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An '''open fracture''', also called a '''compound fracture''', is a type of [[bone fracture]] (broken bone) that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. An open fracture can be life threatening or limb-threatening (person may be at risk of losing a limb) due to the risk of a deep infection and/or bleeding. Open fractures are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue.<ref name=":12">{{Cite journal |last1=Chan |first1=James K.-K. |last2=Aquilina |first2=Alexander L. |last3=Lewis |first3=Sharon R. |last4=Rodrigues |first4=Jeremy N. |last5=Griffin |first5=Xavier L. |last6=Nanchahal |first6=Jagdeep |date=2022-04-01 |title=Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs |url= |journal=The Cochrane Database of Systematic Reviews |volume=2022 |issue=4 |pages=CD013555 |doi=10.1002/14651858.CD013555.pub2 |issn=1469-493X |pmc=8973274 |pmid=35363374}}</ref> Other potential complications include nerve damage or impaired bone healing, including [[malunion]] or [[nonunion]]. The severity of open fractures can vary. For diagnosing and classifying open fractures, [[Gustilo open fracture classification|Gustilo-Anderson open fracture classification]] is the most commonly used method.<ref>{{Cite journal |last=Gustilo |first=Ramon B. |date=1979-07-01 |title=Use of Antimicrobials in the Management of Open Fractures |url=http://dx.doi.org/10.1001/archsurg.1979.01370310047010 |journal=Archives of Surgery |volume=114 |issue=7 |pages=805–808 |doi=10.1001/archsurg.1979.01370310047010 |pmid=454175 |issn=0004-0010}}</ref> This classification system can also be used to guide treatment, and to predict clinical outcomes. [[Advanced trauma life support]] is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection.<ref name=":12" /> {{Use mdy dates|date=November 2022}} |
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{{Use mdy dates|date=November 2022}} |
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[[File:Rheumatology - Open fracture -- Smart-Servier.png|thumb|676x676px|Diagram of an open, transverse, midshaft [[Radius (bone)|radius]] fracture|border|center]] |
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{{Infobox medical condition (new) |
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[[Cephalosporin]]s, sometimes with aminoglycosides, are generally the first line of antibiotics and are used usually for at least three days.<ref>{{Cite journal |last1=Chan |first1=James K-K |last2=Aquilina |first2=Alexander L |last3=Lewis |first3=Sharon R |last4=Rodrigues |first4=Jeremy N |last5=Griffin |first5=Xavier L |last6=Nanchahal |first6=Jagdeep |date=2022-04-01 |editor-last=Cochrane Bone, Joint and Muscle Trauma Group |title=Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs |journal=Cochrane Database of Systematic Reviews |language=en |volume=2022 |issue=4 |pages=CD013555 |doi=10.1002/14651858.CD013555.pub2 |pmc=8973274 |pmid=35363374}}</ref> [[Therapeutic irrigation]], wound [[debridement]], early wound closure and bone fixation core principles in management of open fractures.<ref>{{Cite book |title=Standards for the management of open fractures |date=2020 |publisher=Oxford University Press |isbn=978-0-19-884936-0 |editor-last=Eccles |editor-first=Simon |location=Oxford New York, NY |editor-last2=Handley |editor-first2=Bob |editor-last3=Khan |editor-first3=Umraz}}</ref> All these actions aimed to reduce the risk of infections and promote bone healing. The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture. Older people with osteoporosis and soft-tissue problems are also at risk. |
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| name = Open fracture |
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| synonyms = |
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| image = Open fracture 01.JPG |
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| caption = Gustilo Type III fracture |
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| pronounce = |
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| field = [[Orthopedics]] |
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== Epidemiology == |
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An '''open fracture''', also called a '''compound fracture''', is a type of [[bone fracture]] in [[orthopedic]]s that is frequently caused by high energy trauma. It is a bone fracture, also known as a broken bone, associated with a break in the skin continuity which can cause complications such as infection, [[malunion]], and [[nonunion]]. [[Gustilo open fracture classification]] is the most commonly used method to classify open fractures, to guide treatment and to predict clinical outcomes. [[Advanced trauma life support]] is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. [[Cephalosporin]]s are generally the first line of antibiotics. The antibiotics are continued for 24 hours to minimize the risk of infections. [[Therapeutic irrigation]], wound [[debridement]], early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections. |
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Crush injuries are the most common form of injuries, followed by falls from standing height, and road traffic accidents. Open fractures tend to occur more often in males than females at the ratio of 7 to 3 and the age of onset of 40.8 and 56 years respectively. In terms of anatomy location, fractures of finger phalanges are the most common one at the rate of 14 per 100,000 people per year in the general population, followed by fracture of [[tibia]] at 3.4 per 100,000 population per year, and [[distal radius fracture]] at 2.4 per 100,000 population per year.<ref name="Mohamad J 2015" /> Infection rates for Gustilo Grade I fractures is 1.4%, followed by 3.6% for Grade II fractures, 22.7% for Grade IIIA fractures, and 10 to 50% of Grade IIIB and IIIC fractures.<ref>{{cite journal|last1=William W|first1=Cross|last2=Marc F|first2=Swiontkowski|title=Treatment principles in the management of open fractures|journal=Indian Journal of Orthopaedics|date=October 2008|volume=42|issue=4|pages=377–386|doi=10.4103/0019-5413.43373|doi-broken-date=April 24, 2024 |doi-access=free|pmid=19753224|pmc=2740354}}</ref> |
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== |
== Signs and symptoms == |
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There are a range of characteristics of open fractures as the severity of the injury can vary greatly. Most open fractures are characterized by a broken bone that is sticking out of the skin, but there can also be a broken bone that is associated with a very small "poke-hole" skin wound. Both of these injuries are classified as open fractures.<ref name=":11">{{Cite web |title=Open Fractures - OrthoInfo - AAOS |url=https://www.orthoinfo.org/en/diseases--conditions/open-fractures/ |access-date=2022-11-10 |website=www.orthoinfo.org}}</ref> Some open fractures can have significant blood loss. Most open fractures have extensive damage to soft tissues near and around the bone such as nerves, tendons, muscles, and blood vessels.<ref name=":12" /> |
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There are a number of classification systems attempting to categorise open fractures such as [[Gustilo open fracture classification]], [[Tscherne classification]], and [[Müller AO Classification of fractures]]. However, Gustilo open fracture classification is the most commonly used classification system. Gustilo system grades the fracture according to energy of injury, soft tissue damage, level of contamination, and comminution of fractures. The higher the grade, the worse the outcome of the fracture.<ref name="Mohamad J 2015" /> |
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{| class="wikitable" border="1" |
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! |
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!Gustilo Open Fracture Classification |
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! Gustilo Grade !! Definition |
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| I || Open fracture, clean wound, wound <1 cm in length |
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| II || Open fracture, wound > 1 cm but < 10 cm in length<ref name="Paul 2012">{{cite journal |last1=Paul |first1=H Kim |last2=Seth |first2=S Leopold |date=9 May 2012 |title=Gustilo-Anderson Classification |journal=Clinical Orthopaedics and Related Research |volume=470 |issue=11 |pages=3270–3274 |doi=10.1007/s11999-012-2376-6 |pmc=3462875 |pmid=22569719}}</ref> without extensive soft-tissue damage, flaps, avulsions |
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| IIIA || Open fracture with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma ([[gunshot]] and farm injuries) regardless of the size of the wound<ref name="Paul 2012" /><ref name=":2">{{Cite web |title=Ovid: Externer Link |url=http://ovidsp.tx.ovid.com/sp-3.27.1a/ovidweb.cgi?WebLinkFrameset=1&S=ELDCFPAIOBDDKPADNCFKCGIBFDJKAA00&returnUrl=ovidweb.cgi?Main+Search+Page=1&S=ELDCFPAIOBDDKPADNCFKCGIBFDJKAA00&directlink=http://ovidsp.tx.ovid.com/ovftpdfs/FPDDNCIBCGADOB00/fs047/ovft/live/gv039/00005373/00005373-198408000-00009.pdf&filename=Problems+in+the+Management+of+Type+III+(Severe)+Open+Fractures:+A+New+Classification+of+Type+III+Open+Fractures.&navigation_links=NavLinks.S.sh.22.1&link_from=S.sh.22%7C1&pdf_key=FPDDNCIBCGADOB00&pdf_index=/fs047/ovft/live/gv039/00005373/00005373-198408000-00009&D=ovft&link_set=S.sh.22%7C1%7Csl_10%7CresultSet%7CS.sh.22.23%7C0 |access-date=2017-11-10 |website=ovidsp.tx.ovid.com}}</ref> |
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| IIIB || Open fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination.<ref name="Paul 2012" /><ref name=":2" /> Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) |
