Chapter 10: Initial Management of Open Fractures

S. Rajasekaran, A. Devendra, R. Perumal, J. Dheenadhayalan, S.R. Sundararajan

Chapter Outline

Introduction

An open fracture is defined as an injury where the fracture and the fracture hematoma communicate with the external environment through a traumatic defect in the surrounding soft tissues and overlying skin. It should be emphasized that the skin defect may not lie directly over the fracture site and may lie at a distant site. It may communicate with the fracture under degloved skin. Hence any fracture associated with a wound in the same region must be considered to be an open injury until proven otherwise by surgical exploration. 
Open fractures are often high-energy injuries and are frequently associated with life-threatening polytrauma. They are best managed by a team approach in centers that have appropriate facilities for resuscitation and multispecialty care.48,95,121,171,181 Apart from severe bone and soft tissue involvement, these injuries have other risk factors such as skin degloving, soft tissue crushing, contamination with dirt and debris and injury to neurovascular structures. Hence they are associated with a high risk of complications, including amputation. Recent developments such as advances in the management of polytrauma, the availability of powerful antibiotics, refinement of the techniques of radical debridement, bone stabilization, and early soft tissue reconstruction have helped to improve the outcome considerably. The present challenge of the trauma surgeon is not simply salvage of the limb but the restoration of maximal function. Patients with a disfigured or painful limb are often very dissatisfied with the results of treatment and may opt for amputation at the end of a prolonged treatment regime. 
The principles of treatment of open injuries have gradually evolved over the centuries and many advances have come from the experience gained in treating war injuries. Tscherne186 has grouped the developments into four eras of life preservation, limb preservation, infection prevention, and functional restoration. The problem of contamination was recognized in the 16th century by Ambroise Pare who emphasized the need for cleaning wounds of all foreign matter and necrotic tissue and leaving the wound open.110,146 The term “debridement” was coined by Desault in the 18th century to describe a procedure that involved surgical extension of the wound and the removal of all necrotic and contaminated tissue.88,189 In the absence of antibiotics and aseptic surgical techniques, the incidence of mortality and amputation following infection was very high. “Lose a Limb to save a Life” was an accepted dictum of management as gross infection of open injuries often led to gangrene, septicemia, and death. In the Franco-Prussian War of 1870, more than 13,000 therapeutic amputations were performed.194 Billroth (1829–1894) reported a mortality of 39% following open injuries which led him to comment, “Perhaps the treatment of no other condition gives me as much satisfaction as that of a successfully treated open injury.”18 
World War I saw the successful beginning of the “Era of Life Preservation” as mortality was considerably reduced as a result of the application of the principles of good resuscitation, thorough debridement, stabilization, and avoiding closing the wounds. Survival continued to improve as sulfonamides and other antibiotics became available in World War II with more antibiotics being used during the Korean War. 
The 1970s saw major advances in both orthopedic and plastic surgery and the “Era of Limb Preservation” was introduced. The refinement of the principles and techniques of external fixation allowed rapid and effective stabilization of the skeleton in the presence of complex fracture patterns. The advent of bone transport and ring fixators led to the possibility of successful bone regeneration even in the presence of major bone loss. Simultaneous advances in plastic surgery with the evolution of numerous flaps in different regions of the body together with the development of microvascular free tissue transfer made reconstruction of composite tissue loss possible. These advances made limb reconstruction a technical possibility, even in challenging situations. 
The availability of antibiotics and the understanding of the need for aggressive debridement and early soft tissue cover helped to control infection bringing in the “Era of Infection Control.” Meanwhile the principles of treatment were being constantly refined. Gustilo and Anderson84,85,80 published their landmark classification scheme for open fractures that brought attention to the importance of the wound and the need for early soft tissue cover. The seminal work of Godina clearly emphasized the advantages of early soft tissue cover.7274 The source of the infection was frequently identified to be from the hospital environment and the principle of “Fix and Flap” and the indications and advantages of primary skin suturing were developed. The huge variability in presentation and the challenges inherent in the management of Gustilo IIIb injuries led to the development of the Ganga Hospital Open Injury Score (GHOIS) with specific guidelines for salvage and reconstruction in IIIb injuries.154 Recently, the availability of vacuum foam dressings (VFD) using negative pressure wound therapy (NPWT) has also proved to be very useful in wounds that cannot be covered early. It acts as a bridge between the index procedure and the definitive soft tissue cover procedure. 
The understanding that open fractures are not in the domain of any single specialty and must be treated by a combined approach has helped to improve results. The “Orthoplastic approach”25,43 where the orthopedic and plastic teams work together from the stage of wound debridement onward is now recognized as the standard of care and is undertaken in all centers which regularly treat these injuries. This protocol allows surgeons to undertake a meticulous debridement without concern about the problems of late reconstruction. It emphasizes the need for early soft tissue cover and results in better outcomes by reducing complications like infection and nonunion. 
The management of open injuries is now in the “Era of Functional Restoration.” Functional restoration is aided by aggressive wound debridement, early definitive fracture stabilization and early wound closure or cover to achieve bone and soft tissue healing as soon as possible. Surgeons have now realized that success in treatment of open injuries is not merely salvage and they should not succumb to the “triumph of technique over reason.” Patients are often dissatisfied if they are left with a deformed or painful lower limb at the end of the treatment and often opt for a secondary amputation. The future will focus on identifying and understanding factors that affect healing of bone and soft tissues at the molecular and genetic level so that the treatment can be tailored to each patient and secondary amputations avoided. There will also be a focus on the development of safe protocols for reconstruction that will facilitate better function and cosmesis in the shortest possible period of time. 

Pathophysiology

Long bone open fractures have been quoted to occur with a frequency of 11.5 per 100,000 persons per year.39,44,57,99 The incidence must be much higher in developing countries where road traffic and work place accidents are abundant and increasing every day. In many countries motor cycle accidents are the commonest cause of open long bone fractures with more fractures occurring in the lower limbs than in the upper limbs.74 Open tibial diaphyseal fractures are the commonest open long bone fracture but open femoral diaphyseal, distal femoral, and proximal tibial fractures occur frequently. Open fractures of the upper limb are usually associated with less severe soft tissue damage and fewer associated musculoskeletal injuries. Figure 10-1 shows the spectrum of open fractures presenting to our Unit. 
Figure 10-1
The distribution of open injuries in 1,554 consecutive cases treated in our unit.
 
Lower limb injuries are more common with open injuries of tibia accounting for nearly 50% of all open injuries.
Lower limb injuries are more common with open injuries of tibia accounting for nearly 50% of all open injuries.
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Figure 10-1
The distribution of open injuries in 1,554 consecutive cases treated in our unit.
Lower limb injuries are more common with open injuries of tibia accounting for nearly 50% of all open injuries.
Lower limb injuries are more common with open injuries of tibia accounting for nearly 50% of all open injuries.
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Open fractures can occur in low-velocity injuries due to the sharp ends of the fractured bone piercing the skin and soft tissues but more often they are the result of high-energy injuries. The amount of energy absorbed by the injured limb is determined by the equation KE = MV2/2, where KE is the kinetic energy absorbed, M is the mass, and V is the speed.37,78 Examples of energy absorbed in different energy mechanisms are shown in Table 10-1. The bone and soft tissues of the limb absorb the energy but when the threshold is exceeded there is significant comminution of the bone with periosteal stripping and soft tissue damage. The sharp comminuted bone fragments are frequently devoid of all soft tissue attachments and may be displaced with a velocity that results in additional damage to the soft tissues and neurovascular structures. When the skin is torn a temporary vacuum can be created that sucks in all adjacent foreign material. This dirt and debris may be deposited in the depths of the wound in the deep intermuscular planes and is often deposited in the intramedullary cavity of the bone. This fact should be borne in mind during the wound debridement where meticulous examination of all possible areas of contamination must be done. 
 
