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Open Fracture

Open Fractures

An open fracture is one which communicates with the exterior through the skin. The communication may vary from a small puncture wound to a large break in the skin.


Presentation

The mechanism of the injury usually reveals a lot about the nature of the injury. A fracture is likely to have occurred if there is a pop sound heard by the patient at the time of the impact. Immediate pain after the injury is also suggestive of fractures and ligament or tendon tears. If the pain occurs several hours after the injury, it excludes a fracture. Pain at the site of the injury which is disproportionate to the nature and severity of the injury indicates ischemia or compartment syndrome [5]. This may be as a result of the swelling secondary to hemorrhage.

Open fractures are diagnosed on presentation with an obvious skin break and a protruding fragment or segment of the fractured bone. Depending on the type, there may be damage and loss of soft tissue. Loss of skin and soft tissue presents as extensive bone exposure.

In cases where there is neurovascular compromise, the limbs may feel cold and appear dark.

Hyperkeratosis
  • Clinical examination revealed bland soft tissues without hyperkeratosis or other signs of maladaptation. Articular and cutaneous proprioception was intact all over the left leg.[ncbi.nlm.nih.gov]
Osteophyte
  • Enthesophytes are analogous to osteophytes of osteoarthritis. Enthesopathy is the pathologic change of the enthesis, the insertion site of tendons, ligaments, and joint capsules on the bone.[ncbi.nlm.nih.gov]
Enthesopathy
  • Enthesopathy is the pathologic change of the enthesis, the insertion site of tendons, ligaments, and joint capsules on the bone.[ncbi.nlm.nih.gov]
Joint Effusion
  • Plain radiographs reveal unsuspected fractures and joint effusion resulting from the hemorrhage. Plain radiographs should be taken in at least two views; typically anteroposterior and lateral views.[symptoma.com]
Hip Dislocation
  • “Risk Factors for Late Presentation of Developmental Hip Dislocation and Risk Factors for Failure of Pavlik Harness Use” Principle Investigator: Joseph Janicki, MD A retrospective review of patients presenting developmental hip dislocation will be completed[luriechildrens.org]
Suggestibility
  • Findings of this study suggest that there was no statistical difference between reamed and unreamed intramedullary nailing in clinical treatment of OTF.[ncbi.nlm.nih.gov]
  • This meta-analysis suggests a risk reduction in FRI of 11.9% if additional local antibiotics are given prophylactically for open limb fractures.[ncbi.nlm.nih.gov]
  • Encouraging functional outcomes of reimplantation of extruded talus suggest that excision of the talus with or without tibiocalcaneal fusion should be kept as a salvage procedure.[ncbi.nlm.nih.gov]
  • In vitro and animal studies have suggested that irrigation with detergent solution is more effective than irrigation with a solution containing antibiotic additives.[ncbi.nlm.nih.gov]
  • There is conflicting evident to suggest the effectiveness of Negative-pressure wound therapy (vacuum dressing), with several sources citing a decreased risk in infection, and others suggesting no proven benefit.[en.wikipedia.org]

Workup

A patient with open fractures should undergo a thorough vascular and neurologic evaluation of the affected limb. Physical examination should also include inspection for swelling, hematoma, open wounds, and functionality of the limb. The bones and tendons involved should also be palpated for tenderness, fractures or tears, and other gross injuries.

In severe injuries, imaging studies may be necessary. However, the use of imaging depends a lot on the severity and site of the fractures. In cases where imaging studies are required, plain radiographs are ordered first. Plain radiographs reveal unsuspected fractures and joint effusion resulting from the hemorrhage. Plain radiographs should be taken in at least two views; typically anteroposterior and lateral views.

MRI and CT scannings are indicated if a plain radiograph doesn't reveal a suspected fracture such as a scaphoid fracture, impacted femoral neck fractures, and hip fractures. An MRI or CT imaging is also required when there is no specific and clear indication of fracture. They also help to identify concomitant soft-tissue injuries.

For neurovascular complications, arterography and nerve conduction studies are necessary [6]. In compartment syndrome, neurovascular impingement and compromise could occur and could have fatal effects on the affected limb.

Treatment

For most moderate to severe fractures, immobilization of the joints, proximal and distal to the affected limb, is critical to reduce the pain, maintain the alignment of the fractured bone, and prevent further soft tissue injury. Immobilization is achieved by splinting with a non-rigid material. Immobilization may also help prevent fat embolism in certain cases of long-bone fractures. In some instances, fractures which heal quickly, such as buckle wrist fractures commonly observed in children, are not immobilized or casted; in these fractures, early mobilization offers the best results [7].

Reduction of a fracture is necessary when there is malalignment or significant displacement of the fracture. The bone reduction consists of realigning the bone via external manipulation [8]. Reduction may require sedation and strong analgesia. However, reduction may not be necessary in certain cases of fracture particularly seen in children. In such instances, the subsequent bone remodelling may re-align the bone.

