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OpenFractures

OpenFractures
Author:ThomasMSchaller,MDChiefEditor:JasonHCalhoun,MD,FACSmore...
Updated:Feb4,2014

Overview
Theprocedureforevaluationandmanagementofopenfracturesisbestdescribedasasetofprinciplesthathas
evolvedovertime,oftenrelatedtoadvancesinwartimecareofmilitarypersonnel.Theseprinciplesinvolveboth
initialmanagementandsubsequentsurgicalintervention. [1,2,3]
Thefirststepisaccuratediagnosisanddocumentationofthemechanismofinjury.Appropriatecoverageofthe
woundandsplintingofthefractureareperformedinconjunctionwithinitiationofappropriateantibiotictherapyand
tetanusprophylaxis.Urgentsurgicalinterventiontypicallyfollowsandinvolvesbothsofttissueandbone
management.Adjunctstothecareofopenfractureshaveevolvedandofteninvolvedeliveryofantibioticsor
metabolicallyimportantsubstancestothelocalfractureenvironment.
Theseprinciplesaregenerallywellestablishedandacceptedacrosstheorthopediccommunity,butinsome
respects,controversystillexistsregardingthedetails.
Openfracturesposesomeuniquerisksbeyondthoseencounteredwithsimilarclosedfracturesthatmayoccurwith
similaramountsofforce.Thegreatestproblemistheriskofinfection.Diaphysealbonelossinexcessof3cm
presentsacomplexsetofproblemsaswell.Iftheopenfracturewascausedbypenetratingtrauma,directinjuryto
majorneurovascularstructuresmaybemorelikely,therebyaffectingtheprognosisforlimbfunction.Theriskofa
fracturebeingopenisrelatedtotheamountofsofttissuecoverageinthatregionofthebodyandtotheamountof
energyimpartedtothatregion.Forexample,thetibiahasalongmedialaspectthatissubcutaneous,andtherefore,
itiseasierfortraumatothelowerlegtoexposetheboneandfracturesite.Conversely,thefemurissurroundedby
thickmusclelayerscircumferentiallyand,therefore,islesslikelytobeexposedafterasimilaramountofforcetothe
thigh.
Formoreinformation,seethefollowingMedscapeReferencetopics:
OpenTibiaFractures
TibiaandFibularFractures
DiaphysealFemurFractures
SupracondylarFemurFractures

EtiologyandPathophysiology
Openfracturesoccurinmanyways,andthelocationandseverityoftheinjuryaredirectlyrelatedtothelocationand
magnitudeoftheforceappliedtothebody.Clearly,thisinvolvesabroadspectrumofclinicalscenarios.Inthemost
benignform,anopenfracturemayinvolveaverysmallwoundcausedbyasharpbonespike,creatingasmall,
minimallycontaminatedholeintheoverlyingskin.Theoppositeendofthespectrummayinvolvehighvelocity
gunshotwounds,vehiculartrauma,orindustrialaccidentswithassociatedtissuecrushinganddevitalization.Direct
inoculationofthetissueisabasicissueinthepathophysiologyofopenfracturemanagement.Furthermore,bacteria
cancolonizewoundsatlaterstagesofcare,beingintroducedintothewoundatsubsequentdressingchangesor
repeatdebridementspriortodefinitivewoundclosure.GustiloandAndersonreportedthat50.7%oftheir158
patientshadapositivewoundcultureuponinitialevaluation. [4]Another31patientsthatwereinitiallyculture
negativehadasubsequentpositivecultureatthetimeoftheirdefinitiveclosure.Becauseoftheidentificationand
sensitivityoftheinvadingorganisms,afirstgenerationcephalosporinandaminoglycosideshavebecomethemost
commonchoicesforinitiationofantibiotictherapyafteropenfracture.
Devitalizedtissueresultsfromtheenergyimpartedtothebody.Acrushinginjurycanimpairthelocalimmune
response,withlocalischemiaplayingalargeroleinthisprocess.Ischemiamayalsooccurbydirecttraumatothe
largevesselsand/ormicrocirculation.Importantindirectcausesofischemiaincludeincreasedmyofascial
compartmentpressures,increasedvascularpermeability,andtheuseofvasoconstrictivemedicationsduring
resuscitation.