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| IIIC || Open fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury. |
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However, Gustilo system is not without its limitations. The system has limited interobserver reliability at 50% to 60%. The size of injury on the skin surface does not necessarily reflect the extent of deep underlying soft tissue injury. Therefore, the true grading of Gustilo can only be done in operating theatre.<ref name="Mohamad J 2015" /> |
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== Characteristics == |
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There are a range of characteristics of open fractures. There can be an obvious broken bone that is sticking out of the skin, but there can also be a broken bone that is associated with a very small "poke-hole" skin wound. Both of these situations are classified as open fractures.<ref name=":11">{{Cite web |title=Open Fractures - OrthoInfo - AAOS |url=https://www.orthoinfo.org/en/diseases--conditions/open-fractures/ |access-date=2022-11-10 |website=www.orthoinfo.org}}</ref> |
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=== Complications === |
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When a bone is broken and exposed to the outside environment, the probability of infection increases. Both the surrounding soft tissues can become infected, as well as the bone itself, which is called [[osteomyelitis]]. Additional complications include the broken bone ends not healing, called non-union, and the broken bone ends healing in an incorrect orientation, called malunion. Open fractures of long bones may cause subsequent damage to surrounding tissue resulting in compartment syndrome. Additionally there is potential for fat embolism development, both requiring acute intervention.<ref name=":11" /><ref>{{Cite journal |last1=Ali |first1=Parveen |last2=Santy-Tomlinson |first2=Julie |last3=Watson |first3=Roger |date=2014-11-01 |title=Assessment and diagnosis of acute limb compartment syndrome: A literature review |url=https://www.sciencedirect.com/science/article/pii/S1878124114000045 |journal=International Journal of Orthopaedic and Trauma Nursing |language=en |volume=18 |issue=4 |pages=180–190 |doi=10.1016/j.ijotn.2014.01.002 |issn=1878-1241}}</ref> Lastly, open fractures commonly occur in the setting of traumatic experiences, and the co-occurrence of these events may lead to chronic pain and mental health disorders.<ref>{{Cite book |date=2020-08-01 |chapter=Patient Experience of Open Fracture and Practical Psychological Support |chapter-url=https://academic.oup.com/book/29872/chapter/253098374 |language=en |doi=10.1093/med/9780198849360.003.0017|title=Standards for the Management of Open Fractures |pages=159–168 |isbn=978-0-19-884936-0 |editor-last1=Eccles |editor-last2=Handley |editor-last3=Khan |editor-last4=McFadyen |editor-last5=Nanchahal |editor-last6=Nayagam |editor-first1=Simon |editor-first2=Bob |editor-first3=Umraz |editor-first4=Iain |editor-first5=Jagdeep |editor-first6=Selvadurai }}</ref><ref>{{Citation |last1=Sop |first1=Jessica L. |title=Open Fracture Management |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK448083/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=28846249 |access-date=2022-11-10 |last2=Sop |first2=Aaron}}</ref> |
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== Causes == |
== Causes == |
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Open fractures can occur due to direct impacts such as high-energy physical forces ([[Major trauma|trauma]]), motor vehicular accidents, firearms, and falls from height.<ref name=":3" /> |
Open fractures can occur due to direct impacts such as high-energy physical forces ([[Major trauma|trauma]]), motor vehicular accidents, firearms, and falls from height.<ref name=":3" /> Indirect mechanisms include twisting ([[Torsion (mechanics)|torsional]] injuries) and falling from a standing position.<ref name=":3">{{Cite journal|last1=Halawi|first1=Mohamad J.|last2=Morwood|first2=Michael P.|date=November 2015|title=Acute Management of Open Fractures: An Evidence-Based Review|journal=Orthopedics|volume=38|issue=11|pages=e1025–1033|doi=10.3928/01477447-20151020-12|issn=1938-2367|pmid=26558667|s2cid=21482036}}</ref> These mechanisms are usually associated with substantial [[degloving]] of the soft-tissues, but can also have a subtler appearance with a small poke hole and accumulation of clotted blood in the tissues. Depending on the nature of the trauma, it can cause different types of fractures:<ref name=":0">{{Cite book|last=Vanderhave|first=Kelly|chapter=Orthopedic Surgery|date=2015|chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=1105496324|title=CURRENT Diagnosis & Treatment: Surgery|editor-last=Doherty|editor-first=Gerard M.|edition=14|publisher=McGraw-Hill Education|access-date=2018-11-05}}</ref><ref name=":1">{{Cite book|last=Menkes|first=Jeffrey S.|chapter=Initial Evaluation and Management of Orthopedic Injuries|date=2016|chapter-url=http://accessmedicine.mhmedical.com/content.aspx?aid=1121517100|title=Tintinalli's Emergency Medicine: A Comprehensive Study Guide|editor-last=Tintinalli|editor-first=Judith E.|edition=8|publisher=McGraw-Hill Education|access-date=2018-11-05|editor2-last=Stapczynski|editor2-first=J. Stephan|editor3-last=Ma|editor3-first=O. John|editor4-last=Yealy|editor4-first=Donald M.}}</ref> |
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=== Common fractures === |
=== Common fractures === |
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[[Bone fracture |
[[Bone fracture]]s result from significant trauma to the bone. This trauma can come from a variety of forces – a direct blow, axial loading, angular forces, torque, or a mixture of these.<ref>{{Cite journal |last=Rodríguez-Merchán |first=Emerito Carlos |date=2021-01-14 |title=A Review of Recent Developments in the Molecular Mechanisms of Bone Healing |journal=International Journal of Molecular Sciences |volume=22 |issue=2 |pages=767 |doi=10.3390/ijms22020767 |issn=1422-0067 |pmc=7828700 |pmid=33466612|doi-access=free }}</ref> There are various fracture types, including closed, open, stress, simple, comminuted, greenstick, displaced, transverse, oblique.<ref>{{Cite web |title=Bone fractures - AOA {{!}} Australian Orthopaedic Association |url=https://aoa.org.au/for-patients/celebrating-orthopaedics/bone-fractures |access-date=2023-02-01 |website=aoa.org.au}}</ref><ref>{{Cite book |last=Marieb |first=Elaine |title=Essentials of Human Anatomy & Physiology, 10th Edition |publisher=Pearson |year=2009 |isbn=9780321695987 |edition=9 |location=United Kingdom |pages=209–212 |language=English}}</ref> |
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=== Pathological fractures === |
=== Pathological fractures === |
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==Diagnosis== |
==Diagnosis== |
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The initial evaluation for open fractures is to rule out any other life-threatening injuries. [[Advanced Trauma Life Support]] (ATLS) is the initial protocol to rule out such injuries. Once the patient is stabilised, orthopedic injuries can be evaluated. Mechanism of injury is important to know the amount energy that is transferred to the patient and the level of contamination. Every limb should be exposed to evaluate any other hidden injuries. Characteristics of the wound should be noted in detail. Neurology and the vascular status of the affected limb are important to rule out any nerve or blood vessels injuries. High index of suspicion of [[compartment syndrome]] should be maintained for leg and forearm fractures.<ref name="Mohamad J 2015">{{cite journal |last1=Mohamad J |first1=Halawi |last2=Michael P |first2=Morwood |date=8 April 2015 |title=Acute Management of Open Fractures: An Evidence-Based Review |
The initial evaluation for open fractures is to rule out any other life-threatening injuries. [[Advanced Trauma Life Support]] (ATLS) is the initial protocol to rule out such injuries. Once the patient is stabilised, orthopedic injuries can be evaluated including determining the severity of injury using a classification system. Mechanism of injury is important to know the amount energy that is transferred to the patient and the level of contamination. Every limb should be exposed to evaluate any other hidden injuries. Characteristics of the wound should be noted in detail. Neurology and the vascular status of the affected limb are important to rule out any nerve or blood vessels injuries. High index of suspicion of [[compartment syndrome]] should be maintained for leg and forearm fractures.<ref name="Mohamad J 2015">{{cite journal |last1=Mohamad J |first1=Halawi |last2=Michael P |first2=Morwood |date=8 April 2015 |title=Acute Management of Open Fractures: An Evidence-Based Review |journal=Orthopaedics |volume=38 |issue=11 |pages=1026–1033 |doi=10.3928/01477447-20151020-12 |pmid=26558667 |s2cid=21482036}}</ref> |
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=== Classification === |
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There are a number of classification systems attempting to categorise open fractures such as [[Gustilo open fracture classification|Gustilo-Anderson open fracture classification]], [[Tscherne classification]], and [[Müller AO Classification of fractures]]. However, Gustilo-Anderson open fracture classification is the most commonly used classification system.<ref name=":12" /> Gustilo system grades the fracture according to energy of injury, soft tissue damage, level of contamination, and comminution of fractures. The higher the grade, the worse the outcome of the fracture.<ref name="Mohamad J 2015" /> |