Table 10-1
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Table 10-1
Energy Transmitted by Injury Mechanism (ft–lb)37
  •  
    Fall from curb
100
  •  
    Skiing injury
300–500
  •  
    High-velocity gunshot wound (single missile)
2000
  •  
    20-mph bumper injury (assumes bumper strikes fixed target)
100,000
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A few facts require emphasis. The size and nature of the external wound may not reflect the damage to the deeper structures (Fig. 10-2). Frequently small lacerated wounds are associated with extensive occult degloving with severe soft tissue damage and bone comminution. Open injuries may damage one or more compartments of the limb, but the severe swelling may result in compartment syndrome of the other intact compartments of the same limb.128 It must be remembered that the presence of an open wound does not preclude the occurrence of a compartment syndrome in the injured limb. One must also be aware that the extent of injury to the soft tissues and bone may not be fully exposed on day 1 and the actual “zone of injury” may be revealed only over the next few days. This has important implications in choosing the timing and nature of soft tissue reconstruction. It should also be understood that an open injury is just not a simple combination of a fracture and a wound. Additional factors such as contamination with dirt and debris and devitalization of the soft tissues increase the risk of infection and other complications. 
Figure 10-2
The severity of the skin wound often has no bearing on the extent of damage to deeper tissues.
 
An open tibial diaphyseal fractures with a small skin wound (A) was associated with significant bone (B, D) and soft tissue (C) damage. The wound ultimately required a free fibula graft (E) and a soft tissue flap (F).
An open tibial diaphyseal fractures with a small skin wound (A) was associated with significant bone (B, D) and soft tissue (C) damage. The wound ultimately required a free fibula graft (E) and a soft tissue flap (F).
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An open tibial diaphyseal fractures with a small skin wound (A) was associated with significant bone (B, D) and soft tissue (C) damage. The wound ultimately required a free fibula graft (E) and a soft tissue flap (F).
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Figure 10-2
The severity of the skin wound often has no bearing on the extent of damage to deeper tissues.
An open tibial diaphyseal fractures with a small skin wound (A) was associated with significant bone (B, D) and soft tissue (C) damage. The wound ultimately required a free fibula graft (E) and a soft tissue flap (F).
An open tibial diaphyseal fractures with a small skin wound (A) was associated with significant bone (B, D) and soft tissue (C) damage. The wound ultimately required a free fibula graft (E) and a soft tissue flap (F).
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An open tibial diaphyseal fractures with a small skin wound (A) was associated with significant bone (B, D) and soft tissue (C) damage. The wound ultimately required a free fibula graft (E) and a soft tissue flap (F).
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Assessment

Initial Evaluation

Every open injury is an orthopedic emergency and the success of treatment depends on a thorough initial evaluation and management that starts at the emergency room. 
An open injury always presents dramatically and has the capacity to distract the untrained person from assessing the more serious occult injuries which may be life threatening (Fig. 10-3). Thirty percent of patients with open injuries have more than one injury and the temptation to focus attention on the bleeding wound must be avoided. The emergency room doctor must not restrict his or her attention to the obvious injury but undertake a thorough evaluation as per ATLS protocols. The patient must be thoroughly assessed for airway, breathing, and circulation. There may be a number of injuries that are missed and there is a role for fast whole-body CT scanning which helps to identify injuries to the head, neck, spine, chest, and pelvis. 
Figure 10-3
Open fractures are often high-energy injuries and have a variable amount of damage to the skin, soft tissues, and bone (A, B).
 
They are often associated with serious life-threatening injuries such as the intracranial bleeding seen in this patient (C).
They are often associated with serious life-threatening injuries such as the intracranial bleeding seen in this patient (C).
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Figure 10-3
Open fractures are often high-energy injuries and have a variable amount of damage to the skin, soft tissues, and bone (A, B).
They are often associated with serious life-threatening injuries such as the intracranial bleeding seen in this patient (C).
They are often associated with serious life-threatening injuries such as the intracranial bleeding seen in this patient (C).
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An estimate of the blood loss must be undertaken quickly and, if necessary, resuscitation measures immediately instituted. Inadequate resuscitation is an important cause of avoidable deaths and later comorbidities such as infection, delayed wound healing, and pulmonary complications. Acidosis, hypothermia, and coagulopathy, the deadly triad in injured patients, are often present in patients with open injuries and these must be identified and corrected quickly.27,106,169 It is now understood that simply monitoring the vital signs may be insufficient to determine the adequacy of resuscitation and treatment regimes that simply target vital signs may be harmful in the setting of polytrauma.53,136,167 Surgeons should consider damage control orthopedics as a part of the resuscitation process.94,141,179 This is discussed in Chapter 9
Once the patient is stabilized it is important that the circumstances of the accident and the patient’s history are meticulously documented. Documentation starts with a thorough history which includes details of the accident, the time of injury, any loss of consciousness, and other evidence of head injury, temporary or partial paralysis, the probable velocity of injury, the use of seat belts and helmets, and emergency medical attention received at the site of accident. Witnesses and accompanying family members may provide useful information regarding the nature of the injury. Information about the condition of the patient and the resuscitative measures undertaken at the scene of the accident, and the condition of the patient during transport to the hospital must be obtained from the emergency medical attendants. The type of injuries sustained by accompanying passengers in the vehicle will also provide information about the circumstances of the accident. 
Special attention should be paid to documenting any comorbidities of the patient as they may significantly influence treatment decisions and the final outcome.155,154 (Fig. 10-4). Any systemic illness, history of smoking, medications, and pertinent allergies should be documented. Illnesses such as diabetes mellitus, rheumatoid arthritis, and connective tissue disorders which are associated with osteoporosis and bleeding disorders should be recorded as should the use of drugs such as phenytoin which may cause osteomalacia or osteoporosis. Any history of previous surgery must also be documented. Smoking is associated with an increased rate of flap failure, delayed union, and nonunion and this must be documented. Patients who are smoking must be urged to stop smoking during the treatment process.2,35 
Figure 10-4
The functional outcome in a type IIIb injury depends on a triad of factors related to the patient, any comorbidities that may be present and the severity of injury.
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Examination

A thorough physical examination of the patient is important. The patient should be adequately undressed so that any bruising and contusions in other parts of the body that might indicate more significant injury can be seen. This is especially important in patients who are not fully conscious or under the influence of alcohol. All constrictive clothing must be removed and the vascularity and movements of all four limbs must be examined. An injured limb that is grossly deformed or shortened must be gently reduced and splinted so that vascularity is not compromised. Tenting of the skin by sharp bone fragments or dislocated joints may lead to avascularity and further loss of skin and these fractures must be considered as impending open fractures even when no wound is present (Fig. 10-5). Persistent dislocation of the joints, especially the knee and ankle joints, may also cause vascular compromise and these joints require urgent reduction in the emergency room. The limb must also be examined for any signs of compartment syndrome (see Chapter 29). 
Figure 10-5
The sharp ends of the broken bone may cause skin tethering jeopardizing its vascular supply (A).
 