IndicationsandContraindications
Virtuallyallopenfracturesneedtobeconsideredforoperativeintervention.Theintroductionofbacteriaandsoft
tissuecompromiseassociatedwithevenminoropenfracturesmandateappropriatepresurgicalandsurgical
managementtominimizetheriskofclinicallyimportantcomplications. [5,6]
Perhapstheonlyabsolutecontraindicationtooperativemanagementofanopenfractureisifthepatientisina
criticalconditionsuchthatanyoperativeinterventioncouldleadtofurtherdeteriorationhowever,thereisno
evidencefromrandomizedcontrolledtrialstosupportthisconcept.Eventhepatientinextremismaybenefitfrom
woundirrigationandsterileapplicationoftractionorexternalfixationinthetraumabayortraumacareunituntila
formalirrigationanddebridementcanbeundertakenintheoperatingroom.

LaboratoryStudies
Laboratorytestsaretypicallynotdirectlyimportantfortheacutecareofanopenfracture.However,manypatients
withopenfractureswillhaveotherinjuriesthatrequireappropriatelaboratoryinvestigation,andAdvancedTrauma
LifeSupport(ATLS)guidelinesshouldbefollowedforworkupofthetraumatizedpatient. [7]
Acutebacterialcultureofopenfracturewounds,beforeorshortlyafterinitialdebridement,isoflittleclinicalutility. [8]

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Organismsisolatedintheacutephaseoftreatmentdonotcorrelatewellwithclinicalinfectionsthatresultfrom
openfractures.Therefore,theroutineuseofculturesatthisstageofcareisoflittlebenefittothepatientandisnot
costeffective.

ImagingStudies
Radiography
Basicorthogonalradiographs(typically,anteroposteriorandlateralprojections)aretakenoftheinjuredextremity.
Theimagesshouldincludethejointproximalanddistaltotheareaofinjury.Obliqueimagescanbeusedtoobtain
furtherinformation,asneeded.
Evaluationofskeletallyimmaturepatientsisoftenfacilitatedbyuseofcomparisonviewsofthecontralateral
extremityorjointinvolved.
Seetheradiographicimagesofanopenmidfootfracturebelow.

Anopenmidfootfracturewithbonelossatthebaseofthefirstmetatarsal,includingapproximately66%ofthejointsurface.

Thefootwascaredforwithserialdebridementandtemporarypinningofthemidfoottopreservealignmentwithminimaladditional
surgicaltrauma.

Anantibioticimpregnatedcementspacerwasplacedinthebonevoid,and12weekslater,afterthepinshadalreadybeenremoved,
amidfootfusionwasperformed.

Intraoperativeimageofthemidfootfusion.Thecementspacerhasbeenreplacedbyautologousbonegraftfromtheiliaccrest.

CTscanningandMRI
Computedtomography(CT)andmagneticresonanceimagingprovidefurtherdetailofboneandsofttissueinjury,
buttheyareoftennotimmediatelyneededfortheacutemanagementofanopenfracture.Theytendtobemost
usefulinthemanagementofcomplexperiarticularinjuries.

Ultrasonographyandmagneticresonanceangiography
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Theuseofultrasoundtoassesstissueperfusion,myofascialcompartmentpressuremonitors,andperhapsmagnetic
resonanceangiography(MRA)orenhancedCTimagingofthesofttissueelementsoftheextremityareallcurrent
areasofintenseresearchandshouldprovideincreasedlevelsofpredictivedatawhenvalidated.