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{| class="wikitable" border="1" |
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! |
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!Gustilo Open Fracture Classification |
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|- |
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! Gustilo Grade !! Definition |
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|- |
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| I || Open fracture, clean wound, wound <1 cm in length |
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|- |
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| II || Open fracture, wound > 1 cm but < 10 cm in length<ref name="Paul 2012">{{cite journal |last1=Paul |first1=H Kim |last2=Seth |first2=S Leopold |date=9 May 2012 |title=Gustilo-Anderson Classification |journal=Clinical Orthopaedics and Related Research |volume=470 |issue=11 |pages=3270–3274 |doi=10.1007/s11999-012-2376-6 |pmc=3462875 |pmid=22569719}}</ref> without extensive soft-tissue damage, flaps, avulsions |
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|- |
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| IIIA || Open fracture with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma ([[gunshot]] and farm injuries) regardless of the size of the wound<ref name="Paul 2012" /><ref name=":2">{{Cite web |title=Ovid: Externer Link |url=http://ovidsp.tx.ovid.com/sp-3.27.1a/ovidweb.cgi?WebLinkFrameset=1&S=ELDCFPAIOBDDKPADNCFKCGIBFDJKAA00&returnUrl=ovidweb.cgi?Main+Search+Page=1&S=ELDCFPAIOBDDKPADNCFKCGIBFDJKAA00&directlink=http://ovidsp.tx.ovid.com/ovftpdfs/FPDDNCIBCGADOB00/fs047/ovft/live/gv039/00005373/00005373-198408000-00009.pdf&filename=Problems+in+the+Management+of+Type+III+(Severe)+Open+Fractures:+A+New+Classification+of+Type+III+Open+Fractures.&navigation_links=NavLinks.S.sh.22.1&link_from=S.sh.22%7C1&pdf_key=FPDDNCIBCGADOB00&pdf_index=/fs047/ovft/live/gv039/00005373/00005373-198408000-00009&D=ovft&link_set=S.sh.22%7C1%7Csl_10%7CresultSet%7CS.sh.22.23%7C0 |access-date=2017-11-10 |website=ovidsp.tx.ovid.com}}</ref> |
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| IIIB || Open fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination.<ref name="Paul 2012" /><ref name=":2" /> Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) |
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| IIIC || Open fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury. |
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{{Infobox medical condition (new) |
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| name = Gustilo Type III Open fracture |
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| synonyms = |
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| field = [[Orthopedics]] |
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| complications = |
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}}However, Gustilo system is not without its limitations. The system has limited interobserver reliability at 50% to 60%.<ref name="Mohamad J 2015" /> The size of injury on the skin surface does not necessarily reflect the extent of deep underlying soft tissue injury. Therefore, the true grading of Gustilo can only be done in operating theatre.<ref name="Mohamad J 2015" /> |
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==Management== |
==Management== |
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=== Acute management === |
=== Acute management === |
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Urgent interventions, including [[therapeutic irrigation]] and wound [[debridement]], are often necessary to clean the area of injury and minimize the risk of infection.<ref name=":9">{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK344250/|title=Fractures (Complex): Assessment and Management|last=National Clinical Guideline Centre (UK)|date=2016|publisher=National Institute for Health and Care Excellence (UK)|series=National Institute for Health and Care Excellence: Clinical Guidelines|location=London|pmid=26913311}}</ref> Other risks of delayed intervention include long-term complications, such as deep infection, vascular compromise and complete limb loss.<ref name=":9" /> After wound irrigation, dry or wet gauze should be applied to the wound to prevent bacterial contamination. Taking photographs of the wound can help to reduce the need of multiple examinations by different doctors, which could be painful. Limb should be reduced and placed in a well-padded splint for immobilization of fractures. Pulses should be documented before and after reduction.<ref name="Mohamad J 2015" /> |
Urgent interventions, including [[therapeutic irrigation]] and wound [[debridement]], are often necessary to clean the area of injury and minimize the risk of infection.<ref name=":9">{{Cite book|url=https://www.ncbi.nlm.nih.gov/books/NBK344250/|title=Fractures (Complex): Assessment and Management|last=National Clinical Guideline Centre (UK)|date=2016|publisher=National Institute for Health and Care Excellence (UK)|series=National Institute for Health and Care Excellence: Clinical Guidelines|location=London|pmid=26913311}}</ref> Other risks of delayed intervention include long-term complications, such as deep infection, vascular compromise and complete limb loss.<ref name=":9" /> After wound irrigation, dry or wet gauze should be applied to the wound to prevent bacterial contamination. Taking photographs of the wound can help to reduce the need of multiple examinations by different doctors, which could be painful. Limb should be reduced and placed in a well-padded splint for immobilization of fractures. Pulses should be documented before and after reduction.<ref name="Mohamad J 2015" /> |
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[[File:Flowchart for Treatment of Open Fractures.png|thumb|398x398px|This flowchart describes the treatment steps for an individual with an open fracture. Note: Diagnostic steps such as obtaining imaging are excluded.]] |
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Wound cultures are positive in 22% of pre-debridement cultures and 60% of post-debridement cultures of infected cases. Therefore, pre-operative cultures no longer recommended. The value of post-operative cultures is unknown. Tetanus prophylaxis is routinely given to enhance immune response against ''[[Clostridium tetani]]''. [[Anti-tetanus immunoglobulin]] is only indicated for those with highly contaminated wounds with uncertain vaccination history. Single intramuscular dose of 3000 to 5000 units of tetanus immunoglobulin is given to provide immediate immunity.<ref name="Mohamad J 2015" /> |
Wound cultures are positive in 22% of pre-debridement cultures and 60% of post-debridement cultures of infected cases. Therefore, pre-operative cultures no longer recommended. The value of post-operative cultures is unknown. Tetanus prophylaxis is routinely given to enhance immune response against ''[[Clostridium tetani]]''. [[Anti-tetanus immunoglobulin]] is only indicated for those with highly contaminated wounds with uncertain vaccination history. Single intramuscular dose of 3000 to 5000 units of tetanus immunoglobulin is given to provide immediate immunity.<ref name="Mohamad J 2015" /> |
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===Antibiotics=== |
===Antibiotics=== |
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Administration of antibiotics as soon as possible is necessary to reduce the risk of infection. However, antibiotics may not provide necessary benefits in open finger fractures and low [[velocity]] firearms injury. First generation [[cephalosporin]] ([[cefazolin]]) is recommended as first line antibiotics for the treatment of open fractures. The antibiotic is useful against [[gram positive]] cocci and [[gram negative]] rods such as ''[[Escherichia coli]]'', ''[[Proteus mirabilis]]'', and ''[[Klebsiella pneumoniae]]''. To extend the coverage of antibiotics against more bacteria in Type III Gustilo fractures, combination of first generation cephalosporin and [[aminoglycoside]] ([[gentamicin]] or [[tobramycin]]) or a third generation cephalosporin is recommended to cover against nosocomial gram negative bacilli such as ''[[Pseudomonas aeruginosa]]''. Adding [[penicillin]] to cover for [[gas gangrene]] caused by anaerobic bacteria ''[[Clostridium perfringens]]'' is a controversial practice. Studies has shown that such practice may not be necessary as the standard antibiotic regimen is enough to cover for Clostridial infections. Antibiotic impregnated devices such as tobramycin impregnated [[Poly(methyl methacrylate)]] (PMMA) beads and antibiotic [[bone cement]] are helpful in reducing rates of infection.<ref name="Mohamad J 2015"/> The use of absorbable carriers with implant coatings at the time of surgical fixation is also an effective means of delivering local antibiotics.<ref>{{Cite journal|last1=Morgenstern|first1=M.|last2=Vallejo|first2=A.|last3=McNally|first3=M. A.|last4=Moriarty|first4=T. F.|last5=Ferguson|first5=J. Y.|last6=Nijs|first6=S.|last7=Metsemakers|first7=W. J.|date=2018|title=The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis|journal=Bone & Joint Research|volume=7|issue=7|pages=447–456|doi=10.1302/2046-3758.77.BJR-2018-0043.R1|issn=2046-3758|pmc=6076360|pmid=30123494}}</ref> |