The bone ends may also cause pressure on local neurovascular structures resulting in distal avascularity. In this patient the flexed distal fragment (B, C) caused local vascular pressure resulting in absent distal pulses. Distal vascularity was established once the bone was reduced by gentle traction.
The bone ends may also cause pressure on local neurovascular structures resulting in distal avascularity. In this patient the flexed distal fragment (B, C) caused local vascular pressure resulting in absent distal pulses. Distal vascularity was established once the bone was reduced by gentle traction.
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Figure 10-5
The sharp ends of the broken bone may cause skin tethering jeopardizing its vascular supply (A).
The bone ends may also cause pressure on local neurovascular structures resulting in distal avascularity. In this patient the flexed distal fragment (B, C) caused local vascular pressure resulting in absent distal pulses. Distal vascularity was established once the bone was reduced by gentle traction.
The bone ends may also cause pressure on local neurovascular structures resulting in distal avascularity. In this patient the flexed distal fragment (B, C) caused local vascular pressure resulting in absent distal pulses. Distal vascularity was established once the bone was reduced by gentle traction.
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The size and severity of the wound and the relationship of the wound to the fracture must be carefully examined. Although most open fractures, especially Gustilo type III fractures, expose one or both ends of the fractured bone, the wound may be distant and there may be no direct exposure of the fracture (Fig. 10-6). Any wound, no matter how small or distant from the fracture, must still be considered indicative of an open fracture. Communication with the actual fracture site due to disruption of the fascia and degloving of the skin is often obvious during the debridement. Persistent oozing from a small laceration, especially if it carries fat globules indicates a discharging fracture hematoma. 
Figure 10-6
The skin wound in this patient, although located proximal to the fracture (A), communicated with it under degloved skin (B).
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In the emergency room examination of the wound should include the size and location of the wound, the orientation of the wound, to define if it is longitudinal, transverse or irregular, the depth of the wound and whether bone, tendons, and muscle are exposed. Attention should be paid to the status of the skin adjacent to the wound. If there is extensive damage or contusions to the skin around the wound there may be significant skin avascularity and therefore skin loss during debridement (Fig. 10-7). 
Figure 10-7
Closed degloving is a major risk factor for extensive skin avascularity.
 
In this case there was a large skin defect after debridement of nonviable skin (A). This required to be covered with a skin graft (B).
In this case there was a large skin defect after debridement of nonviable skin (A). This required to be covered with a skin graft (B).
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Figure 10-7
Closed degloving is a major risk factor for extensive skin avascularity.
In this case there was a large skin defect after debridement of nonviable skin (A). This required to be covered with a skin graft (B).
In this case there was a large skin defect after debridement of nonviable skin (A). This required to be covered with a skin graft (B).
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Photographic documentation of the wound should ideally be undertaken. This is important as a good visual documentation surpasses any written description and will be of immense value during follow-up examinations and for research purposes.132 A digital camera should be available in the emergency room where open injuries are received.174 Following the initial assessment and documentation, the wound must be quickly covered with a sterile dressing. Probing or further handling of the wound may in fact be disadvantageous as it may provoke unnecessary bleeding and increase the chances of secondary contamination and nosocomial infections. 
Significant bleeding may be controlled by application of a compression dressing and firm bandages with elevation of the limb. This will be sufficient to arrest the bleeding in the majority of patients. The surgeon should not attempt to blindly clamp a bleeding vein or artery in the emergency room as this may result in the inadvertent clamping of an adjacent major neurovascular structure and lead to permanent and irreversible neurologic deficit. Uncontrollable bleeding from a wound can be arrested with the help of a tourniquet. The patient should then be taken to the operating room as quickly as possible. 
Establishing and documenting intact vascularity in all fractured limbs, and especially in severely mangled limbs, is crucial. Signs of vascular injury are listed in Table 10-2. Apart from the presence of a positive pulse examination, adequate filling of the veins and a positive capillary refill sign, a warm and normally colored distal limb is also indicative of an intact circulation. If pulses are absent, one must reexamine the limb after the limbs are anatomically aligned and splinted as shortening and angulation of the fractured skeleton may result in kinking and occlusion of the vessels. If the pulses are still absent, a vascular injury must be suspected unless proven otherwise. A diagnosis of vascular spasm should not be made as the inevitable loss of time in initiating treatment may result in amputation. Additional investigations such as arterial doppler or a CT angiogram may be necessary. CT angiograms are particularly useful as apart from indicating the location and type of the block, they reveal the status and adequacy of the collateral circulation (Fig. 10-8). The disadvantage, however, is that they are time consuming and not available in all centers. The high dose of contrast required may also cause renal damage in a patient in severe shock and precipitate acute renal failure. 
Here there is a complete block of the artery due to a supracondylar fracture of the femur with poor collateral blood supply.
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Figure 10-8
In the absence of the distal pulses, if there is no contraindication to undertaking it, a CT angiogram will not only show the level and severity of the block but will also show the status of the collateral vessels.
Here there is a complete block of the artery due to a supracondylar fracture of the femur with poor collateral blood supply.
Here there is a complete block of the artery due to a supracondylar fracture of the femur with poor collateral blood supply.
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Table 10-2
Signs of Vascular Injury
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Table 10-2
Signs of Vascular Injury
Hard Signs
  •  
    Absent or significant difference in pulsations compared to normal side.
  •  
    Severe hemorrhage from the wound.
  •  
    Expanding and pulsatile hematoma.
  •  
    Bruit or thrill.
Associated Signs
  •  
    Associated numbness and neurologic deficit.
  •  
    Difference in skin temperature distal to injury.
  •  
    Absence of venous filling.
  •  
    Absence of pulse-oximeter reading. No capillary blanching.
X
Although a thorough neurologic examination may be difficult in the emergency room setting due to pain, documentation of the distal neurologic status is the next step. Both touch sensation and pinprick testing can be used to examine distal dermatomes and motor movements can also be tested. Determination of the exact power of the muscle groups may be difficult. If for any reason testing of specific muscle groups is not possible, it should be documented so that a proper evaluation can be done later as soon as possible. 
The surgeon should look for wounds over the thorax, abdomen, or pelvis. These may be associated with a very poor prognosis if not recognized and treated properly as they may represent communications with the body cavities. In the pelvis, a laceration of the rectum, vagina, or urinary tract represents an open fracture of the pelvis and a colostomy is required to prevent fecal contamination. Overlooking these wounds and delaying treatment is a frequent cause of increased mortality and morbidity. 

Role of Cultures in the Emergency Room

Infection is the major complication that leads to the need for secondary procedures, nonunions, failure of flaps, and even amputations. This fact stimulated surgeons to try to identify the bacteria that cause wound contamination. However studies have shown poor correlation between the presence of positive cultures and subsequent rate of clinical infection.131 There is disparity between the organisms grown on the initial wound swabs and the organisms grown subsequently129,192 after the development of wound infection The commonly isolated organisms from established infection are Staphylococcus aureus, Pseudomonas, and Escherichia coli.148 These organisms are frequently due to hospital contamination34 and are never isolated from the environment where the accidents occur. The practice of obtaining routine cultures from the wound either pre- or post-debridement is no longer advocated.111,116,138,188 It is now understood that in addition to contamination, infection is influenced by various factors related to the wound, host, and environment. 