ClassificationofOpenFractures
Internationally,foradultsandpediatricpatients,themodifiedGustiloAndersonclassificationiswidelyused. [4]Their
initialdescriptionwaspublishedin1976,asfollows:
TypeI:anopenfracturewithawoundlessthan1cminlength,andclean
TypeII:anopenfracturewithalacerationmorethan1cminlength,withoutextensivesofttissuedamage,
flaps,oravulsions
TypeIII:eitheranopensegmentalfracture,anopenfracturewithextensivesofttissuedamage,ora
traumaticamputation
ThedescriptionoftypeIIIfractureswassubsequentlyfurtherrefinedanddescribedbyGustiloetalin1984, [9]as
follows:
TypeIIIa:severecomminutionorsegmentalfractures,butwithadequatecoverageofboneandawoundthat
iscloseablebysimplemeans
TypeIIIb:extensivesofttissuedamageinassociationwiththeopenfracture,withsignificantboneexposure
andperiostealstripping,typicallyrequiringtissuerotationorfreetissuetransferforclosure
TypeIIIc:anyopenfracturewithanarterialinjurythatrequiresrepair
Itisimportanttonotethattheseverityoftheinjurymaynotbefullyappreciatedatthetimeofinitialevaluation,and
therefore,classificationshouldbebasedontheintraoperativefindings.

ParenteralAntibioticAdministration
Patzakisandassociatesdescribedthevalueofacutesystemicantibioticuseforopenfractures. [10]Inalaterreview
article,PatzakisandZalavraspointedoutthattheadministrationofantibioticsisbestconsideredtherapeutic,not
prophylactic,duetothehighriskofinfectionintheabsenceofantibiotics. [11]
Althoughdebatestillsurroundssomeaspectsofantibioticadministrationforopenfractures,thefollowing
generalizationscanbemade:
Allpatientswithopenfracturesshouldreceivecefazolinorequivalentgrampositivecoveragethismaybe
sufficientfortypeIinjuries
TypeIIortypeIIIinjurieslikelybenefitfromtheadditionofadequategramnegativecoverage,typicallywith
anaminoglycoside
Injuriesatriskforanaerobicinfections(eg,farminjuries,severetissuenecrosis)probablybenefitfromthe
additionofpenicillinorclindamycin
Nostudieshaveaddressedtheemergenceofvariousantibioticresistantorganismsandalternativeregimensof
antibioticsforuseinopenfractures.

TetanusImmunizationandProphylaxis
Immunizationandprophylaxisagainsttetanusdeservespecificconsideration.Tetanusiscausedbyinfectionfrom
Clostridiumtetani,whichisananaerobicbacteriumcommonlyfoundinsoil,andthetoxinsproducedbythebacteria
leadtosevereandpotentiallylifethreateningmuscularspasm.Immunizationofciviliansbecamewidespreadafter
successfuluseofheatinactivatedtoxinduringWorldWarII. [12]
Onthebasisofareviewofvarioussources,Rheeandassociatesmadethefollowingrecommendationsregarding
tetanusvaccineincasesoftraumaticwounds[12]:
1. Performappropriateirrigationanddebridementasindicated
2. Obtainpatientsimmunizationhistory
3. Administertetanustoxoidifthelastboosterwasgivenmorethan10yearspriororifhistoryisnotreliableor
available
4. Givetetanusimmunoglobulintopatientswithincompleteprimaryimmunizationortopatientsforwhomithas
beenlongerthan10yearssincetheirlastboosterdose
Theauthorspointoutthattheseverityofthewoundshouldnotbeafactorindeterminingtheneedfortetanus
immunizationorprophylaxis.

