Open Fractures: Evaluation and Management

Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD

Abstract
Open fractures are complex injuries that involve both the bone and surrounding Veliskakis2 proposed a classifica-
soft tissues. Management goals are prevention of infection, union of the fracture, tion system for open fractures that
and restoration of function. Achievement of these goals requires a careful approach included three types based on in-
based on detailed assessment of the patient and injury. The classification of open creasing severity. This concept was
fractures is based on type of fracture, associated soft-tissue injury, and bacterial con- refined by Gustilo and Anderson,3
tamination present. Tetanus prophylaxis and intravenous antibiotics should be ad- and their classification system, sub-
ministered immediately. Local antibiotic administration is a useful adjunct. The sequently modified by Gustilo et al,4
open fracture wound should be thoroughly irrigated and débrided, although the op- has found widespread application.
timal method of irrigation remains uncertain. Controversy also exists regarding the Type I includes puncture wounds ≤1
optimal timing and technique of wound closure. Extensive soft-tissue damage may cm, with minimal contamination
necessitate the use of local or free muscle flaps. Techniques of fracture stabilization and muscle damage. Type II in-
depend on the anatomic location of the fracture and characteristics of the injury. cludes lacerations >1 cm, with mod-
J Am Acad Orthop Surg 2003;11:212-219 erate soft-tissue injury. Bone cover-
age is adequate and comminution is
minimal. Type III includes three sub-
types. Type IIIA involves extensive
Open fractures often result from Assessment and soft-tissue damage with adequate
high-energy trauma and are charac- Classification of Open bone coverage. Usually it is the re-
terized by variable degrees of soft- Fractures sult of a high-velocity injury with a
tissue and skeletal injury, both of severe crushing component. Type
which impair local tissue vasculari- Patients who present with associated IIIA also includes heavily contami-
ty. Open fractures communicate life-threatening injuries should be nated wounds with severe commu-
with the outside environment, and initially evaluated and resuscitated nition and segmental fractures. Type
the resulting contamination of the according to Advanced Trauma Life IIIB involves extensive soft-tissue
wound with microorganisms, cou- Support protocols. Injured extremities damage, with stripping of the peri-
pled with the compromised vascular then should be assessed for neurovas- osteum and exposure of the bone.
supply to the region, leads to an in- cular injury and compartment syn-
creased risk of infection as well as to drome. The presence of an open frac-
complications in healing. In addi- ture wound does not exclude the
Dr. Zalavras is Assistant Professor, Department
tion, bone, tendons, nerves, and ar- extremity from the complication of of Orthopaedic Surgery, University of Southern
ticular cartilage may be exposed and compartment syndrome.1 In addition, California Keck School of Medicine, Los Angeles,
subject to damage. complete assessment of the open frac- CA. Dr. Patzakis is Professor and Chairman, The
The principles that govern open ture includes reviewing the mecha- Vincent and Julia Meyer Chair, Chief of Ortho-
paedic Surgery Service, University of Southern
fracture management include as- nism of injury, condition of the soft
California University Hospital and Los Angeles
sessment of the patient and classifi- tissues, degree of bacterial contami- County+University of Southern California Med-
cation of the injury, prevention of in- nation, and characteristics of the frac- ical Center, Department of Orthopaedic Surgery,
fection, wound management, and ture. The evaluation of these factors University of Southern California Keck School of
fracture stabilization, including ear- will help to classify the fracture, de- Medicine.
ly bone grafting. Management of termine the treatment regimen, and
Reprint requests: Dr. Patzakis, GNH 3900, 2025
open fractures can be challenging, establish the prognosis and potential Zonal Avenue, Los Angeles, CA 90089-9312.
and multiple surgical procedures clinical outcome. In particular, the de-
frequently are needed to achieve gree of bacterial contamination and Copyright 2003 by the American Academy of
soft-tissue coverage and fracture soft-tissue damage is important in Orthopaedic Surgeons.
union. classifying an open fracture.

212 Journal of the American Academy of Orthopaedic Surgeons


Usually it is associated with heavy
contamination and severe comminu-
tion of the bone. Coverage using free
muscle flaps is necessary. Type IIIC
involves any open fracture with ar-
terial injury requiring repair, regard-
less of the degree of soft-tissue inju-
ry. Gustilo et al5 later classified open
fractures more than 8 hours old at
presentation as a special category of
type III fracture. Despite its wide
acceptance, however, the reliability
of this classification has been ques-
tioned. Brumback and Jones6 report-
ed that the average agreement
among orthopaedic surgeons on the
classification of open tibial fractures
was 60% overall, which was deemed
to be moderate to poor.
Classification systems have the
inherent limitation of attempting to
classify a continuous variable, such
as severity of injury, into distinct cat-
egories. Nevertheless, the classifica-
tion of open fractures is important
because it directs the attention of the
treating surgeon to the presence and
extent of injury variables. Misclassi-
fication of an open fracture can oc-
cur, especially in a patient with a
relatively small skin wound. To im-
prove the accuracy of the classifica-
tion of open fractures, the extent and
severity of the injury should be as-
sessed only during surgery, after
wound exploration and débride-
ment, and not at presentation in the
emergency department.