Antibiotics

Once the limb is properly splinted, bleeding has been controlled and the wound is covered with a wet saline dressing appropriate intravenous antibiotics should be administered The antibiotic therapy should be considered therapeutic and not prophylactic and it must be instituted as early as possible26,148,179 as all open fractures are contaminated to a varying extent.72,87,81,82 In the absence of organic or sewage contamination intravenous first or second generation cephalosporins are typically given before the patient leaves the emergency room.77,81,137,162,184,185 An aminoglycoside is added in Gustilo type III injuries. Penicillin, with or without metronidazole, should be given to patients with gross organic contamination. Recommendations for the administration of intravenous antibiotics are given in Table 10-3. In addition, the patient’s tetanus status must be documented and supplementary injections given if necessary. It should be remembered that the prolonged use of antibiotics is not indicated and will lead to the development of resistant organisms.71 Guidelines for the use of intravenous antibiotics are shown in Table 10-4
 
Table 10-3
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Table 10-3
Intravenous Antibiotic Therapy for Open Fractures26
Latest British Orthopaedic Association online recommendations (Open fractures of lower limb—September 2009)
  •  
    Give antibiotics as soon as possible (within 3 hours).
  •  
    Agent of choice co-amoxiclav (1.2 g 8 hourly), or a cephalosporin (e.g., cefuroxime 1.5 g 8 hourly), continued until first debridement (excision).
  •  
    At the time of first debridement, co-amoxiclav (1.2 g) or a cephalosporin (such as cefuroxime 1.5 g) and gentamicin (1.5 mg/kg) should be administered and co-amoxiclav/cephalosporin continued until soft tissue closure or for a maximum of 72 hours, whichever is sooner.
  •  
    Gentamicin 1.5 mg/kg and either vancomycin 1 g or teicoplanin 800 mg should be administered on induction of anesthesia at the time of skeletal stabilization and definitive soft tissue closure. These should not be continued postoperatively. Ideally start the vancomycin infusion at least 90 minutes before surgery.
  •  
    True penicillin allergy (anaphylaxis) clindamycin (600 mg IV pre-op/qds) in place of co-amoxiclav/cephalosporin. Lesser allergic reaction to penicillin (rash, etc.) a cephalosporin is considered to be safe and is the agent of choice.
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Table 10-4
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Table 10-4
Intravenous Antibiotic Therapy71
Evidence Supports
  •  
    Intravenous antibiotics at the earliest, preferably in the emergency room.
  •  
    Use of metronidazole and aminoglyosides in severely contaminated wounds.
  •  
    Equivalent efficacy of oral to parenteral antibiotics during the follow-up (when necessary).
Evidence Does Not Support
  •  
    Prolonged and continuous use of antibiotics.
  •  
    Continuing antibiotics as long as the drains are in.
  •  
    Continuation of the empirical antibiotic regime till wound drainage is present.
  •  
    Prophylactic antibiotics to prevent pin tract infections.
  •  
    Antibiotic therapy as a substitute for debridement in presence of necrotic and contaminated material.
X

Radiographic Imaging and Other Diagnostic Studies

Plain radiographs are sufficient in the majority of cases to identify the extent of injury and plan treatment. An anteroposterior and lateral radiograph of the injured bone with inclusion of the joints above and below is the minimum that is required. Open injuries are often high-velocity injuries and the fracture may extend into the adjacent joints or there could be associated injuries of the articular surfaces. Hence radiographs including the adjacent joints are essential. In high-energy injuries involving the femur, radiographs of the pelvis which depict the status of the sacroiliac joints, pubic symphysis, and both hips are important (Fig. 10-9). Radiographic clearance of the cervical and thoracolumbar spines must be undertaken when necessary. 
Figure 10-9
Radiographs of a severely injured limb must include the joints on both sides of a fracture.
 
Here, an open injury of the knee joint (A, B) was associated with an undiagnosed dislocation of the right hip (C) which was detected only after a delay of 48 hours.
Here, an open injury of the knee joint (A, B) was associated with an undiagnosed dislocation of the right hip (C) which was detected only after a delay of 48 hours.
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Figure 10-9
Radiographs of a severely injured limb must include the joints on both sides of a fracture.
Here, an open injury of the knee joint (A, B) was associated with an undiagnosed dislocation of the right hip (C) which was detected only after a delay of 48 hours.
Here, an open injury of the knee joint (A, B) was associated with an undiagnosed dislocation of the right hip (C) which was detected only after a delay of 48 hours.
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The presence of air in the subcutaneous tissues, intramuscular planes, and joint cavities and the visualization of foreign bodies are indicative of open injuries. The presence of air in the subcutaneous tissues in puncture wounds or small lacerations indicates severe degloving of the skin. Radiographic evidence of severe mud contamination, shattered glass, or metal pieces suggests significant contamination (Fig. 10-10). In patients presenting late the presence of radiographic gas shadows in the muscular planes should arose suspicion of an established infection by gas producing organisms such as Clostridium perfringens or Escherichia coli.29,157 
Figure 10-10
Major open injuries often carry contamination deep into the wound.
 
This may be seen on radiographs. In this case a type IIIb open fracture of the tibia and fibula had extensive contamination of mud and dirt in the intramuscular planes (A, B). Glass fragments and air in the joint can also be identified on radiographs (C).
This may be seen on radiographs. In this case a type IIIb open fracture of the tibia and fibula had extensive contamination of mud and dirt in the intramuscular planes (A, B). Glass fragments and air in the joint can also be identified on radiographs (C).
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Figure 10-10
Major open injuries often carry contamination deep into the wound.
This may be seen on radiographs. In this case a type IIIb open fracture of the tibia and fibula had extensive contamination of mud and dirt in the intramuscular planes (A, B). Glass fragments and air in the joint can also be identified on radiographs (C).
This may be seen on radiographs. In this case a type IIIb open fracture of the tibia and fibula had extensive contamination of mud and dirt in the intramuscular planes (A, B). Glass fragments and air in the joint can also be identified on radiographs (C).
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In the absence of life-threatening injuries, a CT scan may prove helpful particularly in intra-articular fractures of the ankle and knee joint. It will identify the three dimensional orientation of the fracture planes and any distortion of the articular margins. This will facilitate fracture reduction and skeletal stabilization following debridement during the index surgery. If the state of the patient does not permit a CT scan temporary external fixation may be undertaken during the index procedure and a detailed CT scan of the joints can be performed later. The role of an MRI of the limb or the whole body is minimal in the acute setting and it is rarely performed. 

Role of Biochemical Markers

Major injuries activate multiple humoral and cellular cascade mechanisms involving the inflammatory mediators and complex mechanisms of host defense.10,63,67,140 These include an increase in capillary damage and permeability, multiple organ dysfunction syndrome (MODS), and even mortality. The value of markers in identifying the presence of systemic inflammatory response syndrome (SIRS) and in predicting outcomes is being investigated20,69,143145 (Table 10-5). Identification of a single ideal marker in trauma has been elusive and may in fact be impossible given the wide diversity of injured patients and the wide range of underlying injuries and comorbidities. 
 