Administration of broad-spectrum intravenous antibiotics as soon as possible (within an hour ideally) is necessary to reduce the risk of infection.<ref name=":12" /> However, antibiotics may not provide necessary benefits in open finger fractures and low [[velocity]] firearms injury. First generation [[cephalosporin]] ([[cefazolin]]) is recommended as first line antibiotics for the treatment of open fractures. The antibiotic is useful against [[gram positive]] cocci and [[gram negative]] rods such as ''[[Escherichia coli]]'', ''[[Proteus mirabilis]]'', and ''[[Klebsiella pneumoniae]]''. To extend the coverage of antibiotics against more bacteria in Type III Gustilo fractures, combination of first generation cephalosporin and [[aminoglycoside]] ([[gentamicin]] or [[tobramycin]]) or a third generation cephalosporin is recommended to cover against nosocomial gram negative bacilli such as ''[[Pseudomonas aeruginosa]]''. Adding [[penicillin]] to cover for [[gas gangrene]] caused by anaerobic bacteria ''[[Clostridium perfringens]]'' is a controversial practice. Studies has shown that such practice may not be necessary as the standard antibiotic regimen is enough to cover for Clostridial infections. Antibiotic impregnated devices such as tobramycin impregnated [[Poly(methyl methacrylate)]] (PMMA) beads and antibiotic [[bone cement]] are helpful in reducing rates of infection.<ref name="Mohamad J 2015"/> The use of absorbable carriers with implant coatings at the time of surgical fixation is also an effective means of delivering local antibiotics.<ref>{{Cite journal|last1=Morgenstern|first1=M.|last2=Vallejo|first2=A.|last3=McNally|first3=M. A.|last4=Moriarty|first4=T. F.|last5=Ferguson|first5=J. Y.|last6=Nijs|first6=S.|last7=Metsemakers|first7=W. J.|date=2018|title=The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis|journal=Bone & Joint Research|volume=7|issue=7|pages=447–456|doi=10.1302/2046-3758.77.BJR-2018-0043.R1|issn=2046-3758|pmc=6076360|pmid=30123494}}</ref> |
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There has been no agreement on the optimal duration of antibiotics. Studies has shown that there is no additional benefits of risk of infection when giving antibiotics for one day, when compared to giving antibiotics for three days or five days.<ref name="Mohamad J 2015"/><ref name=":4">{{Cite journal|last1=Chang|first1=Yaping|last2=Kennedy|first2=Sean Alexander|last3=Bhandari|first3=Mohit|last4=Lopes|first4=Luciane Cruz|last5=Bergamaschi|first5=Cristiane de Cássia|last6=Carolina de Oliveira E Silva|first6=Maria|last7=Bhatnagar|first7=Neera|last8=Mousavi|first8=S. Mohsen|last9=Khurshid|first9=Saqib|date=2015-06-09|title=Effects of Antibiotic Prophylaxis in Patients with Open Fracture of the Extremities: A Systematic Review of Randomized Controlled Trials|journal=JBJS Reviews|volume=3|issue=6|pages=1|doi=10.2106/JBJS.RVW.N.00088|issn=2329-9185|pmid=27490013|s2cid=7011075}}</ref> However, at present, there is only low to moderate evidence for this and more research is needed.<ref name=":4" /> Some authors recommended that antibiotics to be given for three doses for Gustilo Grade I fractures, for one day after wound closure in Grade II fractures, three days in Grade IIIA fractures, and three days after wound closure for Grade IIIB and IIIC.<ref name="Mohamad J 2015"/> |
There has been no agreement on the optimal duration of antibiotics.<ref name=":12" /> Studies has shown that there is no additional benefits of risk of infection when giving antibiotics for one day, when compared to giving antibiotics for three days or five days.<ref name="Mohamad J 2015"/><ref name=":4">{{Cite journal|last1=Chang|first1=Yaping|last2=Kennedy|first2=Sean Alexander|last3=Bhandari|first3=Mohit|last4=Lopes|first4=Luciane Cruz|last5=Bergamaschi|first5=Cristiane de Cássia|last6=Carolina de Oliveira E Silva|first6=Maria|last7=Bhatnagar|first7=Neera|last8=Mousavi|first8=S. Mohsen|last9=Khurshid|first9=Saqib|date=2015-06-09|title=Effects of Antibiotic Prophylaxis in Patients with Open Fracture of the Extremities: A Systematic Review of Randomized Controlled Trials|journal=JBJS Reviews|volume=3|issue=6|pages=1|doi=10.2106/JBJS.RVW.N.00088|issn=2329-9185|pmid=27490013|s2cid=7011075}}</ref> However, at present, there is only low to moderate evidence for this and more research is needed.<ref name=":4" /> Some authors recommended that antibiotics to be given for three doses for Gustilo Grade I fractures, for one day after wound closure in Grade II fractures, three days in Grade IIIA fractures, and three days after wound closure for Grade IIIB and IIIC.<ref name="Mohamad J 2015"/> |
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===Wound irrigation=== |
===Wound irrigation=== |
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===Wound debridement=== |
===Wound debridement=== |
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The purpose of wound [[debridement]] is to remove all contaminated and non-viable tissues including skin, [[subcutaneous fat]], muscles and bones. Viability of bones and soft tissues are determined by their capacity to bleed. Meanwhile, the viability of muscles is determined by colour, contractility, consistency, and their capacity to bleed. The optimal timing of performing wound debridement and closure is debated and dependent on the severity of the injury, resources and antibiotics available, and individual needs.<ref name=":7">{{Cite journal|last1=O'Brien|first1=C.L|last2=Menon|first2=M|last3=Jomha|first3=N.M|date=2014|title=Controversies in the Management of Open Fractures|journal=The Open Orthopaedics Journal|volume=8|issue=20|pages=178–184|doi=10.2174/1874325001408010178|pmid=25067972|pmc=4110387}}</ref> Debridement time can vary from 6 to 72 hours, and closure time can be immediate (less than 72 hours) or delayed (72 hours to up to 3 months).<ref name=":7" /> There is no difference in infection rates for performing surgery within 6 hours of injury when compared to until 72 hours after injury.<ref name="Mohamad J 2015"/><ref>{{Cite journal|last1=Davies|first1=James|last2=Roberts|first2=Tobias|last3=Limb|first3=Richard|last4=Mather|first4=David|last5=Thornton|first5=Daniel|last6=Wade|first6=Ryckie G.|date=2020-02-17|title=Time to surgery for open hand injuries and the risk of surgical site infection: a prospective multicentre cohort study|journal=Journal of Hand Surgery (European Volume)|volume=45|issue=6|language=en-US|pages=622–628|doi=10.1177/1753193420905205|pmid=32065001|s2cid=211136445|issn=1753-1934|url=http://eprints.whiterose.ac.uk/157611/3/19-436R3%5BGH%5D%20revised%20manuscript%20v2.pdf}}</ref> |
The purpose of wound [[debridement]] is to remove all contaminated and non-viable tissues including skin, [[subcutaneous fat]], muscles and bones. Viability of bones and soft tissues are determined by their capacity to bleed. Meanwhile, the viability of muscles is determined by colour, contractility, consistency, and their capacity to bleed. The optimal timing of performing wound debridement and closure is debated and dependent on the severity of the injury, resources and antibiotics available, and individual needs.<ref name=":7">{{Cite journal|last1=O'Brien|first1=C.L|last2=Menon|first2=M|last3=Jomha|first3=N.M|date=2014|title=Controversies in the Management of Open Fractures|journal=The Open Orthopaedics Journal|volume=8|issue=20|pages=178–184|doi= 10.2174/1874325001408010178 |doi-access=free|pmid=25067972|pmc=4110387}}</ref><ref name=":12" /> Debridement time can vary from 6 to 72 hours, and closure time can be immediate (less than 72 hours) or delayed (72 hours to up to 3 months).<ref name=":7" /> There is no difference in infection rates for performing surgery within 6 hours of injury when compared to until 72 hours after injury.<ref name="Mohamad J 2015"/><ref>{{Cite journal|last1=Davies|first1=James|last2=Roberts|first2=Tobias|last3=Limb|first3=Richard|last4=Mather|first4=David|last5=Thornton|first5=Daniel|last6=Wade|first6=Ryckie G.|date=2020-02-17|title=Time to surgery for open hand injuries and the risk of surgical site infection: a prospective multicentre cohort study|journal=Journal of Hand Surgery (European Volume)|volume=45|issue=6|language=en-US|pages=622–628|doi=10.1177/1753193420905205|pmid=32065001|s2cid=211136445|issn=1753-1934|url=http://eprints.whiterose.ac.uk/157611/3/19-436R3%5BGH%5D%20revised%20manuscript%20v2.pdf}}</ref> [[NICE guidelines]] suggest that the surgical debridement should be done immediately for open fracture that are highly contaminated or where there is a lot of bleeding (vascular compromise).<ref name=":13">{{Cite web |title=Overview {{!}} Fractures (complex): assessment and management {{!}} Guidance {{!}} NICE |url=https://www.nice.org.uk/guidance/ng37 |access-date=2023-03-26 |website=www.nice.org.uk|date=February 17, 2016 }}</ref> For high-energy open fractures that are not highly contaminated NICE guidelines suggest surgical debridement within 12 hours of the accident, and for other open fractures within 24 hours.<ref name=":13" /> |
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===Surgical management=== |
===Surgical management=== |
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Early fracture immobilisation and fixation helps to prevent further soft tissue injury and promotes wound and bone healing. This is especially important in the treatment of [[intraarticular fractures]] where early fixation allows early joint motion to prevent joint stiffness. Fracture management depends on the person's overall well-being, fracture pattern and location, and the extent of soft tissue injury. Both reamed and unreamed [[Intramedullary rod|intramedullary nailing]] are accepted surgical treatments for open tibial fracture.<ref name=":5">{{Cite journal|last1=Shao|first1=Yinchu|last2=Zou|first2=Hongxing|last3=Chen|first3=Shaobo|last4=Shan|first4=Jichun|date=2014-08-23|title=Meta-analysis of reamed versus unreamed intramedullary nailing for open tibial fractures|journal=Journal of Orthopaedic Surgery and Research|volume=9|pages=74|doi=10.1186/s13018-014-0074-7|issn=1749-799X|pmc=4145248|pmid=25149501}}</ref> Both techniques have similar rates of postoperative healing, postoperative infection, implant failure and compartment syndrome.<ref name=":5" /> Unreamed intramedullary nailing is advantageous because it has a lower incidence of superficial infection and malunion compared to [[external fixation]].<ref name=":6">{{Cite journal|last1=Fu|first1=Qiang|last2=Zhu|first2=Lei|last3=Lu|first3=Jiajia|last4=Ma|first4=Jun|last5=Chen|first5=Aimin|date=2018-08-24|title=External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials|journal=Scientific Reports|volume=8|issue=1|pages=12753|doi=10.1038/s41598-018-30716-y|issn=2045-2322|pmc=6109134|pmid=30143702|bibcode=2018NatSR...812753F}}</ref> However, unreamed intramedullary nailing can result in high rates of hardware failure if a person's weight bearing after surgery is not closely controlled.<ref name=":6" /> |