Prevention of Infection
All open fracture wounds should be
considered contaminated because of
the communication of the fracture
site with the outside environment. A
contamination rate of approximately
65% has been reported.3,7,8 Infection
is promoted by the bacterial contam-
ination and colonization of the
wound, the presence of dead space
with devitalized tissues, foreign ma-
terial, and the compromised host re-
sponse resulting from poor vascular-
Vol 11, No 3, May/June 2003
Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
ity and soft-tissue damage. The risk
of infection is related to severity of
injury. Infection rates range from 0%
to 2% for type I, 2% to 10% for type
II, and 10% to 50% for type III.3,8 Pre-
vention of infection is based on im-
mediate antibiotic administration
and wound débridement. Tetanus
prophylaxis should be administered
based on the patient’s immunization
status.
Wound Cultures
In the early postfracture period,
results of wound cultures may indi-
cate the most probable infecting or-
ganism and determine the patho-
gen’s sensitivity to antibiotics.
However, the usefulness of initial
cultures (obtained either at patient
presentation or intraoperatively be-
fore and after débridement of open
fracture wounds) has been contro-
versial because they often fail to
identify the causative organism.9,10
In one prospective randomized
double-blind trial, only 3 (18%) of 17
infections that developed in a series
of 171 open fracture wounds were
caused by an organism identified by
the initial cultures.11
The predictive value of wound cul-
tures obtained before wound débri-
dement is especially low. This may be
attributed to early wide-spectrum an-
tibiotic coverage, multiple wound dé-
bridements, and late contamination
with nosocomial pathogens.10 Thus,
multiple initial cultures are not rec-
ommended. Only postdébridement
cultures should be obtained, which
can be useful in the management of
early infections or in wounds with
marine or other unusual environmen-
tal contamination.
Antibiotics
The crucial role of antibiotic ad-
ministration in the management of
open fractures was established in a
prospective randomized study by
Patzakis et al,7 who demonstrated a
marked reduction in the infection
rate when cephalothin was adminis-
tered (2.4% [2/84 fractures]) com-
pared with no antibiotics (13.9%
[11/79]) or with penicillin and strep-
tomycin (9.8% [9/92]). The antibiot-
ics were administered before wound
débridement. However, further
questions regarding administration
involve selection of antibiotics, in-
cluding choice of single or combina-
tion therapy; duration of therapy;
and usefulness of local administra-
tion. It is important that, in the set-
ting of an open fracture, antibiotics
not be considered prophylactic. This
term can be confusing because anti-
biotics routinely administered in or-
thopaedic elective procedures are
prophylactic. But because infection
commonly occurs in open fractures
not treated with antibiotics, their ad-
ministration is better viewed as ther-
apeutic.
Selection
The antibiotics used in the man-
agement of open fractures should be
selected based on the wound micro-
biology. Wound contamination with
both gram-positive and gram-
negative microorganisms occurs;
therefore, the antimicrobial regimen
should be effective against both
types of pathogens. Currently, sys-
temic combination therapy using a
first-generation cephalosporin (eg,
cefazolin), which is active against
gram-positive organisms, and an
aminoglycoside (eg, gentamicin or
tobramycin), which is active against
gram-negative organisms, appears
to be optimal, although other
combinations also may be effective.
Substitutes for aminoglycosides in-
clude quinolones, aztreonam, third-
generation cephalosporins, or other
antibiotics with coverage for gram-
negative organisms. Ampicillin or
penicillin should be added to the an-
tibiotic regimen when conditions fa-
voring development of anaerobic
infections, such as clostridial myo-
necrosis (gas gangrene), are present,
as in farm injuries and vascular in-
juries (ischemia, low-oxygen ten-
213
Open Fractures: Evaluation and Management
sion, and necrotic tissues). The re-
sults of cultures obtained after
débridement and of antibiotic-
sensitivity testing may help in select-
ing the best agents for a subsequent
surgical procedure or in case of an
early infection.
The lowest reported infection rate
with various systemic antibiotic
regimens occurred with combina-
tion therapy with a cephalosporin
and an aminoglycoside. Patzakis
and Wilkins8 reported that the com-
bination therapy was associated
with a 4.6% infection rate (5/109
open tibial fractures), whereas ad-
ministration of only cephalosporin
was associated with a 13% infection
rate (25/192). Type I and II open
fractures were not analyzed sepa-
rately, but the distribution of frac-
ture types was comparable between
the two groups. Templeman et al12
proposed administration of a ceph-
alosporin as a single agent in type I
and II open fractures. However,
cephalosporin does not provide cov-
erage against contaminating gram-
negative organisms. Moreover, a po-
tential misclassification of an open
fracture because of its small wound
size could result in a type IIIA frac-
ture being treated with a single
agent.