Table 10-5
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Table 10-5
Biochemical Markers used in Trauma63
Normal Levels Significant Levels Uses Disadvantages
Serum lactate 0.5–2 22 mmol/L >2.5 mmol/L
  •  
    High levels indicate cellular hypoxia with hypoperfusion and anaerobic metabolism
  •  
    Delay in return to normal indicates poor prognosis.
  •  
    Persistent continuous elevation in spite of resuscitation indicates high chances of MODS and mortality.
Serial estimation
lnterleukin-6 <7 pg/mL >200 pg/mL
  •  
    High levels in initial stages indicate presence of SIRS.
  •  
    High levels indicate an inappropriate situation for definitive reconstruction surgery.
  •  
    High levels indicate a high risk of mortality.
  •  
    Has bimodal initial proinflammatory action and downregulatory’ action in late stages.
  •  
    Exact use in isolated limb injury is not yet defined.
  •  
    Not easily available in all centers.
  •  
    Expensive, serial estimations are required.
C-reactive protein <3 ug/mL >30 ug/mL
  •  
    Easily available.
  •  
    Less expensive.
  •  
    Raised in both inflammatory and infective conditions.
  •  
    Cannot distinguish inflammatory and infective conditions.
X
The following markers are being investigated.63,65,182 
  1.  
    CRP
     
    The CRP is commonly used in clinical practice and is widely available. However it has the disadvantage of being unable to distinguish infection and inflammation and it does not exhibit a proportionate increase to the injury thereby being unable to predict outcome. It is still however used widely as a high level of CRP may indicate either infection or severe inflammation, both of which have important implications in deciding future reconstruction.
  2.  
    Interleukins
     
    Many interleukins have been investigated for their relevance to major trauma and IL-6 has been identified to be a reliable and consistent marker of systemic inflammation.68,102,103,156 IL-6 is a cytokine with both pro- and anti-inflammatory properties and its increase in the peripheral blood is an early marker of the severity of injury following trauma. Although in the acute phase of inflammatory response, its proinflammatory properties dominate, later its anti-inflammatory properties dominate as it downregulates proinflammatory responses of tumor necrosis factor TNF-α and IL-1.65,69,117
     
    Stensballe et al.177 concluded that early systemic inflammatory response measured with serum IL-6 and IL-10 correlated well with injury severity and 30-day mortality following trauma. The detection limit (minimum detectable dose) of IL-6 was 0.039 pg/mL and 0.5 pg/mL for IL-10 and it requires serial estimation at 6, 12, 24 hours following injury.2,3,6
     
    Tschoeke et al.187 studied the early second hit in trauma management with respect to the proinflammatory response in multiple injuries and concluded that immediate surgical treatment causes additional surgical stress which might promote post-traumatic complications. The exact implications of a raised IL-6 are still not clear but current studies have confirmed a significant association between altered levels and mortality and morbidity. Current interest concerns whether the level of IL-6 would provide information to identify safe windows for secondary soft tissue reconstruction in open injuries especially when associated with other major injuries.153
  3.  
    Serum Lactate
     
    Another approach to identify ongoing physiologic insult is the estimation of products of tissue hypoperfusion and anaerobic metabolism such as lactic acidosis.1,112,122 Serum lactate is a good screening method for occult hypoperfusion and both a high and persistent lactate level is predictive of organ failure and increasing mortality. The time needed to normalize lactate following resuscitation is also an important prognostic indicator and a persistent or increasing lactate level may be one of the earliest signs of MODS.9,89,127 Studies have revealed higher mean lactate levels in nonsurvivors as compared with survivors in patients with trauma and major sepsis.
     
    Although the above studies have all concentrated on the importance of these changes in polytrauma, the relevance of these markers in isolated major injuries has not been extensively reported. In a preliminary study involving 285 patients with Gustilo IIIb injuries done in our Unit, it was found that there is a proportionate increase in both serum lactate and IL-6 even in isolated injuries of limbs when the severity was measured by the Ganga Hospital Score. The clinical implication of this phenomenon needs to be further investigated.

Classifications and Scores for Open Fractures

Gustilo and Anderson proposed a classification for open injuries in 1976 which still is the most commonly followed classification worldwide.84 Open injuries were divided into three types. Type I injuries were associated with minimal soft injury, type II with moderate injury, and type III injuries were severe injuries which exposed the fracture site and were associated with muscle damage and periosteal stripping. In 1984, Type III open fractures were subdivided again into three types, depending upon the nature and size of the skin wound, degree of muscle damage, extent of contamination, amount of periosteal stripping, and the presence of arterial injury.85 The classification is listed in Table 10-6
 
Table 10-6
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Table 10-6
Gustilo and Anderson’s Classification84,85
Type Wound Level of Contamination Soft Tissue Injury Bone Injury
I <1 cm long Clean Minimal Simple, minimal comminution
II >1 cm long Moderate Moderate; some muscle damage Moderate comminution
III A Usually >10 cm High Severe with crushing Usually communited; soft tissue coverage of bone possible
III B Usually >10 cm High Very severe loss of cover Bone cover poor; usually requires soft tissue reconstructive surgery
III C Usually >10 cm High Very severe loss of cover and vascular injury requiring repair Bone cover poor; usually requires soft tissue reconstructive surgery
X
Gustilo’s contribution was a milestone in the management of open injuries as it brought into focus the importance of soft tissue injury and wound contamination. Gustilo reported that the infection rate was 1.9% in type I injuries, 8% in type II injuries but it increased to 41% in type III injuries.86 Their work emphasized the need for early coverage of wounds and the requirement for early plastic surgery intervention. 
However, many disadvantages have been exposed in the routine use of Gustilo and Anderson’s classification. These are listed in Table 10-7. A classification system is useful in routine practice only if it is capable of consistently and reliably grouping injuries according to their severity. It should form a basis on which guidelines for treatment can be formed, predict the ultimate outcomes, and promote research by allowing comparison of results from different units. Gustilo’s classification is deficient in many of the above22,151155 and the following deficiencies have been noted. 
  1.  
    From the time of its original description, the classification has undergone many modifications which have led to different interpretations by various authors, resulting in loss of uniformity in its global application.
  2.  
    Type IIIb injuries, by definition, include a wide spectrum of easily manageable to barely salvageable injuries (Fig. 10-11). Hence it cannot offer uniform guidelines in management nor allow comparison of published results from different units.
  3.  
    Gustilo originally proposed the classification on the basis of the severity of the wound but the description is now frequently based on treatment. In North America any wound, irrespective of its size and nature, is Type IIIA if it is closed and Type IIIB, if treated by a flap. So rather than guiding treatment it has become a retrospective classification.
  4.  
    The classification is based more on the nature and size of the wound and does not address equally the severity of the injuries to the musculotendinous and skeletal structures. In practice, injury to the muscles, nerves, and bones are often more crucial than the nature of the wound in predicting function and deciding whether limb salvage is worthwhile (Fig. 10-12).
  5.  
    The classification does not provide for scoring of the comorbid factors which influence the timing and safety of major reconstructive procedures.
  6.  
    The system relies on subjective description such as “significant periosteal stripping” and “extensive soft tissue damage,” and this leads to significant variation of interpretation and evaluation among surgeons. There are two major studies which have both reported a low interobserver agreement rate of only 60%. Agreement varied widely depending upon the experience of the surgeon and the type of injury as some of these injuries were inherently difficult to classify.30,83,98,184
  7.  
    Being a classification and not a score, Gustilo’s classification does not address and provide guidelines for salvage.
 