Early fracture immobilisation and fixation helps to prevent further soft tissue injury and promotes wound and bone healing. This is especially important in the treatment of [[intraarticular fractures]] where early fixation allows early joint motion to prevent joint stiffness. Fracture management depends on the person's overall well-being, fracture pattern and location, and the extent of soft tissue injury. Both reamed and unreamed [[Intramedullary rod|intramedullary nailing]] are accepted surgical treatments for open tibial fracture.<ref name=":5">{{Cite journal|last1=Shao|first1=Yinchu|last2=Zou|first2=Hongxing|last3=Chen|first3=Shaobo|last4=Shan|first4=Jichun|date=2014-08-23|title=Meta-analysis of reamed versus unreamed intramedullary nailing for open tibial fractures|journal=Journal of Orthopaedic Surgery and Research|volume=9|pages=74|doi=10.1186/s13018-014-0074-7|issn=1749-799X|pmc=4145248|pmid=25149501 |doi-access=free }}</ref> Both techniques have similar rates of postoperative healing, postoperative infection, implant failure and compartment syndrome.<ref name=":5" /> Unreamed intramedullary nailing is advantageous because it has a lower incidence of superficial infection and malunion compared to [[external fixation]].<ref name=":6">{{Cite journal|last1=Fu|first1=Qiang|last2=Zhu|first2=Lei|last3=Lu|first3=Jiajia|last4=Ma|first4=Jun|last5=Chen|first5=Aimin|date=2018-08-24|title=External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials|journal=Scientific Reports|volume=8|issue=1|pages=12753|doi=10.1038/s41598-018-30716-y|issn=2045-2322|pmc=6109134|pmid=30143702|bibcode=2018NatSR...812753F}}</ref> However, unreamed intramedullary nailing can result in high rates of hardware failure if a person's weight bearing after surgery is not closely controlled.<ref name=":6" /> Compared to external fixation, unreamed intramedullary nailing has similar rates of deep infection, delayed union and nonunion following surgery.<ref name=":6" /> For open tibial fractures in children, there is an increasing trend of using [[orthopedic cast]] rather than external fixation. [[Bone grafting]] is also helpful in fracture repair. However, [[internal fixation]] using plates and screws is not recommended as it increase the rate of infection.<ref name="Mohamad J 2015"/> [[Amputation]] is a last resort intervention, and is determined by factors such as tissue viability and coverage, infection, and the extent of damage to the [[vascular system]].<ref name=":8">{{Cite journal|last1=Manway|first1=Jeffrey|last2=Highlander|first2=Peter|date=2014-11-14|title=Open Fractures of the Foot and Ankle|journal=Foot & Ankle Specialist|volume=8|issue=1|pages=59–64|doi=10.1177/1938640014557072|pmid=25398852|s2cid=8695455|issn=1938-6400}}</ref> |
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===Wound management=== |
===Wound management and closure=== |
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Early wound closure is recommended to reduce the rates [[hospital-acquired infection]]. For Grade I and II fractures, wound can be healed by secondary intention or through primary closure. There is conflicting evident to suggest the effectiveness of [[Negative-pressure wound therapy]] (vacuum dressing), with several sources citing a decreased risk in infection,<ref name=":8" /><ref>{{Cite journal|last1=Schlatterer|first1=Daniel R.|last2=Hirschfeld|first2=Adam G.|last3=Webb|first3=Lawrence X.|date=2015-01-17|title=Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?|journal=Clinical Orthopaedics and Related Research|volume=473|issue=5|pages=1802–1811|doi=10.1007/s11999-015-4140-1|issn=0009-921X|pmc=4385370|pmid=25595096}}</ref> and others suggesting no proven benefit.<ref>{{Cite journal|last1=Iheozor-Ejiofor|first1=Zipporah|last2=Newton|first2=Katy|last3=Dumville|first3=Jo C|last4=Costa|first4=Matthew L|last5=Norman|first5=Gill|last6=Bruce|first6=Julie|date=2018-07-03|title=Negative pressure wound therapy for open traumatic wounds|journal=Cochrane Database of Systematic Reviews|volume=2018|issue=7|pages=CD012522|doi=10.1002/14651858.cd012522.pub2|pmid=29969521|pmc=6513538|issn=1465-1858}}</ref> |
Early wound closure is recommended to reduce the rates [[hospital-acquired infection]]. For Grade I and II fractures, wound can be healed by secondary intention or through primary closure. There is conflicting evident to suggest the effectiveness of [[Negative-pressure wound therapy]] (vacuum dressing), with several sources citing a decreased risk in infection,<ref name=":8" /><ref>{{Cite journal|last1=Schlatterer|first1=Daniel R.|last2=Hirschfeld|first2=Adam G.|last3=Webb|first3=Lawrence X.|date=2015-01-17|title=Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?|journal=Clinical Orthopaedics and Related Research|volume=473|issue=5|pages=1802–1811|doi=10.1007/s11999-015-4140-1|issn=0009-921X|pmc=4385370|pmid=25595096}}</ref> and others suggesting no proven benefit.<ref>{{Cite journal|last1=Iheozor-Ejiofor|first1=Zipporah|last2=Newton|first2=Katy|last3=Dumville|first3=Jo C|last4=Costa|first4=Matthew L|last5=Norman|first5=Gill|last6=Bruce|first6=Julie|date=2018-07-03|title=Negative pressure wound therapy for open traumatic wounds|journal=Cochrane Database of Systematic Reviews|volume=2018|issue=7|pages=CD012522|doi=10.1002/14651858.cd012522.pub2|pmid=29969521|pmc=6513538|issn=1465-1858}}</ref> |
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=== Adjunct Treatments === |
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A limited number of studies have assessed the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) on healing and infection risk. Results are encouraging, but no conclusive answers have been agreed upon to date.<ref>{{Cite journal |last1=Okike |first1=Kanu |last2=Bhattacharyya |first2=Timothy |date=December 2006 |title=Trends in the Management of Open Fractures: A Critical Analysis |url=http://journals.lww.com/00004623-200612000-00025 |journal=The Journal of Bone & Joint Surgery |language=en |volume=88 |issue=12 |pages=2739–2748 |doi=10.2106/JBJS.F.00146 |pmid=17142427 |issn=0021-9355}}</ref> |
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Prophylactic bone grafting, typically performed after the wound has been closed for two weeks but within 12 weeks of injury, may help those treated with external fixation heal faster. Bone graft can be impregnated with antibiotics to theoretically decrease infection risk.<ref>{{Cite journal |last1=Okike |first1=Kanu |last2=Bhattacharyya |first2=Timothy |date=December 2006 |title=Trends in the Management of Open Fractures: A Critical Analysis |url=http://journals.lww.com/00004623-200612000-00025 |journal=The Journal of Bone & Joint Surgery |language=en |volume=88 |issue=12 |pages=2739–2748 |doi=10.2106/JBJS.F.00146 |pmid=17142427 |issn=0021-9355}}</ref> |
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=== Complications === |
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When a bone is broken and exposed to the outside environment, the probability of infection increases. Both the surrounding soft tissues can become infected, as well as the bone itself, which is called [[osteomyelitis]]. Additional complications include the broken bone ends not healing, called non-union, and the broken bone ends healing in an incorrect orientation, called malunion. Open fractures of long bones may cause subsequent damage to surrounding tissue resulting in compartment syndrome. Additionally there is potential for fat embolism development, both requiring acute intervention.<ref name=":11" /><ref>{{Cite journal |last1=Ali |first1=Parveen |last2=Santy-Tomlinson |first2=Julie |last3=Watson |first3=Roger |date=2014-11-01 |title=Assessment and diagnosis of acute limb compartment syndrome: A literature review |url=https://www.sciencedirect.com/science/article/pii/S1878124114000045 |journal=International Journal of Orthopaedic and Trauma Nursing |language=en |volume=18 |issue=4 |pages=180–190 |doi=10.1016/j.ijotn.2014.01.002 |issn=1878-1241}}</ref> Lastly, open fractures commonly occur in the setting of traumatic experiences, and the co-occurrence of these events may lead to chronic pain and mental health disorders.<ref>{{Cite book |date=2020-08-01 |chapter=Patient Experience of Open Fracture and Practical Psychological Support |chapter-url=https://academic.oup.com/book/29872/chapter/253098374 |language=en |doi=10.1093/med/9780198849360.003.0017|title=Standards for the Management of Open Fractures |pages=159–168 |publisher=Oxford University PressOxford |isbn=978-0-19-884936-0 |editor-last1=Eccles |editor-last2=Handley |editor-last3=Khan |editor-last4=McFadyen |editor-last5=Nanchahal |editor-last6=Nayagam |editor-first1=Simon |editor-first2=Bob |editor-first3=Umraz |editor-first4=Iain |editor-first5=Jagdeep |editor-first6=Selvadurai }}</ref><ref>{{Citation |last1=Sop |first1=Jessica L. |title=Open Fracture Management |date=2022 |url=http://www.ncbi.nlm.nih.gov/books/NBK448083/ |work=StatPearls |place=Treasure Island (FL) |publisher=StatPearls Publishing |pmid=28846249 |access-date=2022-11-10 |last2=Sop |first2=Aaron}}</ref> The setting or mechanism of injury of the open fracture can have an effect on the risk of infection, for example, external objects or dirt in the wound increase the risk of infection.<ref>{{Cite web |title=Open Fractures - OrthoInfo - AAOS |url=https://www.orthoinfo.org/en/diseases--conditions/open-fractures/ |access-date=2023-03-26 |website=www.orthoinfo.org}}</ref> |