Quinolones are a promising alter-
native to intravenous antibiotics
because they offer broad-spectrum
antimicrobial coverage, are bacteri-
cidal, can be administered orally
with less frequent dosing than intra-
venous antibiotics, and are well tol-
erated clinically. Ciprofloxacin as
single-agent therapy is effective in
the management of type I and II
open fractures. In a randomized pro-
spective study, ciprofloxacin was
compared with combination therapy
(cefamandole and gentamicin). In-
fection rates were similar (6%) in the
type I and II fractures; however, in
type III open fractures, the ciproflox-
acin group had an infection rate
of 31% (8/26) compared with 7.7%
(2/26) in the combination therapy
214
group.11 Therefore, in type III open
fractures, ciprofloxacin should be
used only in combination with a
cephalosporin as a substitute for an
aminoglycoside. Oral ciprofloxacin
can be used for open fracture
wounds secondary to low-velocity
gunshot injuries because it is as ef-
fective as intravenous administra-
tion of cephapirin and gentamicin.13
However, further studies are war-
ranted to elucidate the clinical ben-
efits of quinolones because their use
has been associated with the inhibi-
tion of experimental fracture healing
and of osteoblasts.14,15
Duration of Therapy
Antibiotics should be started as
soon as possible after the injury oc-
curs because a delay >3 hours in-
creases the risk of infection.8 The du-
ration of antibiotic administration is
controversial. Dellinger et al16 dem-
onstrated that a prolonged course of
5-day antibiotic administration was
not superior to a 1-day course for
prevention of fracture site infections.
The duration of therapy should be
limited to 3 days, with repeated
3-day administration of antibiotics
at wound closure, bone grafting, or
any major surgical procedure.8,12
Local Administration
In a series of 1,085 open fractures,
Ostermann et al17 demonstrated that
the additional use of local amino-
glycoside-impregnated polymethyl-
methacrylate (PMMA) beads signif-
icantly (P < 0.001) reduced the
overall infection rate to 3.7%, com-
pared with 12% when only intrave-
nous antibiotics were used. When
the types of open fractures were an-
alyzed separately, the reduction of
infection was statistically significant
(P < 0.001) in only the type III frac-
tures (6.5% versus 20%, respectively,
for PMMA beads and intravenous
antibiotics).
Antibiotic-impregnated PMMA
beads are inserted into the open
fracture wound, which is subse-
Journal of the American Academy of Orthopaedic Surgeons
quently sealed with a film dressing
or similar semipermeable barrier.
Commercially available antibiotic-
impregnated PMMA beads have not
been approved by the Food and
Drug Administration for use in the
United States, so they must be made
by the physician. Forty grams of
PMMA beads are mixed with the an-
tibiotic in powder form and are po-
lymerized; the beads then are strung
onto or incorporated with a bead
mold onto a 24-gauge wire. The an-
tibiotic selected should be heat sta-
ble, water soluble, and available in
powder form and have wide-
spectrum antimicrobial activity (for
example, 3.6 g of tobramycin mixed
with 40 g of PMMA). Vancomycin is
not recommended as an initial agent
because of concerns regarding resis-
tant enterococci.
The bead pouch technique is most
often used for select type II or type
III open fractures. If the anteromedi-
al aspect of the tibia is exposed, re-
quiring delayed closure or muscle
transfer, the beads are placed inside
the bone defect, if present, and on
top of the exposed bone. If the soft-
tissue coverage is delayed, the bead
pouch does not need to be changed
because the antibiotics have been
shown to elute at levels above the
minimum inhibitory concentration
for at least 1 month.18 However, if
the patient undergoes repeat dé-
bridement, the bead pouch can be
changed.
The advantages of the bead
pouch technique include (1) a high
local concentration of antibiotics, of-
ten 10 to 20 times higher than that
with systemic administration; (2) a
low systemic concentration, which
protects from the adverse effects of
aminoglycosides (although when a
tobramycin bead pouch is used, sys-
temic aminoglycoside administra-
tion is not needed); (3) a decreased
need for the use of systemic ami-
noglycosides; and (4) sealing of the
wound from the external environ-
ment with film dressing. This tech-

nique prevents secondary bacterial
contamination by nosocomial patho-
gens, which have been shown to be
responsible for many of the infec-
tions in type III open fracture
wounds. 8,9 In addition, this tech-
nique allows for the period for soft-
tissue transfers to be safely extend-
ed. Also, film dressing establishes an
aerobic wound environment, which
is important for avoiding cata-
strophic anaerobic infections; main-
tains the local antibiotic within the
wound; and promotes patient com-
fort by avoiding painful changes of
wound dressing.
Wound Management
Irrigation and Débridement
Irrigation is an essential part of
wound management; however, the
optimal volume, delivery method,
and irrigation solution have not
been determined.19 Although high-
pressure irrigation improves the re-
moval of bacteria and debris, it also
may damage the bone.20 Pulsatile
flow per se does not add to the effec-
tiveness of irrigation. Antiseptic so-
lutions may be toxic to host cells and
should be avoided. Antibiotic solu-
tions have been shown in animal
and in vitro studies to be more effec-
tive than saline alone, but clinical
data on open fracture wounds are
lacking. Detergent solutions help re-
move bacteria and appear to be a
promising alternative.21 One proto-
col is a 10-L saline solution delivered
to the wound by gravity tubing, with
50,000 U of bacitracin and 1,000,000
U of polymyxin added to the last li-
ter of irrigation fluid.
After irrigation of the wound,
surgical débridement is the most im-
portant principle in open fracture
management because nonviable tis-
sues and foreign material enhance
bacterial growth and hinder the
host’s defense mechanisms. The goal
is a clean wound with viable tissues
and no infection. A sterile tourniquet
Vol 11, No 3, May/June 2003
Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
is applied to the extremity, to be used
only when necessary. Débridement
without inflating the tourniquet fa-
cilitates identification of viable tis-
sues and prevents additional is-
chemic damage to the already
traumatized tissues. The injury
wound may be insufficient for thor-
ough débridement, as in type I and
II open fractures, so the wound usu-
ally is extended. Skin and subcuta-
neous tissues are sharply débrided
back to bleeding edges. Viable mus-
cle can be identified by its bleeding,
color, consistency, and contractility.