Table 10-7
Disadvantages of Gustilo and Anderson’s Classification
  •  
    Definition has undergone many modifications and does not have uniformity in application.
  •  
    Includes wide spectrum of injuries in Type IIIB injuries.
  •  
    Mainly depends on size of the skin wound.
  •  
    Does not evaluate the severity of injury to skin, bone and musculotendinous units separately.
  •  
    Does not address the question of salvage.
  •  
    Poor interobserver reliability.
X
Figure 10-11
Gustilo type IIIb fractures include a wide variety of fractures.
 
By definition fractures A, B, and C are all type IIIb injuries. However their severity varies between the easily treatable and the barely salvageable.
By definition fractures A, B, and C are all type IIIb injuries. However their severity varies between the easily treatable and the barely salvageable.
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Figure 10-11
Gustilo type IIIb fractures include a wide variety of fractures.
By definition fractures A, B, and C are all type IIIb injuries. However their severity varies between the easily treatable and the barely salvageable.
By definition fractures A, B, and C are all type IIIb injuries. However their severity varies between the easily treatable and the barely salvageable.
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X
Figure 10-12
Each type IIIb injury has involvement of soft tissues and bone to a different extent.
 
Some injuries have severe involvement of the soft tissues (A), some have more severe involvement of bone (B) and others have severe injuries of both bone and soft tissues (C).
Some injuries have severe involvement of the soft tissues (A), some have more severe involvement of bone (B) and others have severe injuries of both bone and soft tissues (C).
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Figure 10-12
Each type IIIb injury has involvement of soft tissues and bone to a different extent.
Some injuries have severe involvement of the soft tissues (A), some have more severe involvement of bone (B) and others have severe injuries of both bone and soft tissues (C).
Some injuries have severe involvement of the soft tissues (A), some have more severe involvement of bone (B) and others have severe injuries of both bone and soft tissues (C).
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X
It is now accepted that a more accurate and objective method for the assessment of these challenging injuries is needed. 
Many injury severity scores such as the Mangled Extremity Severity Score (MESS),104 the limb salvage index,161 the predictive salvage index,100 the nerve injury, ischemia, soft tissue injury, skeletal injury, shock and age patient (NISSSA) score126 and the Hannover fracture scale180 have since been proposed. The components of different lower-extremity injury scoring systems are listed in Table 10-8. These scores have attempted to evaluate the degree of injury to different tissues separately and include a few external factors which influence the outcome.168 Retrospective design, small sample sizes, and a bias of the score designers in the selection of the component and weighting of the indices have been identified as disadvantages in these scores.21,22,55,114 These scores also have been designed to address limbs which have combined orthopedic and vascular injuries and they are not suitable for evaluating Gustilo IIIb injuries. A severely injured limb with large bone loss and crushing of the soft tissues, which will be a poor choice for salvage, will be grossly underweighted by the above scores if it does not have a vascular injury. This flaw in design will guide the treating surgeon toward attempts at salvage and lead to a higher incidence of secondary amputation.155 A prospective evaluation of their clinical use documented poor performance when applied to Gustilo IIIb injuries. These scores are also not easily applied and therefore not regularly used in practice. 
Table 10-8
Components of Lower-Extremity Injury Severity Scoring Systems22,168
Scoring Systemsa
MESS LSI PSI NISSSA HFS-97 GHOIS
Age X X X
Shock X X X X
Warm ischemia time X X X X X X
Bone injury X X X X
Muscle injury X X X
Skin injury X X X
Nerve injury X X X
Deep-vein injury X
Skeletal/Soft tissue injury X X
Contamination X X X
Time to treatment X
Comorbid conditions X
X

Mangled Extremity Severity Score

The MESS,104 although originally designed to address limbs with vascular damage, is frequently used to predict the likelihood of amputation in Gustilo IIIb injuries. The system is based on four criteria these being the energy of trauma that decides the extent of skeletal and soft tissue injury, the presence and duration of limb ischemia, the presence of shock, and the age of the patient (Table 10-9). A score of >7 has been reported to predict amputation accurately in both retrospective and prospective studies.104 However it has not been duplicated in other prospective series in which an overall sensitivity rate of 46%, increasing to 72% when only ischemic limbs are considered, has been reported.22 Our experience with this score has been the same. In the absence of a vascular deficit, severely injured limbs which are barely salvageable often score below 7 prompting attempts at salvage. This may increase the number of patients requiring secondary amputation.168 
 
Table 10-9
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Table 10-9
Mangled Extremity Severity Score (MESS)104
Type Definition Points
A Skeletal/soft tissue injury
  •  
    Low energy (stab;simple fracture; “civilian” GSW)
  •  
    Medium energy (open or multiple fractures; dislocation)
  •  
    High energy (close-range shotgun or “military” GSW; crush injury)
  •  
    Very high energy (above and gross contamination; soft tissue avulsion)
1
2
3
4
B Limb ischemia (*Score doubled for ischemia >6 hours)
  •  
    Pulse reduced or absent but perfusion normal
  •  
    Pulseless; paraesthesia; diminished capillary refill
  •  
    Cool; paralysed; insensate; numb.
1*
2*
3*
C Shock
  •  
    Systolic BP always >90 mm Hg
  •  
    Hypotensive transiently
  •  
    Persistent hypotension
0
1
2
D Age (years) 0
1
2
X

Ganga Hospital Open Injury Score

The GHOIS was described in 2005 by Rajasekaran et al.154 to specifically address the issue of salvage and reconstruction pathways in Type IIIb injuries. It is shown in Table 10-10. The basis of the score is that the three components of a limb—covering tissues (skin), structural tissues (bone), and functional tissues (muscles, tendons, and nerves) are injured to different severity in every type III injury and hence are graded separately by points ranging from one to five (Figs. 10-13 to 10-15). In addition, seven comorbidities that are known to influence the outcomes are given two points each. The total score is used to assess the need for amputation and the individual scores provide guidelines for management such as the need for a flap or the requirement for bone transport. The scoring involves a detailed assessment of the degree of injury of the different components of the limb and hence must be done after debridement. 
Figure 10-13
Examples of the covering tissues (skin) score for the Ganga Hospital Open Injury Score.
 
A: score 1, wound without skin loss and not exposing the fracture, (B) score 2, wound without skin loss but exposing the fracture site, (C) score 3, wound with skin loss and not over the fracture site, (D) score 4, wound with skin loss and over the fracture site, and (E) score 5, circumferential wound with bone circumferentially exposed.
A: score 1, wound without skin loss and not exposing the fracture, (B) score 2, wound without skin loss but exposing the fracture site, (C) score 3, wound with skin loss and not over the fracture site, (D) score 4, wound with skin loss and over the fracture site, and (E) score 5, circumferential wound with bone circumferentially exposed.
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Figure 10-13
Examples of the covering tissues (skin) score for the Ganga Hospital Open Injury Score.
A: score 1, wound without skin loss and not exposing the fracture, (B) score 2, wound without skin loss but exposing the fracture site, (C) score 3, wound with skin loss and not over the fracture site, (D) score 4, wound with skin loss and over the fracture site, and (E) score 5, circumferential wound with bone circumferentially exposed.
A: score 1, wound without skin loss and not exposing the fracture, (B) score 2, wound without skin loss but exposing the fracture site, (C) score 3, wound with skin loss and not over the fracture site, (D) score 4, wound with skin loss and over the fracture site, and (E) score 5, circumferential wound with bone circumferentially exposed.
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X
Figure 10-14
Examples of the structural tissues (bone) score for the Ganga Hospital Open Injury Score.
 