In cases of significant hemorrhage and entrapment, hypovolemia and hemorrhagic shock are corrected urgently. Neurovascular injuries are surgically repaired if the vessels are large and without collateral circuit. Cases of neuropraxia and axonotmesis are managed with watchful waiting, supportive care, and physiotherapy. Furthermore, all open fractures require wound dressings, broad-spectrum antibiotic coverage, and tetanus prophylaxis. Administration of antibiotics should be started within three hours of the patient's presentation. Debridement is also required to prevent secondary infection at the fracture site [7] [9] [10].

Analgesia is achieved typically with strong analgesics such as opioids. Sprains and tears of other musculoskeletal structures are also surgically repaired. Furthermore, healing and significant resolution of symptoms can be achieved by the application of the PRICE strategy (Protection of the affected limb, Rest of the affected limb, application of Ice severally every day, Compression, and Elevation of the limb).

Prognosis

The severity of open fractures depends on several factors including the impact and nature of the trauma. Open fractures are classified into three categories (types I to III) with progressive levels of severity and increasing risk of complications. Type I is characterized by small skin breaks while type III is classified by extensive soft tissue loss and exposure with neurovascular injury. Type II is characterized by large skin breaks without significant soft tissue damage or loss. Typically, open fractures heal slower than closed fractures.

Etiology

Open fractures are most likely a result of severe trauma, as compared to closed fractures. However, low-intensity indirect trauma might cause open fractures especially at the sites where the bone is very close to the skin and unprotected by muscle and soft tissue. Typically, open fractures result from direct high-intensity trauma. 

Epidemiology

The incidence rate of open fractures varies depending on the geographical factors, socioeconomic conditions, size of the population, and the trauma care system of the location.

The Edinburgh Orthopedic Trauma Unit treats all cases of fractures in a region of approximately 750,000 people [4]. Within a six-year period between January 1998 and March 1994, 1,000 cases of open fractures affecting 933 patients were treated; the reported numbers represents an incidence rate of 21.3 per 100,000 of the population. Diaphyseal fractures most commonly affected the tibia and the humerus the least. These diaphyseal open fractures were a more common occurrence than metaphyseal fractures in the major long bones.

Sex distribution
Age distribution

Pathophysiology

The severity of open fractures is determined by the force of the impact. In mild cases, the skin break is minimal and only limited to a small puncture wound in the skin. Severe tissue crushing and devitalization occurs in high impact cases such as in road traffic accidents, gunshot wounds, and industrial accidents.

In the management of open fractures, there is a major risk of bacterial inoculation of the exposed tissue. This risk is increased by iatrogenic factors such as repeated wound dressings and debridements. A study by Gustilo and Anderson observed that more than half of their 158 patients tested positive for bacterial growth after wound culture in the initial stages of the management [2]. In 31 cases, though the cultures were initially negative, eventually turned positive when the wound was to be closed.

Furthermore, crush injuries coupled with the local tissue ischemia may cause a compromise in the patients immune integrity. Tissue ischemia results from trauma to the blood vessels and damaged capillaries, compartment syndrome, and use of vasoconstrictive drugs during the initial rescusitative management.

Prevention

Fractures can be prevented by minimizing the risk of road traffic, industrial, and domestic accidents. Driving instructions should be adhered to and use of personal protective equipments in industries should be used.

Another form of prevention is increasing bone strength. This can be achieved via a healthy diet and regular exercise. The diet should contain foods rich in vitamin D and calcium.

Summary

An open fracture is so called because the fractured bones make communication with the exterior through a break in the skin [1].

Open fractures are usually caused by high-intensity direct trauma such as falls from heights, injuries from road traffic accidents or high impact sports, and industrial accidents. The severity of the open fractures is determined by the intensity of the trauma.

There is a common classification system which categorizes open fractures into types. This classification helps in diagnosis and appropriate institution of treatment protocol and monitoring of treatment and patient's clinical progression. The most commonly used and widely acceptable classification system [2] is described below:

  • Type I:  This type of open fracture is characterized by a skin break of less than 1 cm in length.
  • Type II: In these fractures, the skin break is more than 1cm in length but there are no extensive skin and soft tissue injuries, neither is there loss of bone coverage.
  • Type III: In this type of open fractures, there are large skin breaks with extensive soft tissue injury. However this class of fractures is further subdivided into three subtypes: type III A, B, and C. Type III A is characterized by extensive soft tissue injury but in the absence of soft tissue loss leaving the bone coverage relatively intact. Type III B is characterized by both significant soft tissue injury and loss. There is also stripping of the periosteum of the bone involved and extensive bone exposure. Type III C is characterized by severe vascular injury in addition to soft tissue destruction and loss.