SurgicalTherapy
Thesurgicalcareofopenfracturesinvolvesadheringtoaseriesofprinciplesthathaveevolvedovertimeandthat
arelargelybasedonthecareofwarwoundedmilitarypersonnelbymilitarysurgeons.Aleadingexampleisthework
byTrueta,inwhichhedescribedthesuccessfuluseofdebridementwithsplintingofinjuredextremities. [13]
Introductionofinvasiveskeletalstabilizationandcontinuedfocusonwoundmanagementledtoincreasingsuccess.
AmodernprotocolfromOperationEnduringFreedom,byLinetal,wasnotassociatedwithanyinfectionsin14
openfractures. [14]

Preoperativedetails
ItiscriticaltofollowAdvancedTraumaLifeSupport(ATLS)andinstitutionalprotocolstoproperlyevaluateatrauma
patient. [7]Thepreoperativeevaluationneedstoaccuratelydocumentneurologicandvascularstatus.Digitalphotos
arehelpfulfordocumentingtheinitialappearanceoftheextremityandcanbeavaluableadditiontothemedical
record.Digitalimagingallowsothermembersofthetreatmentteamtoseethewoundpreoperativelywithout
repeatedmanipulationsofthewound.
Openfracturewoundscanthenbedressedwithsterile,moistgauze,andclinicalrealignmentofthelimbcanbe

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accomplishedwithatemporarysplintortraction.Patientswhoareappropriateforoperativemanagementshouldbe
urgentlybroughttotheoperatingroom.

Irrigation
Washingthewoundwithlargevolumesoffluidwillremovemacrocontaminationandclottingthatmayobscurethe
viewofdeeperlevelsofcontaminationordamagedtissue.Oncethemacrocontaminationiseliminated,the
irrigationservestodiminishtheresidualbacterialcontaminationoftheremaininghealthytissue.Irrigationisoften
doneinconjunctionwithsurgicaldebridement.Theuseofantibioticsandotherbactericidaladditivestotheirrigant
continuestobeacontroversialtreatmenttopic,butthechemicalmakeupofmanyoftheadditivesissimilartothat
ofsoapandthuspotentiallycancausetissueswellingandthecreationofsurfacelayersoverthedamagedtissue.
[15]

Debridement
Thedebridementofanopenfracturemustbedoneinathoroughandsystematicmannersoastoavoidleaving
devitalizedtissueorcontaminationbehind. [16]Theskinedgesofthetraumaticwoundshouldbetrimmedtoa
healthybleedingedge.Loosesubcutaneousfatisalsoremoved,alongwithanyseverelycontusedornoncontractile
muscle.Toensureadequatedebridement,traumaticwoundsmustbeextendedandmusclecompartmentsopened
andexplored.
Theremovalofdevitalizedtissueisnotlimitedtothesofttissuesboneshouldalsoberemovedifitisfreeofsoft
tissueattachment.Majorarticularfragmentsmaybeanexceptiontothisrule,astheyshouldberetainedwhenever
possibletoallowforattemptsatfixationandrestorationofjointstabilityandmotion.Ingeneral,thegoalisto
removedamagedtissuethatwouldserveasabreedinggroundforbacteria,withoutcreatingextensiveadditional
surgicaltraumabyunnecessaryperiostealstrippingorunderminingoftheskinflaps.
Itisoftennecessaryinhighenergycasestoperformmultipledebridements,soastoadequatelyremovetissuethat
mayevolveafterthetimeoftheinitialoperativeinspection.Inprinciple,itisbesttoavoidinfectionbyremovalof
devitalizedboneandmuscleandtothendealwithlaterreconstructionusingbonegraftingandsofttissueflapsinan
asepticenvironment.

Stabilization
Fracturestabilizationiscriticalformanagementoftheinjuredextremityandfortheoverallbenefitofthepatient.
Thestabilityimpartedtothebonehelpsminimizeongoingtraumatothesofttissuesandprovidesastablescaffold
fortissuehealing.Furthermore,bonestabilityallowsforearlyfunctionalmotionoftheextremity.Nursingcareand
mobilizingthepatientoutofbedarefacilitatedaswell.Thechoiceoffracturefixationmethodisbasedonmany
factors,includingqualityoflocalsofttissues,locationandpatternofthefracture,overallhealthofthepatient,and
associatedinjuries.Adetaileddiscussionofallthepossiblefixationmethodsforthevarietyofopenfracturesis
beyondthescopeofthisarticle.Generallyspeaking,themethodoffixationmustminimizeadditionalsurgical
traumatothezoneofinjurywhileprovidingadequatestabilityforpatientmobilizationandsofttissuehealing.