A: score 1, transverse or oblique fractures or a butterfly fragment involving less than 50% of the circumference. B: score 2, the presence of a large butterfly fragment involving more than 50% of the circumference (C) score 3, extensively comminuted or segmental fractures without loss of bone. D: score 4, primary or secondary loss of bone of less than 4 cm (E) score 5 loss of more than 4 cm.
A: score 1, transverse or oblique fractures or a butterfly fragment involving less than 50% of the circumference. B: score 2, the presence of a large butterfly fragment involving more than 50% of the circumference (C) score 3, extensively comminuted or segmental fractures without loss of bone. D: score 4, primary or secondary loss of bone of less than 4 cm (E) score 5 loss of more than 4 cm.
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Figure 10-14
Examples of the structural tissues (bone) score for the Ganga Hospital Open Injury Score.
A: score 1, transverse or oblique fractures or a butterfly fragment involving less than 50% of the circumference. B: score 2, the presence of a large butterfly fragment involving more than 50% of the circumference (C) score 3, extensively comminuted or segmental fractures without loss of bone. D: score 4, primary or secondary loss of bone of less than 4 cm (E) score 5 loss of more than 4 cm.
A: score 1, transverse or oblique fractures or a butterfly fragment involving less than 50% of the circumference. B: score 2, the presence of a large butterfly fragment involving more than 50% of the circumference (C) score 3, extensively comminuted or segmental fractures without loss of bone. D: score 4, primary or secondary loss of bone of less than 4 cm (E) score 5 loss of more than 4 cm.
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X
Figure 10-15
 
Examples of the functional tissues (muscles, tendons, and nerves) score for the Ganga Hospital Open Injury Score (A) score 1, partial injury to musculotendinous units, (B) score 2, complete but repairable injury to musculotendinous units, (C) score 3, irreparable injury to musculotendinous units involving one or more muscles in a compartment or complete injury to the posterior tibial nerve, (D) score 4, loss of one entire compartment (E) score 5, loss of two or more compartments or subtotal amputation.
Examples of the functional tissues (muscles, tendons, and nerves) score for the Ganga Hospital Open Injury Score (A) score 1, partial injury to musculotendinous units, (B) score 2, complete but repairable injury to musculotendinous units, (C) score 3, irreparable injury to musculotendinous units involving one or more muscles in a compartment or complete injury to the posterior tibial nerve, (D) score 4, loss of one entire compartment (E) score 5, loss of two or more compartments or subtotal amputation.
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Figure 10-15
Examples of the functional tissues (muscles, tendons, and nerves) score for the Ganga Hospital Open Injury Score (A) score 1, partial injury to musculotendinous units, (B) score 2, complete but repairable injury to musculotendinous units, (C) score 3, irreparable injury to musculotendinous units involving one or more muscles in a compartment or complete injury to the posterior tibial nerve, (D) score 4, loss of one entire compartment (E) score 5, loss of two or more compartments or subtotal amputation.
Examples of the functional tissues (muscles, tendons, and nerves) score for the Ganga Hospital Open Injury Score (A) score 1, partial injury to musculotendinous units, (B) score 2, complete but repairable injury to musculotendinous units, (C) score 3, irreparable injury to musculotendinous units involving one or more muscles in a compartment or complete injury to the posterior tibial nerve, (D) score 4, loss of one entire compartment (E) score 5, loss of two or more compartments or subtotal amputation.
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X
 
Table 10-10
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Table 10-10
Ganga Hospital Open Injury Score (GHOIS)154
Covering Structures: Skin and Fascia
  •  
    Wound with no skin loss and not over the fracture site
  •  
    Wound with no skin loss and over the fracture site
  •  
    Wound with skin loss and not over the fracture site
  •  
    Wound with skin loss and over the fracture site
  •  
    Wound with circumferential skin loss
1
2
3
4
5
Functional Tissues: Musculotendinous and Nerve Units
  •  
    Partial injury to musculotendinous unit
  •  
    Complete but repairable injury to musculotendinous units
  •  
    Irreparable injury to musculotendinous units, partial loss of a compartment, or complete injury to posterior tibial nerve
  •  
    Loss of one compartment of musculotendinous units
  •  
    Loss of two or more compartments or subtotal amputation
1
2
3
4
5
Skeletal Structures: Bone and Joints
  •  
    Transverse or oblique fracture or butterfly fragment <50% circumference
  •  
    Large butterfly fragment >50% circumference
  •  
    Comminution or segmental fractures without bone loss
  •  
    Bone loss <4 cm
  •  
    Bone loss >4 cm
1
2
3
4
5
Comorbid Conditions: Add Two Points for Each Condition Present
  •  
    Injury leading to debridement interval >12 hours
  •  
    Sewage or organic contamination or farmyard injuries
  •  
    Age >65 years
  •  
    Drug-dependent diabetes mellitus or cardiorespiratory diseases leading to increased anesthetic risk
  •  
    Polytrauma involving chest or abdomen with injury severity score >25 or fat embolism
  •  
    Hypotension with systolic blood pressure <90 mm Hg at presentation
  •  
    Another major injury to the same limb or compartment syndrome
  •  
    Injuries with a score equal to 14 or below are advised salvage.
  •  
    Injuries with score 17 and above usually end up in amputation.
  •  
    Injuries with score 15 and 16 fall into gray zone where decision is made on patient to patient basis.
X
In an initial study of 109 consecutive Type IIIb injuries, all limbs with a score of 14 and below were salvaged successfully. All limbs with a score of 17 and above required an amputation.154 The injuries with a score of 15 and 16 were categorized to be in a gray zone. The unique feature of GHOIS was to recognize that there could not be a single cut off score in a complex clinical situation such as an open injury. The authors, while recommending salvage in all injuries with a score of <14 and that amputation should be considered in injuries with a score of >17 emphasized that there was a gray zone of scores 15 and 16 where the decision to salvage or amputate must be based on factors such as associated injuries, the expertise of the treating team, the social, educational, and cultural background of the patient, the personality of the patient and considerations of the cost where this was applicable. 
In practice GHOIS has many advantages over both the Gustilo classification and MESS. These are listed in Table 10-11. At a threshold score of 14 the score was found to be more accurate than MESS in predicting the need for amputation and avoidance of secondary amputations.155 The individual scores of the GHOIS were found to predict the need for soft tissue cover and the requirement for complex flap procedures.155 Ninety-five percent of patients with a skin score of <3 were treated successfully by simple wound management either by primary skin closure or skin grafting. In comparison, 92% of patients with a score of ≥4 required flap cover. The skeletal score was useful in predicting the nature of the reconstruction procedures that were required.155 Injuries with a score of ≤2 were found to have a high rate of union without the need for bone grafting. Injuries with a bony score of 4 and 5 had a prolonged time to union and required additional surgical procedures. Injuries with a bone score of 4 may be treated with bone grafting alone as the defect was less than 4 cm whereas injuries with a bone score of 5 will require either a bone transport procedure or a free fibular graft procedure as the defect too large to manage by grafting alone. 
 
