yet their management remains a topic of debate.This article discusses the basic tenets of management and the subsequent impact on clinical outcome. These include the rationale for initial debridement, antimicrobial cover, addressing the soft-tissue injury and definitive skeletal management.The classification of injury severity continues to be a useful tool in guiding treatment and predicting outcome and prognosis. The Gustilo-Anderson classification continues to be the mainstay, but the adoption of severity scores such as the Ganga Hospital score may provide additional predictive utility.Recent literature has challenged the perceived need for rapid debridement within 6 hours and the rationale for prolonged antibiotic therapy in the open fracture. The choice of definitive treatment must be decided against known efficacy and injury severity/type.Recent data demonstrate better outcomes with internal fixation methods in most open tibial fractures, but external fixation continues to be an appropriate choice in more severe injuries. The incidence of infection and non-union has decreased with new treatment approaches but continues to be a source of significant morbidity and mortality.Assessment of functional outcome using various measures has been prevalent in the literature, but there is limited consensus regarding the best measures to be used. Cite this article: EFORT Open Rev 2018;3 DOI: 10.1302/2058-5241.3.170072.

Keywords: debridement; infection; open fractures.

Fig. 1

A spectrum of injury severity of open tibial fractures exists.

Fig. 2

The importance of wound debridement: a) grade I open tibial fracture; b) skin incision marked before debridement; c) exposure of the zone of injury; d) removal of devitalized (avascular) bony fragments.

Fig. 3

i. a, b) Anteroposterior and lateral radiographs of a right tibial open grade III-B fracture in a 24-year-old female following a road traffic accident. ii. Intra-operative photograph demonstrating the extent of soft-tissue damage. The arrow indicates a piece of bone that had no soft tissue attachment (non-viable) which required removal. iii. a, b, c, d) Intra-operative fluoroscopic images illustrating stabilization of the tibia with reamed IM nailing after irrigation and debridement. The wound was covered at the same theatre setting with a latissimus dorsi flap. At the end of flap reconstruction, a BMP-2 growth factor was implanted to attempt to promote fracture healing. iv. Radiographs of the right tibia four weeks after reconstruction. The arrow demonstrates the area of bone loss. v. a, b) Anteroposterior and lateral radiographs at six-month follow-up demonstrating some healing activity at the area of the previous bone loss (arrow). The patient had previously undergone, at four months, removal of the proximal locking screws for dynamization. vi. a, b) Radiographs at 12-month follow-up demonstrating union of the fracture. The patient underwent, nine months previously, exchange nailing to attempt further stimulation of the healing response.