Cortical bone fragments without any
soft-tissue attachments are avascular
and should be débrided, even if this
will result in a large bone defect. Ar-
ticular fragments, however, should
be preserved even when they have
no attached blood supply, provided
they are large enough and recon-
struction of the involved joint is pos-
sible. If necessary, a repeat débride-
ment can be done after 24 to 48 hours
based on the degree of contamina-
tion and soft-tissue damage. In inju-
ries requiring muscle flap coverage,
débridement also should be repeat-
ed at the time of soft-tissue recon-
struction.
Wound Closure
Wound closure is possible when
the available soft tissues are ade-
quate; otherwise, soft-tissue recon-
struction will be necessary later. The
optimal time for wound closure
remains controversial. Primary
wound closure after a thorough
débridement is not associated with
an increased rate of infection, may
prevent secondary contamination,
and may reduce surgical morbidity,
hospital stay, and cost.22 Neverthe-
less, it carries the potential for
clostridial myonecrosis, which can
lead not only to loss of the limb but
also to loss of life.23 Primary wound
closure, inadequate débridement,
and inadequate antibiotic therapy
increase the risk of these complica-
tions.7
We recommend leaving all open
fracture wounds open initially. De-
layed wound closure (within 3 to 7
days) prevents anaerobic conditions
in the wound, facilitates drainage,
allows for repeat débridements at
24- to 48-hour intervals, offers the
opportunity to reexamine tissues of
questionable viability, and permits
use of the antibiotic bead pouch
technique. Sealing the wound with
film dressing prevents secondary
contamination and makes delayed
wound closure even more prefera-
ble. Dressings are not changed in the
surgical ward; instead, the wound
remains sealed with film dressing.
Split-thickness skin grafts are ap-
plied on well-vascularized granula-
tion tissue. Small wounds, especially
in type I open fractures, may be al-
lowed to heal secondarily.
In type I and II open fractures, the
extended wound made to facilitate
débridement can be safely closed
primarily, leaving the original injury
wound open. 24 Part of the injury
wound also can be sutured if it is di-
rectly over bone, tendons, nerves, or
vessels, but the rest of the wound
should be left open.
Soft-Tissue Reconstruction
Severe damage to the soft tissues,
as in type IIIB open fractures, pre-
cludes adequate bone coverage, and
soft-tissue reconstruction is neces-
sary. A well-vascularized soft-tissue
envelope is critically important
because it enhances vascularity at
the fracture site, promotes fracture
healing, allows for delivery of anti-
biotics, and enhances action of the
host defense mechanisms. Soft-
tissue coverage prevents secondary
wound contamination, desiccation,
and damage to bone, articular carti-
lage, tendons, and nerves.
The location and magnitude of
the soft-tissue defect determine the
choice of method of coverage. Re-
construction usually is achieved
with local or free muscle transfers.25
Fasciocutaneous flaps are useful
215
Open Fractures: Evaluation and Management
when dead space is minimal, when
the flaps are pliable, and when they
facilitate tendon gliding. They may
restore sensibility to the affected area
if the flap remains innervated.
Local pedicle muscle flaps in-
clude the gastrocnemius for frac-
tures in the proximal third of the tib-
ia and the soleus for fractures in the
middle third. However, for fractures
in the distal third of the tibia, free
muscle flaps are necessary; com-
monly used flaps include the rectus
abdominis, gracilis, and latissimus
dorsi muscles. In considering local
muscle flaps, the condition of the
muscle to be transferred must be
carefully evaluated. Muscle that is
traumatized, crushed, or affected by
a compartment syndrome should
not be transferred; free muscle trans-
fer should be used instead. Pollak et
al26 reported that in the presence of
severe osseous injury, use of rota-
tional flaps was notably more likely
to lead to wound complications
compared with free flaps.
Soft-tissue reconstruction should
be done early, within the first 7 days.
Delays beyond this period have
been associated with increased com-
plications related to the flap or infec-
tion under the flap.9 Some have ad-
vocated that flap coverage be done
within 72 hours.27,28 Godina27 report-
ed a failure rate of free muscle flaps
in <1% (1/134) when done within 72
hours compared with a failure rate
of 12% (20/167) when done from 72
hours to 90 days. In the same series,
the infection rate was 1.5% (2/134)
in the early surgical group compared
with 17.4% (29/167) in the late sur-
gical group. Gopal et al28 showed
that results of an early aggressive
protocol in type IIIB and IIIC open
fractures also were satisfactory. In
their series, deep infection devel-
oped in 6% of fractures (4/63) that
were covered with a flap within 72
hours compared with 29% of frac-
tures (6/21) covered after 72 hours.
However, in these studies, the
antibiotic-impregnated bead pouch
216
was not used; therefore, secondary
contamination may have played a
notable role in contributing to the in-
creased infection rate in patients
with delayed flap coverage.9,27,28
Fracture Stabilization
Adequate stabilization protects the
soft tissues from further injury by
fracture fragments and facilitates the
host response to bacteria despite the
presence of implants. In addition,
stable fixation improves wound care
and mobilization of the patient and
allows for early motion of adjacent
joints, which contributes to function-
al rehabilitation.