This classification was later modified by Gustilo et al in 1984 [3]. The modification, however, affected type III only. According to this new classification, type III was described and divided thus:

Type III A: Characterized by severe comminuted fractures with substantial bone coverage and minimal skin break.

Type III B: Open fractures with significant soft tissue damage and loss in addition to stripping of the periosteum and extensive bone exposure.

Type III C: Open fractures which are associated with vascular injury requiring urgent surgical repair. Undoubtedly, this constitutes the most severe form of open fractures.

Open fractures present with pain, swelling, and hematoma within the skin covering the affected limb. In certain cases, the hemorrhage may result in compartment syndrome which may lead to neurovascular compromise. Generally, prognosis depends on the class or type of fracture and the promptness of treatment.

Diagnosis is by physical examination coupled with imaging studies to locate the site and number of fractures. Plain radiography is the initial choice; however, MRI and CT scans are indicated if further details are required and in the presence of occult fractures.

Management of an open fracture consists of immobilization of the bone: the distal and proximal joints, and reduction or realignment of the bone. Supportive care is equally critical and includes tetanus prophylaxis, prompt antibiotic therapy, administration of strong analgesics, and wound dressing.

The initial wound cleaning and dressing is the most critical step in preventing secondary bacterial infection of the wounds. The initial wound management precedes bone immobilization and reduction. Debridement of the wound is also critical for infection prevention and bone healing.

Patient Information

  • Overview

An open fracture is one in which the broken bone pierces the skin to the exterior. Closed fractures are those in which the broken bone remains within the body underneath the skin. A fracture is a break in the bone affecting the alignment of the involved bone.

  • Etiology

Most cases of open fractures are caused by high-intensity direct impact or injury such as fall from a height, road traffic accidents, injuries from high impact sports, and direct blows. Typically, the greater is the force of the trauma, the more severe is the fracture.

  • Presentation

Open fractures usually present with severe pain with a part of the bone sticking out through the skin. There may be swelling of the affected limb, significant bleeding, and inability to move the limb. The swelling results from bleeding into the tissues of the limb and this may further compress the blood vessels and nerves within the limb triggering a vicious circle, this compression is what's termed compartment syndrome. Nerve damage presents as numbness or tingling sensation on the skin over the affected limb. In cases where the blood vessels and nerves are severely compromised, the limb may be amputated.

  • Prognosis

The outcome of open fractures depends on the nature and severity of the injury and the timeliness of treatment. Generally, open fractures heal very slowly and carry a significant risk of bacterial infection.

  • Diagnosis

Imaging studies are critical for the establishment of a diagnosis of fracture. The plain X-ray is the initial modality used and it provides a clear picture of the bone and the sites of fractures, if any. In some cases, the X-ray may not show the fracture or may provide insufficient information; in such cases an MRI (magnetic resonance imaging) or a CT scan (computed tomography) may be required.

  • Treatment

Treatment of an open fracture is handled by a team comprising of the trauma surgeons, orthopedic surgeons, and emergency medical team. Prompt treatment of an open fracture is pertinent and is aimed at preventing damage to the blood vessels and nerves, initiating wound healing, and preventing infection.

Treatment would include immobilization of the bone with a nonrigid material such as a cast. The joint above and below the fracture are immobilized to promote fracture healing. However, there are a few instances where immobilization is not useful especially in certain wrist fractures seen in children. Reduction or realignment of the bone is also considered. This is achieved by external manipulation of the fractured bone by a doctor.

Management of an open fracture also includes adequate fluid resuscitation, analgesia, administration of antibiotics, and tetanus immunization

References

Article

  1. Chapman MW, Olson SA. Open fractures. In: Rockwood CA, Jr., Green DP, Bucholz RW, Heckman JD, editors. Fractures in adults. Philadelphia: Lippincott-Raven; 1996. pp. 305-352.
  2. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976; 58 (4):453-458.
  3. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984; 24 (8):742-746.
  4. Court-Brown CM, Brewster N. Epidemiology of open fractures. Court-Brown CM, McQueen MM, Quaba AA (eds), Management of open fractures. London: Martin Dunitz. 1996; 25–35.
  5. Patzakis MJ. Clostridial myonecrosis. Instr Course Lect. 1990; 39: 491-493.
  6. Heller L, Levin LS. Lower extremity microsurgical reconstruction. Plast Reconstr Surg. 2001;108:1029-1041; quiz 1042.
  7. Worlock P, Slack R, Harvey L, et al. The prevention of infection in open fractures: an experimental study of the effect of fracture stability. Injury. 1994; 25: 31-38.
  8. Levin LS. New developments in flap techniques. J Am Acad Orthop Surg. 2006; 14 (10 Suppl): S90-3.
  9. Patzakis MJ, Bains RS, Lee J, et al. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma. 2000; 14(8):529–533.
  10. Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am. 1974 ; 56(3):532-541.

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Last updated: 2019-07-11 22:14