Open Fractures

Recommended if the fractured bone sticks out of the skin causing damage to the other soft tissues

What are open fractures?

When there is damage to the continuity of bone, it is known as a fracture. Fractures usually occur when a bone gets impacted with great force or pressure than it can support. Depending on the impact the fracture can be lengthwise, crosswise, or multiple places.

If the bones breaks and the ends of the broken bone tear the skin causing damage to the surrounding muscles, tendons, and ligaments it known as an open or compound fracture. If the broken bone is not puncturing the skin, then it is known as a closed or simple fracture.

Types of Open fractures:

The most commonly applied classification of open fractures is the Gustilo and Anderson classification.

Gustilo and Anderson classified open fractures depending on the type of wound. This type of classification includes:

Type I

Clean wounds which are smaller than 1 cm in diameter, appearing clean, with simple fracture pattern, and without skin crushing, are included in this type.

Type II

Wounds with a laceration larger than 1 cm but without significant soft-tissue crushing, without flaps, degloving or contusion are included in this type. Fracture pattern may be more complex comparatively in type II wounds.

Type III

Wounds with an open segmental fracture or a single fracture with an extensive soft-tissue injury are included in type III. Injuries older than eight hours are also included.

  • Type III injuries are further classified into three types:
    • Type IIIA
      Wounds with adequate soft-tissue coverage of the fracture despite extensive laceration.
    • Type IIIB
      Wounds with inadequate soft-tissue coverage with periosteal stripping are classified under type III B. Soft-tissue reconstruction is recommended.
    • Type IIIC
      Wounds with any open fracture associated with a vascular injury that requires repair.

What are the goals of treatment in an open fracture?

Goals of open fracture management include the prevention of infection, achievement of bony union, and the restoration of function

The most important aspect in the treatment of open fractures is the initial surgical intervention with irrigation and meticulous debridement of the injury zone. In fact, the surgeon should spend as much time for planning and performing the debridement as for the fixation of the fracture. This initial debridement should include a sequential evaluation of skin, fat, fascia, muscle, and bone The propensity to excise as little possible should be avoided in open fracture management given the relatively high contamination rate of these injuries, especially in Type III injuries.

Surgical debridement’s are best performed by plastic surgeon as he is trained in the anatomy, soft tissue management, vascularity and coverage of the open fracture and associated injuries. It helps him assess the wound first hand so that ideal soft tissue coverage can be planned and patient benefits the most.

Most Orthopedic surgeons are limited by their capacity to provide coverage to an open fracture and hence cannot do justice to both surgical debridement and soft tissue coverage both of which are vital to management of open wounds.

Early stabilization of open fractures provides many benefits to the injured patient. It protects the soft tissues around the zone of injury by preventing further damage from mobile fracture fragments. It also restores length, alignment, and rotation—all vital principles of fracture fixation. This restoration of length also helps decrease soft tissue dead spaces and has been shown in studies to decrease the rates of infection in open fractures

Why is plastic surgeon important in open fracture management?

Surgical debridement’s are best performed by plastic surgeon as he is trained in the anatomy, soft tissue management, vascularity and coverage of the open fracture and associated injuries. It helps him assess the wound first hand so that ideal soft tissue coverage can be planned and patient benefits the most.

What are the types of the surgeries?

Open fractures may cause damage to the bone along with the surrounding muscles, tendons, and ligaments which are needed to be fixed.

The types of surgical procedures used to fix the fractured bone include:

Surgical debridement

This is most important aspect in the treatment of open fractures is the initial surgical intervention with irrigation and meticulous debridement of the injury zone. It requires in-depth knowledge of angiosomes and attention to their patterns can help with avoiding wound-healing complications. Incisions are optimally placed between angiosomes to prevent devascularizing portions of the wound

Internal Fixation:

A surgical procedure called internal fixation might be used for more complex or compound fractures. In this procedure, first, the bones are repositioned (or reduced) into their normal alignment which is then connected (or fixed), with the help of metal plates and screws. In some cases, rods are inserted through the center of the bone (marrow space). This type of surgery is used when the open fractures are less severe, minor, and has a minimal fixation.

External Fixation:

This technique can be used to hold the bones in general alignment. Initially, pins or screws are placed into the broken bone above and below the fracture site. The placed Pins and screws are then connected to a metal bar outside the skin once the bone is repositioned. The bar assists in healing by holding the bones in place. This type of surgery is preferred when the open fractures are severe. External fixation is also used to keep broken bones from moving.

The types of surgical procedures used to fix the damaged soft tissue include:

Local flap

In this technique, the muscle tissue from the involved limb is rotated to cover the fracture. A patch of skin (graft) taken from a different area of the body is placed over this.

Free flap:

This technique is suitable for wounds which may require a complete transfer of tissue. This tissue is often taken from the back or abdomen.

Vacuum-assisted closure (VAC)

Your doctor may use negative-pressure wound therapy (NPWT) which helps to decrease the bacterial load and preparing the wound for skin grafting or flap coverage. It cannot replace definitive wound coverage unless there is sufficient mobile soft tissue around the wound which can be mobilized to cover the wound.

How should I prepare for the surgery?

Open fractures are treated on an emergency basis and hence you may not get any time to prepare for the surgery. Although your doctor may ask you about your medical problems such as diabetes or about the medications, you are taking.

What is the aftercare of the surgery?

Open fractures may require multiple settings of surgery. So you should be prepared for two or three surgeries if needed to allow for early union.

You need to follow certain instructions suggested by your surgeon for better healing process:

  • Take oral or parenteral antibiotics to prevent = infections.
  • Take painkillers and other prescribed drugs as a part of pain management therapy.
  • Keep your surgical area clean and dry
  • Follow the physical therapy exercise regularly as instructed by your doctor.

Call the surgeon immediately if you experience:

  • Swelling
  • Redness
  • Foul-smelling drainage
  • Numbness

What are the post-surgical considerations?

  • Severe infection which may lead to further surgeries and amputation
  • Development of acute compartment syndrome
  • Surgery may be required if your fracture is failing to heal
  • Hematoma
  • Pin-site infections
  • Osteomyelitis
  • Chronic pain syndrome
  • Thromboembolic events

Complications of the bone healing

  • Delayed union- Fracture that has not healed after a reasonable time
  • Malunion- Fracture that heals in unacceptable position in any plane
  • Nonunion- Fracture that has no chance of healing

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