Localadjuncts
Someopenfracturesmaybenefitfromtheadditionoflocalantibiotics.Antibioticsplacedinthezoneofinjurycan
achievehighlocalconcentrationofthedrug,typicallywithoutsystemicsideeffects. [17]Thetechniqueinvolves
antibioticimpregnatedbeadssealedintothewoundforgradualelutionofdrugtothesurroundingtissues.The
techniqueisbasedontheadditionofheatstableantibioticpowdertoabatchofpolymethylmethacrylate(PMMA)
cement,formingbeadsthatarethreadedonnonabsorbablesutureorwire.
Theuseofmultiplesmallbeadscreatesarelativelylargeoverallsurfaceareaforantibioticelution.Antibiotic
cementspacersmayalsobeusedtopreservesofttissuespaceinthepresenceofasignificantbonedefectduring
asubsequentprocedure,thecementspacercanberemovedandthevoidfilledwithbonegraft.Aninteresting
aspectofthistechniqueisthatithasbeenshownthatthepseudocapsulethatformsaroundthecementhassome
osteogenicpropertiesbeneficialforpromotingsuccessfulunionaftersubsequentprocedures. [18]Commercially
availablepreformedantibioticbeadsareavailableandaretypicallymadewithacalciumbased,absorbablebead.
Thesebeadsdonotneedtoberemovedatasubsequentprocedure,andstudiesinanimalmodelsofcontaminated
openfracturesusingthesesystemsappeartodemonstratepromisingoutcomes. [19]

Initialwoundmanagement
Althoughthepracticehascomeunderscrutiny,theprevailingmethodfordealingwithopenfracturewoundshas
beentoperformserialdebridementsandclosewoundsinastagedfashion,particularlywithtypeIIIinjuries.
Delayedwoundclosurebecamethestandardonthebasisoftheexperienceofmilitarysurgeonsandthesevere
consequencesfacedwhendealingwithprimarilyorprematurelyclosedwounds.
Acommonpracticeistoclosethesurgicallycreatedextensionsofthetraumaticwoundsatthetimeoffixationand
initialdebridement,followedbyasecondlookatthewound,withfurtherdebridementifnecessary,in4872hours.
Thiscanberepeatedasindicatedbythepresenceofanyfurtherevolutionoftissuenecrosis.
Vacuumassistedclosurehasbecomeapopulartechniquefordealingwithopenfracturewounds.Somestudies
havesuggestedthattheuseofnegativepressurewoundtherapymaydecreasetheneedforfreetissuetransferor
rotationalflapcoverageinhighenergyopenfractures.Inmanycases,abundantgranulationtissueformsand
residualsofttissuedefectscanbecoveredeffectivelywithbasicskingrafts. [20,21]
Seetheseriesofimagesofsurgicalmanagementofanopentibiafracturebelow.

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Anopentibiafracturewithboneloss.Atibialnailwasplacedandthewoundwasmanagedwithnegativepressurewoundtherapy,
eventuallycoveredwithsplitthicknessskingraft.

Eightweekslater,thedefectwasapproachedfromalateralincisiontoavoidthepreviousmedialopenfracturewound.Acentralbone
graftingtechniquewasperformed.

Thecentralaspectofthelegwasfilledwithbonegraft,andinternalfixationofthefibulawasperformed.

Theappearanceofthematuresynostosis8monthsafterthepatient'soriginalinjury.