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== Outcomes == |
== Outcomes == |
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=== Infection === |
=== Infection === |
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The infection rate of open fractures depend on characteristics of the injury, type and timing of treatment, and patient factors.<ref name=":10">{{Cite web |date=March 21, 2022 |title=AAOS/METRC Prevention of Surgical Site Infection After Major Extremity Trauma Clinical Practice Guideline |url=https://www.aaos.org/SSITraumaCPG |access-date=October 29, 2022}}</ref> Higher rates of infection are associated with a higher Gustilo classification, where the risk of infection with a grade III fracture are up to 19.2% and a grade I or II fracture can have a 7.2% risk of infection.<ref>{{Cite journal |last1=Kortram |first1=Kirsten |last2=Bezstarosti |first2=Hans |last3=Metsemakers |first3=Willem-Jan |last4=Raschke |first4=Michael J. |last5=Van Lieshout |first5=Esther M.M. |last6=Verhofstad |first6=Michael H.J. |date=October 2017 |title=Risk factors for infectious complications after open fractures; a systematic review and meta-analysis |url=http://link.springer.com/10.1007/s00264-017-3556-5 |journal=International Orthopaedics |language=en |volume=41 |issue=10 |pages=1965–1982 |doi=10.1007/s00264-017-3556-5 |pmid=28744800 |s2cid=23589948 |issn=0341-2695}}</ref> Deep infection is more likely with increasing amounts of time between injury sustainment and antibiotic administration.<ref name=":10" /> There is an increased risk of infection in patients who smoke or have diabetes.<ref name=":10" /> The most common pathogen implicated in infected open fractures is ''Staphylococcus aureus''.<ref>{{Cite journal |last1=Dreyfus |first1=Jill G. |last2=Yu |first2=Holly |last3=Begier |first3=Elizabeth |last4=Gayle |first4=Julie |last5=Olsen |first5=Margaret A. |date=January 2022 |title=Incidence and burden of Staphylococcus aureus infection after orthopedic surgeries |url=https://www.cambridge.org/core/product/identifier/S0899823X21000659/type/journal_article |journal=Infection Control & Hospital Epidemiology |language=en |volume=43 |issue=1 |pages=64–71 |doi=10.1017/ice.2021.65 |pmid=34034839 |s2cid=235199988 |issn=0899-823X}}</ref> |
The infection rate of open fractures depend on characteristics of the injury, type and timing of treatment, and patient factors.<ref name=":10">{{Cite web |date=March 21, 2022 |title=AAOS/METRC Prevention of Surgical Site Infection After Major Extremity Trauma Clinical Practice Guideline |url=https://www.aaos.org/SSITraumaCPG |access-date=October 29, 2022}}</ref> Higher rates of infection are associated with a higher Gustilo classification, where the risk of infection with a grade III fracture are up to 19.2% and a grade I or II fracture can have a 7.2% risk of infection.<ref>{{Cite journal |last1=Kortram |first1=Kirsten |last2=Bezstarosti |first2=Hans |last3=Metsemakers |first3=Willem-Jan |last4=Raschke |first4=Michael J. |last5=Van Lieshout |first5=Esther M.M. |last6=Verhofstad |first6=Michael H.J. |date=October 2017 |title=Risk factors for infectious complications after open fractures; a systematic review and meta-analysis |url=http://link.springer.com/10.1007/s00264-017-3556-5 |journal=International Orthopaedics |language=en |volume=41 |issue=10 |pages=1965–1982 |doi=10.1007/s00264-017-3556-5 |pmid=28744800 |s2cid=23589948 |issn=0341-2695|hdl=1765/101009 |hdl-access=free }}</ref> Deep infection is more likely with increasing amounts of time between injury sustainment and antibiotic administration.<ref name=":10" /> There is an increased risk of infection in patients who smoke or have diabetes.<ref name=":10" /> The most common pathogen implicated in infected open fractures is ''Staphylococcus aureus''.<ref>{{Cite journal |last1=Dreyfus |first1=Jill G. |last2=Yu |first2=Holly |last3=Begier |first3=Elizabeth |last4=Gayle |first4=Julie |last5=Olsen |first5=Margaret A. |date=January 2022 |title=Incidence and burden of Staphylococcus aureus infection after orthopedic surgeries |url=https://www.cambridge.org/core/product/identifier/S0899823X21000659/type/journal_article |journal=Infection Control & Hospital Epidemiology |language=en |volume=43 |issue=1 |pages=64–71 |doi=10.1017/ice.2021.65 |pmid=34034839 |s2cid=235199988 |issn=0899-823X}}</ref> |
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==Epidemiology== |
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Crush injuries are the most common form of injuries, followed by falls from standing height, and road traffic accidents. Open fractures tend to occur more often in males than females at the ratio of 7 to 3 and the age of onset of 40.8 and 56 years respectively. In terms of anatomy location, fractures of finger phalanges are the most common one at the rate of 14 per 100,000 people per year in the general population, followed by fracture of [[tibia]] at 3.4 per 100,000 population per year, and [[distal radius fracture]] at 2.4 per 100,000 population per year.<ref name="Mohamad J 2015"/> Infection rates for Gustilo Grade I fractures is 1.4%, followed by 3.6% for Grade II fractures, 22.7% for Grade IIIA fractures, and 10 to 50% of Grade IIIB and IIIC fractures.<ref>{{cite journal|last1=William W|first1=Cross|last2=Marc F|first2=Swiontkowski|title=Treatment principles in the management of open fractures|journal=Indian Journal of Orthopaedics|date=October 2008|volume=42|issue=4|pages=377–386|doi=10.4103/0019-5413.43373|pmid=19753224|pmc=2740354}}</ref> |
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==History== |
==History== |
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During the 19th century Crimean War, the use of [[Plaster|plaster-of-paris]] for the stabilization of open and closed fractures was pioneered. It has been reported that the pioneering Russian surgeon who introduced the novel technique had been inspired by watching sculptors creating works of art.<ref>{{Cite book |last=Peltier |first=Leonard F. |url=https://books.google.com/books?id=kdBfBd5BdEwC&dq=Peltier+LF.+Fractures:+a+history+and+iconography+of+their+treatment.+San+Francisco:+Norman+Publishing,+1990.&pg=PR9 |title=Fractures: A History and Iconography of Their Treatment |date=1990 |publisher=Norman Publishing |isbn=978-0-930405-16-8 |language=en}}</ref> |
During the 19th century Crimean War, the use of [[Plaster|plaster-of-paris]] for the stabilization of open and closed fractures was pioneered. It has been reported that the pioneering Russian surgeon who introduced the novel technique had been inspired by watching sculptors creating works of art.<ref>{{Cite book |last=Peltier |first=Leonard F. |url=https://books.google.com/books?id=kdBfBd5BdEwC&dq=Peltier+LF.+Fractures:+a+history+and+iconography+of+their+treatment.+San+Francisco:+Norman+Publishing,+1990.&pg=PR9 |title=Fractures: A History and Iconography of Their Treatment |date=1990 |publisher=Norman Publishing |isbn=978-0-930405-16-8 |language=en}}</ref> |
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Before the 1850s, surgeons usually amputated the limbs for those with open fractures, as it was associated with severe [[sepsis]] and [[gangrene]] which can be life-threatening. It was |
Before the 1850s, surgeons usually amputated the limbs for those with open fractures, as it was associated with severe [[sepsis]] and [[gangrene]] which can be life-threatening. It was not until the latter half of the 19th century, when [[Joseph Lister]] adopted the [[aseptic technique]] in surgeries, that the rate of death from open fractures reduced from 50% to 9%.<ref name="Mohamad J 2015" /><ref>{{cite journal |last1=Buckwalter |first1=Joseph A. |title=Advancing the Science and Art of Orthopaedics: Lessons from History |journal=Journal of Bone & Joint Surgery - American Volume |date=2000 |volume=82 |issue=12 |pages=1782–1800 |doi=10.2106/00004623-200012000-00012 |pmid=11130651 |url=https://pubmed.ncbi.nlm.nih.gov/11130651/ |access-date=February 22, 2024 |ref=5}}</ref> |
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==References== |
==References== |
Latest revision as of 20:14, 24 April 2024
An open fracture, also called a compound fracture, is a type of bone fracture (broken bone) that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. An open fracture can be life threatening or limb-threatening (person may be at risk of losing a limb) due to the risk of a deep infection and/or bleeding. Open fractures are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue.[1] Other potential complications include nerve damage or impaired bone healing, including malunion or nonunion. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method.[2] This classification system can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection.[1]
![](http://upload.wikimedia.org/wikipedia/commons/thumb/9/9d/Rheumatology_-_Open_fracture_--_Smart-Servier.png/676px-Rheumatology_-_Open_fracture_--_Smart-Servier.png)
Cephalosporins, sometimes with aminoglycosides, are generally the first line of antibiotics and are used usually for at least three days.[3] Therapeutic irrigation, wound debridement, early wound closure and bone fixation core principles in management of open fractures.[4] All these actions aimed to reduce the risk of infections and promote bone healing. The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture. Older people with osteoporosis and soft-tissue problems are also at risk.