The choice of fracture fixation de-
pends on the fractured bone, the lo-
cation of the fracture (eg, intra-
articular, metaphyseal, diaphyseal),
and the extent of soft-tissue injury.
Available techniques for fracture sta-
bilization include intramedullary
nailing, external fixation, and plate-
and-screw fixation. More than one
technique may be applicable in a
specific injury.
Intramedullary Nailing
Intramedullary nailing is an effec-
tive method of stabilization of di-
aphyseal fractures of the lower
extremity.29-32 It is a biomechanically
advantageous method that does not
interfere with soft-tissue manage-
ment. Static interlocking fixation
maintains the length and alignment
of the fractured bone and thus has
expanded the applicability of nailing
to unstable, comminuted fracture
patterns. However, it disrupts the
endosteal bone circulation to a vari-
able degree, especially when the
medullary canal is reamed. Open
femoral fractures are best treated
with reamed intramedullary nailing:
Brumback et al29 observed no infec-
tions in 62 type I, II, and IIIA open
fractures, although infection devel-
oped in 3 (11%) of 27 type IIIB open
femoral fractures. Open tibial frac-
Journal of the American Academy of Orthopaedic Surgeons
tures have been satisfactorily stabi-
lized with unreamed intramedullary
nailing,30-33 but controversies remain
regarding the role of external fixa-
tion and reamed intramedullary
nailing in the stabilization of these
fractures.
Intramedullary Nailing Versus
External Fixation
Both unreamed intramedullary
nailing and external fixation have
been used widely in the manage-
ment of open tibial fractures, but few
prospective randomized studies
have compared the two techniques.
Tornetta et al30 evaluated the two
methods in 29 type IIIB open tibial
fractures. All fractures healed and no
difference in the infection rate was
found. In a prospective series of 174
open tibial fractures, Henley et al31
reported no difference between un-
reamed nailing and external fixation
regarding infection and bone heal-
ing. They observed that the severity
of the soft-tissue injury rather than
the choice of implant appeared to be
the main factor influencing injury
site infection and bone healing.
However, half-pin external fixators
were associated with malalignment
in 31% of cases and with a pin tract
infection in 50%. A meta-analysis of
the management of open tibial frac-
tures demonstrated that unreamed
intramedullary nails reduced the
risk of revision surgery, malunion,
and superficial infection compared
with external fixators.32
Although no advantages in frac-
ture healing and injury site infection
have been established, intramedul-
lary nailing is considered preferable
to external fixation. It does not re-
quire the same high level of patient
compliance, and it is aesthetically
more acceptable than external fixa-
tion. Unreamed intramedullary nail-
ing can be used for types I to IIIA
and for select type IIIB open frac-
tures of the tibial diaphysis. An ex-
ternal fixator may be particularly
useful in cases with heavy bacterial

contamination, extensive soft-tissue
damage, or vascular injury (ie, types
IIIB and IIIC).
Unreamed Versus Reamed
Intramedullary Nailing
Unreamed intramedullary nail-
ing has been widely used in open
tibial fractures.30,31,33 Schemitsch et
al34 showed in a sheep tibia model
that endosteal blood flow at comple-
tion of the procedure was reduced to
18% of the level prior to nailing
when reaming was done whereas it
was reduced to only 44% with un-
reamed nailing. Unreamed nailing
preserves endosteal blood supply to
a greater degree than does reamed
nailing.34,35 Thus, it may be prefera-
ble in open tibial fractures, in which
periosteal vascularity may be al-
ready compromised by the traumat-
ic insult. Reamed nailing, on the
other hand, allows insertion of
larger-diameter implants, improves
stability at the fracture site, and
helps reduce implant failure. More-
over, the cortical circulation that was
disrupted during reaming is gradu-
ally reconstituted, although more
slowly than unreamed nailing.35
Two prospective randomized
studies compared reamed with un-
reamed nailing in open tibial frac-
tures; neither established a signifi-
cant difference in infection rates.36,37
Keating et al36 reported an infection
rate of 2.5% (1/40) in fractures treat-
ed with the unreamed nailing tech-
nique versus 4.4% (2/45) in fractures
treated with the reamed nailing tech-
nique. Finkemeier et al37 observed
infection rates of 3.8% (1/26) in un-
reamed nailing and 5.3% (1/19) in
reamed nailing. In both studies, a re-
duced incidence of screw failure was
seen in the group undergoing the
reamed nailing technique.
Choice of technique remains con-
troversial. Interestingly, surgeons
who prefer unreamed nailing try to
insert a nail of sufficient diameter
to accommodate larger locking
bolts, whereas surgeons who pre-
Vol 11, No 3, May/June 2003
Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
fer reamed nailing tend to insert
smaller nails, resulting in little dif-
ference between the techniques.
However, clinical experience with
reamed nailing is limited, whereas
many investigators have document-
ed satisfactory experience with un-
reamed nailing, including its use
with type IIIB open fractures.30,31,33
The unreamed nailing technique can
be used even in type I open tibial
fractures to reduce damage to bone
vascularity.