Complications
Infectionisthemostobviouscomplicationfromopenfracture. [5,6]Theriskofinfectionisrelatedtotheseverityof
theinjury(seeClassificationofOpenFractures,above),asfollows:
TypeI:02%
TypeII:210%
TypeIII:1050%[11]
Failuretohealmayresultwithanyfracture.Forofavarietyofreasons,nonunionriskisgreaterwithopenfractures
thanwithsimilarclosedfractures.Manyofthefactorsarerelatedtothedamagedbloodsupplyatthezoneofinjury.
Theimpairedcirculationcanleadtopoorformationorlossofthefracturehematoma.Thesubsequentpoordelivery
ofinflammatorymediatorstofacilitatecallusformationandthepresenceofnecroticboneexacerbatestheriskof
nonunion.Boneand/orperiosteumlossfromthefracturesiteimpairsbonehealingaswell.Operativetechniqueof
debridementandfixationmustfocusonminimizingfurthertraumatotheboneandsurrounding
tissues[#OutcomeAndPrognosis].
Detailsregardingoutcomeandprognosisforopenfracturesarevariable,basedonthespecificsofthelocaland
associatedinjuries.

PostoperativeDetailsandFollowup
Thedurationofpostoperativeantibioticuseisnotclearlysupportedbytheliterature,butacommonclinicalpractice
istocontinueperioperativeantibioticsfor2448hoursaftereachoperativeinterventionuntilcompletewound
coverageorclosure.Someoftheliteraturestronglyquestionsthispractice,andconcernhasbeenraisedregarding
thedevelopmentofresistantsystemicnosocomialinfectionsinthepolytraumapatientbecauseofoveruseof
perioperativeantibiotics. [22]Amodernstudyinthesettingofcurrenttraumacare,fixationtechniques,andantibiotic
resistancepatternsisneededtoclarifythisissue.
Insituationsinvolvingsignificantboneloss,thepostoperativeplanmayincludetheuseofautologousbonegraft.In
highenergyopenfractures,thetimingofsubsequentgraftingproceduresshouldbebasedonthepresenceofa
fullyreepithelializedwoundwithnodrainageandnoclinicalevidenceofinfection. [23]

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Thefrequencyoffollowupisdrivenbyvariousfactors.Thewoundmayneedtobemonitoredcloselyintheearly
phasesofhealing.Theparticularfracturesandchosenmethodsoffixationwilldeterminetheneedforradiographic
andclinicalreexamination.
Seetheseriesofimagesbelowregardinganopenmidfootfractureanditsrepair.

Anopenmidfootfracturewithbonelossatthebaseofthefirstmetatarsal,includingapproximately66%ofthejointsurface.

Thefootwascaredforwithserialdebridementandtemporarypinningofthemidfoottopreservealignmentwithminimaladditional
surgicaltrauma.

Anantibioticimpregnatedcementspacerwasplacedinthebonevoid,and12weekslater,afterthepinshadalreadybeenremoved,
amidfootfusionwasperformed.

Intraoperativeimageofthemidfootfusion.Thecementspacerhasbeenreplacedbyautologousbonegraftfromtheiliaccrest.

OpenFractureCareinChildren
Theprinciplesforpreoperativeandintraoperativemanagementofopenfracturesinthepediatricpopulationare
similartothoseforadults,butthereareafewdifferencesthatarelargelyrelatedtotheoverallgreaterhealing
potentialinthispopulation.Inareviewarticle,Stewartandassociatessummarizeeachaspectofopenfracturecare
forchildren. [24]TheynotedthatinitialevaluationandclassificationoftheinjuryshouldfollowthemodifiedGustilo
Andersonsystem,asinadults.Theprimaryantibioticchoicesarethesameasintheadultpopulation,butthe
authorscautionedagainstalternativeregimensinvolvingfluoroquinolonesbecauseofissuesrelatedtobonehealing
andchondropathyinchildren.
Timingofoperativedebridementhasbeenstudiedretrospectively,andtheresultshavecalledintoquestionthe
dogmarelatedtoemergentmanagementofopenfracturesinthispopulation. [25]Inonestudy,nodifferencein
acuteinfectionratewasfoundtobeassociatedwithoperativecarewithin6hoursafterinjuryversusoperativecare
morethan7hoursafterinjury.
FurthercontroversystemsfromstudiesrelatedtononoperativemanagementoftypeIopenfractures,butthe
authorscautionstronglyagainstthispracticewithoutdefinitivestudy.Softtissuecaregenerallyfollowsthatusedin
adults,andtheuseofvacuumassistedclosurehasbeenshowntobesafeandeffectiveinthepediatricpopulation.
[26]Fixationchoicesshouldaccountforthegreaterhealingpotentialinchildrenand,therefore,oftendonotrequire