Epidemiology
[edit]Crush injuries are the most common form of injuries, followed by falls from standing height, and road traffic accidents. Open fractures tend to occur more often in males than females at the ratio of 7 to 3 and the age of onset of 40.8 and 56 years respectively. In terms of anatomy location, fractures of finger phalanges are the most common one at the rate of 14 per 100,000 people per year in the general population, followed by fracture of tibia at 3.4 per 100,000 population per year, and distal radius fracture at 2.4 per 100,000 population per year.[5] Infection rates for Gustilo Grade I fractures is 1.4%, followed by 3.6% for Grade II fractures, 22.7% for Grade IIIA fractures, and 10 to 50% of Grade IIIB and IIIC fractures.[6]
Signs and symptoms
[edit]There are a range of characteristics of open fractures as the severity of the injury can vary greatly. Most open fractures are characterized by a broken bone that is sticking out of the skin, but there can also be a broken bone that is associated with a very small "poke-hole" skin wound. Both of these injuries are classified as open fractures.[7] Some open fractures can have significant blood loss. Most open fractures have extensive damage to soft tissues near and around the bone such as nerves, tendons, muscles, and blood vessels.[1]
Causes
[edit]Open fractures can occur due to direct impacts such as high-energy physical forces (trauma), motor vehicular accidents, firearms, and falls from height.[8] Indirect mechanisms include twisting (torsional injuries) and falling from a standing position.[8] These mechanisms are usually associated with substantial degloving of the soft-tissues, but can also have a subtler appearance with a small poke hole and accumulation of clotted blood in the tissues. Depending on the nature of the trauma, it can cause different types of fractures:[9][10]
Common fractures
[edit]Bone fractures result from significant trauma to the bone. This trauma can come from a variety of forces – a direct blow, axial loading, angular forces, torque, or a mixture of these.[11] There are various fracture types, including closed, open, stress, simple, comminuted, greenstick, displaced, transverse, oblique.[12][13]
Pathological fractures
[edit]Result from minor trauma to diseased bone. These preexisting processes include metastatic lesions, bone cysts, advanced osteoporosis, etc.[10]
Fracture-dislocations
[edit]Severe injury in which both fracture and dislocation take place simultaneously.[9]
Gunshot wounds
[edit]Caused by high-speed projectiles, they cause damage as they go through the tissue, through secondary shock wave and cavitation.[10]
Diagnosis
[edit]The initial evaluation for open fractures is to rule out any other life-threatening injuries. Advanced Trauma Life Support (ATLS) is the initial protocol to rule out such injuries. Once the patient is stabilised, orthopedic injuries can be evaluated including determining the severity of injury using a classification system. Mechanism of injury is important to know the amount energy that is transferred to the patient and the level of contamination. Every limb should be exposed to evaluate any other hidden injuries. Characteristics of the wound should be noted in detail. Neurology and the vascular status of the affected limb are important to rule out any nerve or blood vessels injuries. High index of suspicion of compartment syndrome should be maintained for leg and forearm fractures.[5]
Classification
[edit]There are a number of classification systems attempting to categorise open fractures such as Gustilo-Anderson open fracture classification, Tscherne classification, and Müller AO Classification of fractures. However, Gustilo-Anderson open fracture classification is the most commonly used classification system.[1] Gustilo system grades the fracture according to energy of injury, soft tissue damage, level of contamination, and comminution of fractures. The higher the grade, the worse the outcome of the fracture.[5]
Gustilo Open Fracture Classification | |
---|---|
Gustilo Grade | Definition |
I | Open fracture, clean wound, wound <1 cm in length |
II | Open fracture, wound > 1 cm but < 10 cm in length[14] without extensive soft-tissue damage, flaps, avulsions |
IIIA | Open fracture with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma (gunshot and farm injuries) regardless of the size of the wound[14][15] |
IIIB | Open fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination.[14][15] Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) |
IIIC | Open fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury. |
Gustilo Type III Open fracture | |
---|---|
Specialty | Orthopedics |
However, Gustilo system is not without its limitations. The system has limited interobserver reliability at 50% to 60%.[5] The size of injury on the skin surface does not necessarily reflect the extent of deep underlying soft tissue injury. Therefore, the true grading of Gustilo can only be done in operating theatre.[5]
Management
[edit]Acute management
[edit]Urgent interventions, including therapeutic irrigation and wound debridement, are often necessary to clean the area of injury and minimize the risk of infection.[16] Other risks of delayed intervention include long-term complications, such as deep infection, vascular compromise and complete limb loss.[16] After wound irrigation, dry or wet gauze should be applied to the wound to prevent bacterial contamination. Taking photographs of the wound can help to reduce the need of multiple examinations by different doctors, which could be painful. Limb should be reduced and placed in a well-padded splint for immobilization of fractures. Pulses should be documented before and after reduction.[5]
![](http://upload.wikimedia.org/wikipedia/commons/thumb/2/25/Flowchart_for_Treatment_of_Open_Fractures.png/361px-Flowchart_for_Treatment_of_Open_Fractures.png)
Wound cultures are positive in 22% of pre-debridement cultures and 60% of post-debridement cultures of infected cases. Therefore, pre-operative cultures no longer recommended. The value of post-operative cultures is unknown. Tetanus prophylaxis is routinely given to enhance immune response against Clostridium tetani. Anti-tetanus immunoglobulin is only indicated for those with highly contaminated wounds with uncertain vaccination history. Single intramuscular dose of 3000 to 5000 units of tetanus immunoglobulin is given to provide immediate immunity.[5]
Another important clinical decision during acute management of open fractures involves the effort to avoid preventable amputations, where functional salvage of the limb is clearly desirable.[16] Care must be taken to ensure this decision is not solely based on an injury severity tool score, but rather a decision made following a full discussion of options between doctors and the person, along with their family and care team.[16]
Antibiotics
[edit]Administration of broad-spectrum intravenous antibiotics as soon as possible (within an hour ideally) is necessary to reduce the risk of infection.[1] However, antibiotics may not provide necessary benefits in open finger fractures and low velocity firearms injury. First generation cephalosporin (cefazolin) is recommended as first line antibiotics for the treatment of open fractures. The antibiotic is useful against gram positive cocci and gram negative rods such as Escherichia coli, Proteus mirabilis, and Klebsiella pneumoniae. To extend the coverage of antibiotics against more bacteria in Type III Gustilo fractures, combination of first generation cephalosporin and aminoglycoside (gentamicin or tobramycin) or a third generation cephalosporin is recommended to cover against nosocomial gram negative bacilli such as Pseudomonas aeruginosa. Adding penicillin to cover for gas gangrene caused by anaerobic bacteria Clostridium perfringens is a controversial practice. Studies has shown that such practice may not be necessary as the standard antibiotic regimen is enough to cover for Clostridial infections. Antibiotic impregnated devices such as tobramycin impregnated Poly(methyl methacrylate) (PMMA) beads and antibiotic bone cement are helpful in reducing rates of infection.[5] The use of absorbable carriers with implant coatings at the time of surgical fixation is also an effective means of delivering local antibiotics.[17]
There has been no agreement on the optimal duration of antibiotics.[1] Studies has shown that there is no additional benefits of risk of infection when giving antibiotics for one day, when compared to giving antibiotics for three days or five days.[5][18] However, at present, there is only low to moderate evidence for this and more research is needed.[18] Some authors recommended that antibiotics to be given for three doses for Gustilo Grade I fractures, for one day after wound closure in Grade II fractures, three days in Grade IIIA fractures, and three days after wound closure for Grade IIIB and IIIC.[5]
Wound irrigation
