Management of open fractures: A narrative review

Abstract

Open fractures are an emergency where the principal aim of the treatment is to maximise the restoration of limb function while preventing the dreaded consequences of infection and non-union. The decision-making process for open injuries is influenced by a variety of criteria, such as patient age, injury features, systemic response, activity level, comorbidities, and functional requirements. A collaborative orthoplastic approach to treating these injuries is essential for minimizing complications and need to be considered as a single specialty in early and long-term management. It has been shown that early prophylactic systemic antibiotics, wound irrigation, aggressive debridement of contaminated and devitalized tissue, and appropriate fracture fixation decreases the complications in all grades of open fractures. The advantages of Gram-negative antibiotics, the use of local antibiotics, intraoperative wound cultures, the "fix and flap" approach, and Negative Pressure Wound Therapy are few of the treatment options that are still controversial. The aim of this review is to provide a comprehensive review and practice guidelines regarding the management of open fractures.

Keywords: Debridement; Ganga hospital open injury severity score; Open fractures; Orthoplastic approach; Wound irrigation.

Fig. 1

(a)- Presenting Xrays clinical pictures with a puncture wound over distal third of the leg. (b): After debridement, it was classified as type IIIb with GHIOSS of 7. ‘Global reconstruction’ -Local transposition flap and nailing of tibia was done. (c): At 1 year follow-up, flap has healed well and fracture is united. (d): Patient achieved full range of movements.

Fig. 2

(a)- Presenting Xrays clinical pictures of a IIIb open fracture of tibia and fibula. (b)- After debridement, definitive external fixator was applied and split thickness skin grafting was done. (c): At 4 months follow-up, the fracture was in good alignment. External fixator was removed and full weight bearing started. (d): Good functional outcome at 6 months.

Fig. 3

(a)- Open IIIb fracture of both bones forearm with comminution and protruding bony fragments. (b)- The wound was included in the incision at the time of debridement. Primary shortening and plating was done. (c): At 4 months, wounds have healed well and fracture is united. (d): Clinical pictures showing good range of movements and functional outcome.

Fig. 4

(a): A 22 year old presented 1 week after the injury with external fixator in place. Note the unhealthy wound and dry, dessicated bone. (b)- Removal of the dead bone resulted in a bone gap of 8 cm. Hence, it was decided to apply primary LRS using the “spacer-rod” technique. (c)- X-rays after application of LRS frame showing good alignment of the fracture ends. (d)- Clinical image at the time of the soft tissue cover and Xrays showing corticotomy. (e)- 15 months follow up after removal of LRS and plating showing consolidation of the regenerate. (f)- Clinical pictures showing good functional outcomes.

Fig. 5

(a): Open IIIb fracture of the distal fourth tibia with degloving of the skin. It was decided to follow “fix and flap” approach with primary soft tissue cover and fracture fixation. (b): Wound image at the end of plating and intra-operative images showing anterolateral plating of tibia and rush nail fixation fibula. (c): Post-operative clinical image showing split thickness grafting and definitive fracture fixation. (d): At two years follow up, fracture has united and flap has healed well.

Fig. 6

Stepwise initial assessment and management of open fractures.

Fig. 7

Flowchart for the management of type IIIb fractures, considering various factors that may influence treatment decisions.