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thesamedegreeofstabilityasinadults. [24]

FutureandControversies
Timingofsurgicalinterventionhasbecomecontroversialasaresultofreevaluationoftheliteratureuponwhich
orthopedicdogmawasfoundedthatis,thatallopenfracturesmustbeoperativelydebridedandstabilizedwithin6
hoursaftertheinjury.

Debridement
In2006,Pollakauthoredareviewofpreviousandmorerecentliteratureandconcludedthat"[theconceptof]
mandatorydebridementwithin6hoursofinjuryisminimallysupportedbytheliterature.[27]Manycurrentstudies
thathaveutilizedmodernfixationstrategiesandimmediateuseofantibioticshavenotshownatimerelated
differenceininfectionrate.AsPollakpointsout,arandomizedtrialinthisareaisnotfeasible,butadditionalstudy
isneededtofurtherilluminatetherolethattimingofinitialsurgicalinterventionplaysonimportantoutcome
variables. [27]Schenkeretalpublishedasystematicreviewandalsoconcludedthatthe"6hrrule"isnotwell
supportedbytheexistingliterature.Thiswasbasedupontheauthors'closeevaluationof16studiesthatincluded
over3500openfractures. [28]
Inclinicalpractice,itislikelytobeinthepatientsinteresttouseamorepractical,lessdogmaticapproachthatis,
openfracturesshouldbetreatedsurgicallyinanurgent(butnotnecessarilyemergent)fashion,utilizingappropriate
timelyantibioticcoverage,skilleddebridement,andskeletalstabilization.

Woundclosure
Timingofwoundclosureisanotherareainwhichthetraditionaldogmahasbeenchallenged.Again,thestandard
treatmentisbasedonliteraturepublishedpriortothecurrentstandardsrelatedtoantibiotics,surgicalimplants,and
surgicaltechnique.Inshort,itseemsthat,inmanycases,primarywoundclosureatthetimeofoperative
debridementandfixationcanbedonesafelywithoutadditionalrisktothepatient.AsdescribedbyWeitzMarshall
andBosse,Surgicaljudgment,typicallygainedwithexperience,isrequiredtosuccessfullyuseanimmediate
woundclosureprotocol." [29]
WeitzMarshallandBossemadethefollowingadditionalsuggestions[29]:
Grosscontamination,stagnantwatercontamination,andfarminjuriesorfreshwaterboatinginjuriesshould
notnecessitateimmediatewoundclosure
Delayof12hourspostinjuryfordeliveryofantibiotics,confoundingcomorbidities,anddoubtaboutthe
adequacyoftheinitialdebridementareallcontraindicationsforacuteclosure
Pendingdefinitiveresearch,thebestclinicalpracticemaybetheadoptionofatreatmentplanthatallowsfor
theearliestpossiblesofttissuecoverageoveraclean,stable,viablezoneofinjury.
VerysimilarrecommendationsweremadeinareviewpaperpublishedbyCrowleyandassociates[30]andinclude
considerationofsupportingliteraturepublishedsincethereviewdescribedbyWeitzMarshallandBosse. [29]

Irrigation
Itisclearthatirrigationiscriticalinthesurgicalmanagementofopenfractures,butthemethodofirrigationandthe
choiceofirrigantsolutionaresubjectsofdebate.Aninternationalsurveyof984surgeonsdescribedsomeofthe
differencesinpractice:70.5%preferrednormalsaline,16.8%addedbacitracin,6%addediodinebasedsolution,
and1.3%addedadetergentorsoapsolution.Lowpressuremodesofirrigationwerepreferredby71%.The
differencesinpracticereflectthevariabilityinearlyandmorerecentstudies. [31]
ConclusionsbyCrowleyetalaresummarizedasfollows[30]:
Normalsalineshouldbeusedroutinely
Theuseofantibioticsandantisepticsshouldbelimitedbecauseofthelackofevidenceofefficacyand
becauseofpotentialrisks
Lowpressuremethodsshouldbeusedroutinely,aspressuresabove50psilikelydamagesofttissueand
bone