External Fixation
External fixation can be helpful in
wounds with severe soft-tissue dam-
age and contamination because it
avoids hardware implantation and
does not compromise fracture vas-
cularity. External fixation is techni-
cally expedient and is associated
with minimal blood loss. It is ap-
plied at a site distant to the injury
and thus does not interfere with
wound management. External fixa-
tion is suitable for diaphyseal tibial
fractures because of the subcutane-
ous location of the bone, and it be-
comes a more attractive option than
intramedullary nailing moving to
the proximal or to the distal tibia, if
the size of the proximal or distal
fragment does not allow for stabili-
zation with a nail. Ring or transartic-
ular fixators are useful for periartic-
ular fractures. Spanning external
fixation is becoming popular and
may be safely converted to another
method when applied away from
the zone of injury.
Many authors38-40 have reported
on the effectiveness of external fixa-
tion as definitive treatment as well as
the value of early bone grafting in se-
vere injuries.38-40 Marsh et al,40 in a
prospective study of 101 type II and
III fractures, reported that 96 frac-
tures (95%) healed, 95% of them
with <10° of angulation in any plane,
and that 6 fracture sites (6%) were in-
fected. To avoid healing complica-
tions, early bone grafting should be
considered for comminuted frac-
tures without cortical contact and for
fractures with bone defects treated
with external fixation.
External fixation may be accom-
panied by pin tract infections and
fracture malalignment. These com-
plications can be avoided by the se-
lection of compliant patients; imple-
mentation of an external fixation
protocol, which includes the use of
half-pins inserted after predrilling to
avoid thermal necrosis of bone; and
meticulous care of the pin tract. A
considerable proportion of the com-
plications associated with external
fixation can be attributed to the tran-
sition to another form of fixation. In-
fection has been reported at a rate
approaching 50% after conversion of
the external fixation to delayed in-
tramedullary nailing.9,41 However,
in these series, infection was associ-
ated with a prior pin tract infection
in the majority of patients. Blachut et
al42 showed that by early (mean, 17
days) conversion of the fixator to a
nail in the absence of pin tract infec-
tions, infection developed in only
5% of patients. Loss of alignment fre-
quently occurs when the fixator is
prematurely removed and the pa-
tient is transferred to a brace.38
In heavily contaminated open
fractures, temporary external fixa-
tion can be a useful option. Howev-
er, to minimize the chance of bacte-
rial colonization of the pin tracts,
conversion to intramedullary nail-
ing should be done in the absence of
pin tract infections and when the fix-
ator has been present for only a short
time.42 Otherwise, the fixator should
be maintained until fracture healing.
Plate Fixation
Plate fixation is useful in intra-
articular and metaphyseal fractures
because it stabilizes an accurate res-
toration of joint congruency and ori-
entation. In diaphyseal fractures of
the upper extremity, plate fixation is
often the method of choice. Plate fix-
ation in open tibial fractures has
been associated with an increased
217
Open Fractures: Evaluation and Management
incidence of infection and hardware
failure.43,44 Bach and Hansen43 re-
ported wound infection in 35% (9/
26) and fixation failure in 12% (3/26)
of type II and III open tibial frac-
tures. Clifford et al44 observed im-
plant failure in 7 of 97 open tibial
fractures and infection in 4 of 9 type
III fractures. New plating techniques
using fixed-angle plate screw devic-
es are characterized by minimally in-
vasive insertion and preservation of
bone vascularity, and they may
prove to be a useful alternative for
metaphyseal fractures, especially
when intra-articular extension is
present. However, to date, no pub-
lished data are available to support
their use.
Early Secondary Procedures to
Stimulate Healing
In the presence of bone defects or
delayed healing, early bone grafting
can expedite healing. With bone de-
fects, the preferred timing for bone
grafting ranges from 2 to 6 weeks af-
ter soft-tissue coverage.38,45 Waiting
for 6 weeks after a soft-tissue trans-
fer ensures the absence of infection
References
1. Blick SS, Brumback RJ, Poka A, Burgess
AR, Ebraheim NA: Compartment syn-
drome in open tibial fractures. J Bone
Joint Surg Am 1986;68:1348-1353.
2. Veliskakis KP: Primary internal fixation
in open fractures of the tibial shaft: The
problem of wound healing. J Bone Joint
Surg Br 1959;41:342-354.
3. Gustilo RB, Anderson JT: Prevention of
infection in the treatment of one thou-
sand and twenty-five open fractures of
long bones: Retrospective and prospec-
tive analyses. J Bone Joint Surg Am 1976;
58:453-458.
4. 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;24:742-746.
5. Gustilo RB, Gruninger RP, Davis T: Clas-
sification of type III (severe) open frac-
tures relative to treatment and results.
Orthopedics 1987;10:1781-1788.
218
and restoration of the soft-tissue en-
velope. Then the existing defect is
bone grafted. Depending on the frac-
ture pattern, grafts are applied either
at the fracture site beneath a flap or
posterolaterally away from the site
of injury. Early bone grafting in the
absence of a bone defect also may be
necessary when healing is delayed
and no callus is apparent on radio-
graphs at 8 to 12 weeks. Autogenous
bone graft remains the method of
choice. The usefulness of graft sub-
stitutes in the management of de-
fects associated with open fractures
has not been shown to be effective.
Exchange nailing is another op-
tion to stimulate healing in cases of
delayed union, provided no infec-
tion or bone defect is present. Infec-
tion necessitates additional débride-
ment, whereas bone defects should
be managed with bone grafting.