[edit]There has been no agreement for the optimal solution for wound irrigation. Studies found out that there is no difference in infection rates by using normal saline or other various forms of water (distilled, boiled, or tap).[19] There is also no difference in infection rates when using normal saline with castile soap compared with normal saline together with bacitracin in irrigating wounds. Studies also have shown that there is no difference in infection rates using low pressure pulse lavage (LPPL) when compared to high pressure pulse lavage (HPPL) in irrigating wounds. Optimal amount of fluid for irrigation also has not been established. It is recommended that the amount of irrigation solution to be determined by the severity of the fracture, with 3 litres for type I fractures, 6 litres for type II fractures, and 9 litres for type III fractures.[5]
Wound debridement
[edit]The purpose of wound debridement is to remove all contaminated and non-viable tissues including skin, subcutaneous fat, muscles and bones. Viability of bones and soft tissues are determined by their capacity to bleed. Meanwhile, the viability of muscles is determined by colour, contractility, consistency, and their capacity to bleed. The optimal timing of performing wound debridement and closure is debated and dependent on the severity of the injury, resources and antibiotics available, and individual needs.[20][1] Debridement time can vary from 6 to 72 hours, and closure time can be immediate (less than 72 hours) or delayed (72 hours to up to 3 months).[20] There is no difference in infection rates for performing surgery within 6 hours of injury when compared to until 72 hours after injury.[5][21] NICE guidelines suggest that the surgical debridement should be done immediately for open fracture that are highly contaminated or where there is a lot of bleeding (vascular compromise).[22] For high-energy open fractures that are not highly contaminated NICE guidelines suggest surgical debridement within 12 hours of the accident, and for other open fractures within 24 hours.[22]
Surgical management
[edit]Early fracture immobilisation and fixation helps to prevent further soft tissue injury and promotes wound and bone healing. This is especially important in the treatment of intraarticular fractures where early fixation allows early joint motion to prevent joint stiffness. Fracture management depends on the person's overall well-being, fracture pattern and location, and the extent of soft tissue injury. Both reamed and unreamed intramedullary nailing are accepted surgical treatments for open tibial fracture.[23] Both techniques have similar rates of postoperative healing, postoperative infection, implant failure and compartment syndrome.[23] Unreamed intramedullary nailing is advantageous because it has a lower incidence of superficial infection and malunion compared to external fixation.[24] However, unreamed intramedullary nailing can result in high rates of hardware failure if a person's weight bearing after surgery is not closely controlled.[24] Compared to external fixation, unreamed intramedullary nailing has similar rates of deep infection, delayed union and nonunion following surgery.[24] For open tibial fractures in children, there is an increasing trend of using orthopedic cast rather than external fixation. Bone grafting is also helpful in fracture repair. However, internal fixation using plates and screws is not recommended as it increase the rate of infection.[5] Amputation is a last resort intervention, and is determined by factors such as tissue viability and coverage, infection, and the extent of damage to the vascular system.[25]
Wound management and closure
[edit]Early wound closure is recommended to reduce the rates hospital-acquired infection. For Grade I and II fractures, wound can be healed by secondary intention or through primary closure. There is conflicting evident to suggest the effectiveness of Negative-pressure wound therapy (vacuum dressing), with several sources citing a decreased risk in infection,[25][26] and others suggesting no proven benefit.[27]
Adjunct Treatments
[edit]A limited number of studies have assessed the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) on healing and infection risk. Results are encouraging, but no conclusive answers have been agreed upon to date.[28]
Prophylactic bone grafting, typically performed after the wound has been closed for two weeks but within 12 weeks of injury, may help those treated with external fixation heal faster. Bone graft can be impregnated with antibiotics to theoretically decrease infection risk.[29]
Complications
[edit]When a bone is broken and exposed to the outside environment, the probability of infection increases. Both the surrounding soft tissues can become infected, as well as the bone itself, which is called osteomyelitis. Additional complications include the broken bone ends not healing, called non-union, and the broken bone ends healing in an incorrect orientation, called malunion. Open fractures of long bones may cause subsequent damage to surrounding tissue resulting in compartment syndrome. Additionally there is potential for fat embolism development, both requiring acute intervention.[7][30] Lastly, open fractures commonly occur in the setting of traumatic experiences, and the co-occurrence of these events may lead to chronic pain and mental health disorders.[31][32] The setting or mechanism of injury of the open fracture can have an effect on the risk of infection, for example, external objects or dirt in the wound increase the risk of infection.[33]
Outcomes
[edit]Infection
[edit]The infection rate of open fractures depend on characteristics of the injury, type and timing of treatment, and patient factors.[34] Higher rates of infection are associated with a higher Gustilo classification, where the risk of infection with a grade III fracture are up to 19.2% and a grade I or II fracture can have a 7.2% risk of infection.[35] Deep infection is more likely with increasing amounts of time between injury sustainment and antibiotic administration.[34] There is an increased risk of infection in patients who smoke or have diabetes.[34] The most common pathogen implicated in infected open fractures is Staphylococcus aureus.[36]
History
[edit]In Ancient Egypt, physicians were diagnosing and treating open fractures. Treatment consisted of manual reduction, where the broken bone is made to be straight again with physical maneuvers, and then application of splints and topical ointments. Splints were constructed using linen and sticks or tree bark. A topical ointment consisting of honey, grease, and lint made from vegetable fiber were then applied daily to the open fracture. However, the Ancient Egyptians noted open fractures to have a poor prognosis, and fifth dynasty graves have been discovered containing people who passed away from open fractures.[37]
During the 19th century Crimean War, the use of plaster-of-paris for the stabilization of open and closed fractures was pioneered. It has been reported that the pioneering Russian surgeon who introduced the novel technique had been inspired by watching sculptors creating works of art.[38]
Before the 1850s, surgeons usually amputated the limbs for those with open fractures, as it was associated with severe sepsis and gangrene which can be life-threatening. It was not until the latter half of the 19th century, when Joseph Lister adopted the aseptic technique in surgeries, that the rate of death from open fractures reduced from 50% to 9%.[5][39]
References
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- ^ Gustilo, Ramon B. (July 1, 1979). "Use of Antimicrobials in the Management of Open Fractures". Archives of Surgery. 114 (7): 805–808. doi:10.1001/archsurg.1979.01370310047010. ISSN 0004-0010. PMID 454175.
- ^ Chan, James K-K; Aquilina, Alexander L; Lewis, Sharon R; Rodrigues, Jeremy N; Griffin, Xavier L; Nanchahal, Jagdeep (April 1, 2022). Cochrane Bone, Joint and Muscle Trauma Group (ed.). "Timing of antibiotic administration, wound debridement, and the stages of reconstructive surgery for open long bone fractures of the upper and lower limbs". Cochrane Database of Systematic Reviews. 2022 (4): CD013555. doi:10.1002/14651858.CD013555.pub2. PMC 8973274. PMID 35363374.
- ^ Eccles, Simon; Handley, Bob; Khan, Umraz, eds. (2020). Standards for the management of open fractures. Oxford New York, NY: Oxford University Press. ISBN 978-0-19-884936-0.
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{{cite journal}}
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- ^ a b c Fu, Qiang; Zhu, Lei; Lu, Jiajia; Ma, Jun; Chen, Aimin (August 24, 2018). "External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials". Scientific Reports. 8 (1): 12753. Bibcode:2018NatSR...812753F. doi:10.1038/s41598-018-30716-y. ISSN 2045-2322. PMC 6109134. PMID 30143702.
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- ^ Schlatterer, Daniel R.; Hirschfeld, Adam G.; Webb, Lawrence X. (January 17, 2015). "Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?". Clinical Orthopaedics and Related Research. 473 (5): 1802–1811. doi:10.1007/s11999-015-4140-1. ISSN 0009-921X. PMC 4385370. PMID 25595096.
- ^ Iheozor-Ejiofor, Zipporah; Newton, Katy; Dumville, Jo C; Costa, Matthew L; Norman, Gill; Bruce, Julie (July 3, 2018). "Negative pressure wound therapy for open traumatic wounds". Cochrane Database of Systematic Reviews. 2018 (7): CD012522. doi:10.1002/14651858.cd012522.pub2. ISSN 1465-1858. PMC 6513538. PMID 29969521.
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