Bonemorphogenicprotein
Anotherareaofbothcurrentcontroversyandfutureresearchpertainstotheuseofbonemorphogenicprotein
(BMP).Althoughitmayhavemanyapplicationsrelatedtoorthopedicfracturecare,ithasbeenstudiedinonly1
openfractureapplication.Amulticenter,prospective,randomizedtrialstudiedtheuseofrecombinanthumanBMP
2(rhBMP2)inopentibiafractures.Inshort,thestudyfoundthatpatientswhoreceivedBMPatthetimeoftheir
woundclosurehadlowerinfectionratesandlessfrequentsecondaryinterventiontoobtainunion. [32]
Certainly,costisonecontroversialaspectoftheuseofBMP,butJonesetalshowedthatitsuseinopentibia
fracturescouldresultinasituationwherethecostoftheBMPisoffset,orevensurpassed,bycostsavingsresulting
fromdecreasedsecondaryproceduresandcomplications. [33]Furtherresearchisneededtodefinetheproperpatient
andfracturepopulationsinwhichBMPsaresafeandeffectiveadjunctstoopenfracturecare.

ContributorInformationandDisclosures
Author
ThomasMSchaller,MDOrthopedicTraumaSurgeon,SteadmanHawkinsClinicoftheCarolinas
ThomasMSchaller,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofOrthopaedicSurgeons,AOFoundation,andOrthopaedicTraumaAssociation
Disclosure:synthesHonorariaSpeakingandteachingPaciraPharmaceuticalsConsultingfeeConsulting
SpecialtyEditorBoard
StevenIRabin,MDClinicalAssociateProfessor,DepartmentofOrthopedicSurgeryandRehabilitation,Loyola

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University,ChicagoStritchSchoolofMedicineMedicalDirector,OrthopedicSurgery,Podiatry,Rheumatology,
SportsMedicine,andPainManagement,DreyerMedicalClinicChairman,DepartmentofSurgery,Provena
MercyMedicalCenter
StevenIRabin,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofOrthopaedic
Surgeons,AmericanFractureAssociation,AOFoundation,andOrthopaedicTraumaAssociation
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenter
CollegeofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment
SamuelAgnew,MD,FACSAssociateProfessor,DepartmentsofOrthopedicSurgeryandSurgery,Chiefof
OrthopedicTrauma,UniversityofFloridaatJacksonvilleCollegeofMedicineConsultingSurgeon,Departmentof
OrthopedicSurgery,McLeodRegionalMedicalCenter
SamuelAgnew,MD,FACSisamemberofthefollowingmedicalsocieties:AmericanAssociationforthe
SurgeryofTrauma,AmericanCollegeofSurgeons,OrthopaedicTraumaAssociation,andSouthernOrthopaedic
Association
Disclosure:Nothingtodisclose.
ChiefEditor
JasonHCalhoun,MD,FACSDepartmentChief,MusculoskeletalSciences,SpectrumHealthMedicalGroup
JasonHCalhoun,MD,FACS,isamemberofthefollowingmedicalsocieties:AmericanAcademyof
OrthopaedicSurgeons,AmericanCollegeofSurgeons,AmericanDiabetesAssociation,AmericanMedical
Association,AmericanOrthopaedicAssociation,AmericanOrthopaedicFootandAnkleSociety,MissouriState
MedicalAssociation,MusculoskeletalInfectionSociety,SouthernMedicalAssociation,SouthernOrthopaedic
Association,TexasMedicalAssociation,andTexasOrthopaedicAssociation
Disclosure:BiocompositeGrant/researchfundsOther

References
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