Summary
Assessment and classification of
open fractures should be done intra-
operatively based on the degree of
6. Brumback RJ, Jones AL: Interobserver
agreement in the classification of open
fractures of the tibia: The results of a
survey of two hundred and forty-five
orthopaedic surgeons. J Bone Joint Surg
Am 1994;76:1162-1166.
7. Patzakis MJ, Harvey JP Jr, Ivler D: The
role of antibiotics in the management of
open fractures. J Bone Joint Surg Am
1974;56:532-541.
8. Patzakis MJ, Wilkins J: Factors influenc-
ing infection rate in open fracture
wounds. Clin Orthop 1989;243:36-40.
9. Fischer MD, Gustilo RB, Varecka TF: The
timing of flap coverage, bone-grafting,
and intramedullary nailing in patients
who have a fracture of the tibial shaft
with extensive soft-tissue injury. J Bone
Joint Surg Am 1991;73:1316-1322.
10. Lee J: Efficacy of cultures in the man-
agement of open fractures. Clin Orthop
1997;339:71-75.
11. Patzakis MJ, Bains RS, Lee J, et al: Pro-
Journal of the American Academy of Orthopaedic Surgeons
bacterial contamination, soft-tissue
damage, and fracture characteristics.
To avoid the complication of clos-
tridial myonecrosis, the wound
should be thoroughly irrigated and
débrided and not closed primarily.
Early, systemic, wide-spectrum anti-
biotic therapy is necessary to cover
both gram-positive and gram-
negative organisms. A 3-day admin-
istration of a first-generation cepha-
losporin and an aminoglycoside,
supplemented with ampicillin or
penicillin for injuries occurring on a
farm and for vascular injuries, is a
critically important part of effective
treatment. Local antibiotic delivery
with the bead pouch technique can
prevent secondary wound contami-
nation. In the presence of extensive
soft-tissue loss and exposed bone,
coverage is accomplished with early
transfer of local or free muscle flaps.
Stable fracture fixation is important;
the method chosen depends on the
bone and soft-tissue characteristics.
Early bone grafting is indicated for
bone defects, unstable fractures
treated with external fixation, and
delayed union.
spective, randomized, double-blind
study comparing single-agent antibiot-
ic therapy, ciprofloxacin, to combination
antibiotic therapy in open fracture wounds.
J Orthop Trauma 2000;14:529-533.
12. Templeman DC, Gulli B, Tsukayama
DT, Gustilo RB: Update on the manage-
ment of open fractures of the tibial
shaft. Clin Orthop 1998;350:18-25.
13. Knapp TP, Patzakis MJ, Lee J, Seipel
PR, Abdollahi K, Reisch RB: Compari-
son of intravenous and oral antibiotic
therapy in the treatment of fractures
caused by low-velocity gunshots: A
prospective, randomized study of in-
fection rates. J Bone Joint Surg Am 1996;
78:1167-1171.
14. Holtom PD, Pavkovic SA, Bravos PD,
Patzakis MJ, Shepherd LE, Frenkel B:
Inhibitory effects of the quinolone anti-
biotics trovafloxacin, ciprofloxacin, and
levofloxacin on osteoblastic cells in
vitro. J Orthop Res 2000;18:721-727.

15. Huddleston PM, Steckelberg JM, Hans-
sen AD, Rouse MS, Bolander ME, Patel
R: Ciprofloxacin inhibition of experi-
mental fracture healing. J Bone Joint
Surg Am 2000;82:161-173.
16. Dellinger EP, Caplan ES, Weaver LD, et
al: Duration of preventive antibiotic ad-
ministration for open extremity frac-
tures. Arch Surg 1988;123:333-339.
17. Ostermann PA, Seligson D, Henry SL:
Local antibiotic therapy for severe open
fractures: A review of 1085 consecutive
cases. J Bone Joint Surg Br 1995;77:93-97.
18. Greene N, Holtom PD, Warren CA, et
al: In vitro elution of tobramycin and
vancomycin polymethylmethacrylate
beads and spacers from Simplex and
Palacos. Am J Orthop 1998;27:201-205.
19. Anglen JO: Wound irrigation in muscu-
loskeletal injury. J Am Acad Orthop Surg
2001;9:219-226.
20. Bhandari M, Schemitsch EH, Adili A,
Lachowski RJ, Shaughnessy SG: High
and low pressure pulsatile lavage of
contaminated tibial fractures: An in vit-
ro study of bacterial adherence and
bone damage. J Orthop Trauma 1999;13:
526-533.
21. Burd T, Christensen GD, Anglen JO,
Gainor BJ, Conroy BP, Simpson WA: Se-
quential irrigation with common deter-
gents: A promising new method for de-
contaminating orthopedic wounds. Am
J Orthop 1999;28:156-160.
22. DeLong WG Jr, Born CT, Wei SY, Petrik
ME, Ponzio R, Schwab CW: Aggressive
treatment of 119 open fracture wounds.
J Trauma 1999;46:1049-1054.
23. Patzakis MJ: Clostridial myonecrosis.
Instr Course Lect 1990;39:491-493.
24. Patzakis MJ, Wilkins J, Moore TM: Con-
siderations in reducing the infection
rate in open tibial fractures. Clin Orthop
1983;178:36-41.
25. Sherman R, Ecker J: Soft tissue cover-
age, in Browner BD, Jupiter JB, Levine
AM, Trafton PG (eds): Skeletal Trauma:
Fractures, Dislocations, Ligamentous Inju-
ries, ed 2. Philadelphia, PA: WB Saun-
ders, 1998, pp 419-448.
26. Pollak AN, McCarthy ML, Burgess AR:
Short-term wound complications after
Vol 11, No 3, May/June 2003
Charalampos G. Zalavras, MD, and Michael J. Patzakis, MD
application of flaps for coverage of
traumatic soft-tissue defects about the
tibia: The Lower Extremity Assessment
Project (LEAP) Study Group. J Bone
Joint Surg Am 2000;82:1681-1691.
27. Godina M: Early microsurgical reconstruc-
tion of complex trauma of the extrem-
ities. Plast Reconstr Surg 1986;78:285-292.
28. Gopal S, Majumder S, Batchelor AG,
Knight SL, De Boer P, Smith RM: Fix
and flap: The radical orthopaedic and
plastic treatment of severe open frac-
tures of the tibia. J Bone Joint Surg Br
2000;82:959-966.
29. Brumback RJ, Ellison PS Jr, Poka A,
Lakatos R, Bathon GH, Burgess AR: In-
tramedullary nailing of open fractures
of the femoral shaft. J Bone Joint Surg
Am 1989;71:1324-1331.
30. Tornetta P III, Bergman M, Watnik N,
Berkowitz G, Steuer J: Treatment of grade-
IIIb open tibial fractures: A prospective
randomised comparison of external fix-
ation and non-reamed locked nailing.
J Bone Joint Surg Br 1994;76:13-19.
31. Henley MB, Chapman JR, Agel J, Har-
vey EJ, Whorton AM, Swiontkowski
MF: Treatment of type II, IIIA, and IIIB
open fractures of the tibial shaft: A pro-
spective comparison of unreamed in-
terlocking intramedullary nails and
half-pin external fixators. J Orthop Trau-
ma 1998;12:1-7.
32. Bhandari M, Guyatt GH, Swiontkowski
MF, Schemitsch EH: Treatment of open
fractures of the shaft of the tibia. J Bone
Joint Surg Br 2001;83:62-68.
33. Shepherd LE, Costigan WM, Gardocki
RJ, Ghiassi AD, Patzakis MJ, Stevanovic
MV: Local or free muscle flaps and un-
reamed interlocked nails for open tibial
fractures. Clin Orthop 1998;350:90-96.
34. Schemitsch EH, Kowalski MJ, Swiont-
kowski MF, Harrington RM: Compari-
son of the effect of reamed and un-
reamed locked intramedullary nailing
on blood flow in the callus and strength
of union following fracture of the sheep
tibia. J Orthop Res 1995;13:382-389.
35. Schemitsch EH, Kowalski MJ, Swiont-
kowski MF, Senft D: Cortical bone
blood flow in reamed and unreamed
locked intramedullary nailing: A frac-
tured tibia model in sheep. J Orthop
Trauma 1994;8:373-382.
36. Keating JF, O’Brien PJ, Blachut PA, Meek
RN, Broekhuyse HM: Locking intramed-
ullary nailing with and without ream-
ing for open fractures of the tibial shaft:
A prospective, randomized study. J Bone
Joint Surg Am 1997;79:334-341.
37. Finkemeier CG, Schmidt AH, Kyle RF,
Templeman DC, Varecka TF: A prospec-
tive, randomized study of intramedul-
lary nails inserted with and without
reaming for the treatment of open and
closed fractures of the tibial shaft. J Or-
thop Trauma 2000;14:187-193.
38. Edwards CC, Simmons SC, Browner BD,
Weigel MC: Severe open tibial fractures:
Results treating 202 injuries with exter-
nal fixation. Clin Orthop 1988;230:98-115.
39. Behrens F, Searls K: External fixation of
the tibia: Basic concepts and prospec-
tive evaluation. J Bone Joint Surg Br
1986;68:246-254.
40. Marsh JL, Nepola JV, Wuest TK, Osteen
D, Cox K, Oppenheim W: Unilateral ex-
ternal fixation until healing with the
dynamic axial fixator for severe open
tibial fractures. J Orthop Trauma 1991;5:
341-348.
41. McGraw JM, Lim EV: Treatment of
open tibial-shaft fractures: External fix-
ation and secondary intramedullary
nailing. J Bone Joint Surg Am 1988;70:
900-911.
42. Blachut PA, Meek RN, O’Brien PJ: Ex-
ternal fixation and delayed intramedul-
lary nailing of open fractures of the tib-
ial shaft: A sequential protocol. J Bone
Joint Surg Am 1990;72:729-735.
43. Bach AW, Hansen ST Jr: Plates versus
external fixation in severe open tibial
shaft fractures: A randomized trial. Clin
Orthop 1989;241:89-94.
44. Clifford RP, Beauchamp CG, Kellam JF,
Webb JK, Tile M: Plate fixation of open
fractures of the tibia. J Bone Joint Surg Br
1988;70:644-648.
45. Blick SS, Brumback RJ, Lakatos R, Poka
A, Burgess AR: Early prophylactic bone
grafting of high-energy tibial fractures.
Clin Orthop 1989;240:21-41.
219