Table 10-11
Advantages of Ganga Hospital Open Injury Score
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Table 10-11
Advantages of Ganga Hospital Open Injury Score
  •  
    Specifically designed for Type Illb injuries.
  •  
    Assesses severity of injury to skin, muscle, bone separately.
  •  
    Total score predicts amputation.
  •  
    Individual score provides guidelines for reconstruction.
  •  
    Scoring includes comorbidities which influences outcome.
  •  
    Better intra- and interobserver agreement compared to Gustilo classification.
X

Salvage or Amputation?

The decision to amputate or salvage a severely injured limb is an important, but often difficult, decision that requires experience.90,91,190 Availability of advanced soft tissue reconstruction techniques using microsurgery and skeletal reconstruction devices has made limb salvage technically possible even in extreme cases. If not carefully chosen, the patient may be subjected to prolonged attempts at reconstruction with multiple surgeries but finally have a secondary amputation.22,23,68,92,190,196 Every attempt must be made to avoid the “triumph of technique over reason” and a decision regarding the probability of amputation should be made during the index procedure or at least before the definitive soft tissue reconstruction procedure is attempted. 
The need for primary amputation may be obvious in certain instances (Table 10-12). However many injured limbs fall into a gray zone where the availability of an objective assessment criteria would be helpful. The GHOIS, unlike the other scores that have been described for combined orthopedic and vascular injuries, has a better sensitivity and specificity for predicting amputation in Type IIIb injuries.154,155 It must be remembered that no score is infallible and the final decision should depend on a combination of factors including severity of injury, the overall health status of the patient, the technical expertise of the treating team, and the suitability of the patient for prolonged surgical procedures. The patient and his or her family must also be actively involved in the decision at all stages. 
 
Table 10-12
Indications for Primary Amputation
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Table 10-12
Indications for Primary Amputation
  •  
    Warm ischemia time over 8 hours and the limb is completely nonviable.
  •  
    Vascular injury which is nonrepairable with no collateral flow seen in arteriograms.
  •  
    Limb is severely crushed with minimal viable tissue.
  •  
    Presence of severe and debilitating systemic diseases where lengthy surgical procedures to preserve the limb will endanger life.
  •  
    Presence of severe multisystem injuries with an injury severity score of 25 or more where salvage may lead to MODS and death.
  •  
    Damage is so severe that ultimate function will be less satisfactory than with a prosthesis.
  •  
    Ganga hospital open injury severity score 17 and above.
X

Treatment Options

Debridement and Lavage

Thorough debridement is important if the risk of infection is to be minimized. Debridement is an active surgical procedure and not just wound washing. All foreign material and tissues that are contaminated or suspected to be avascular are systematically removed so that whatever is left behind is vascularized living tissue, devoid of contamination. A secondary aim of debridement is also to minimize risk factors for infection such as dead space or hematoma so that the incidence of infection is reduced. 
Debridement should be done as soon as possible after injury and the traditional teaching was that it preferably be completed within 6 hours. The aim was to prevent contamination from becoming infection and early debridement will prevent colonization of the bacteria within the tissues. The basis of the 6-hour rule was animal studies where a threshold of 103 organisms was found to be critical to establish infection.159 This limit was achieved in 5.17 hours. Others have also documented that a colony count of this level can overrun the immune defenses and lead to infection.42 This led to the practice of debridement being done even in the middle of the night when an experienced work force was often not available. The 6-hour rule has been challenged by many recent studies.32,45,149,164,183 Current literature suggests no obvious advantage in performing debridement within 6 hours compared to debridement performed between 6 and 24 hours after injury.45 The effect of delaying debridement >24 hours is however not yet clear.193 Although debridement must be done as soon as safely possible, the thoroughness of debridement seems to be more important than the timing. There are also other local and systemic factors that influence infection and wound healing. These are listed in Table 10-13
 
Table 10-13
Factors Increasing Risk for Infection
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Table 10-13
Factors Increasing Risk for Infection
Local Factors
  •  
    Organic, farm yard, or sewage contamination.
  •  
    Poor debridement with retention of foreign debris and nonviable tissues.
  •  
    Inadequate skeletal stabilization.
  •  
    Presence of dead space.
  •  
    Debridement later than 24 hours.
Systemic Factors
  •  
    Presence of shock and ARDS
  •  
    Comorbid factors like age above 65 years, metabolic disorders like diabetes mellitus, history of smoking.
  •  
    Compartment syndrome and hypovascular tissues.
  •  
    Prolonged hospital stay and exposure to resistant organisms.
  •  
    Poor nutrition.
X
Debridement should be done by an experienced team of both orthopedic and plastic surgeons. An “Orthoplastic approach” involving the plastic surgeon right from the time of debridement has numerous advantages. The combined experience of both specialists in the assessment of soft tissue and skeletal injury will improve debridement and favor early reconstruction without compromising further reconstruction.25,43 In heavily contaminated wounds, thorough washing with copious amounts of saline is advisable before draping the limb. We utilize specially made trolleys for washing the wound before draping and mesh trays of different sizes with outlet tubing for lavage after draping. A soft brush may be used to aid cleaning of dirt particles and debris. It is preferable to apply a tourniquet to the limb before washing. This will allow quick control of severe hemorrhage which may occur rarely during the stage of lavage either by displacement of a clot or from an injury to an exposed, partially damaged vein. 

Lavage

Lavage is used before and after debridement as it clears the debris and hematoma and provides optimal exposure and reduces contamination and the bacterial count.6,4,46,108,134,158 Adequate quantity of lavage fluid must be used for cleaning on the principle that the “solution for pollution is dilution.” Typically more than 9 L of fluid is required in Type IIIb injuries. Evidence supporting the use of lavage in open injuries is given in Table 10-14. There has been considerable debate regarding the use of soap solutions,5,41 the addition of antibiotics to the lavage fluid52,160 and the use of high and low-pressure lavage.12,15,28,51,54,115 Current evidence indicates that normal saline should be routinely used as there is no advantage in adding any soap, antiseptic, or antibiotic to the fluid.46 The use of betadine has also no advantage but has the disadvantage of staining the tissues and obscuring contamination and small dirt particles.24,70,120 It is also possibly toxic to tendon sheaths, cartilage, and periosteum. High-pressure lavage, which was once popular, is now not used as it has not shown any advantage. It may also have the disadvantage of damaging tissues such as periosteum and tendon sheaths and it may also push dirt and debris deeper into the tissues. At present, low-pressure lavage with normal saline is preferred.46 Debridement must be done in a systematic fashion with proper attention to the thorough removal of devitalized tissues. It is outlined in Table 10-15
 
Table 10-14
Wound Lavage in Open Injuries
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Table 10-14
Wound Lavage in Open Injuries
Evidence Supports
  •  
    Adequate quantity of fluid must be used for lavage. Typically at least 9 L of fluid are used for Type Ill B fractures.
  •  
    Lavage clears blood clot, nonviable tissues and debris from tissue planes and dead spaces.
  •  
    Lavage reduces bacterial population.
  •  
    No advantage in adding antiseptic solutions or antibiotics to lavage fluid.
  •  
    Use of hydrogen peroxide, alcohol solution, povidone iodine, and other chemical agents may impair osteoblast function, inhibit wound healing and cause cartilage damage.
  •  
    High pressure pulsatile lavage can reduce bacterial load by 100-fold but has a disadvantage of microscopic damage to the bone, considerable soft tissue damage and may push the bacteria contamination to deeper tissue plane.
  •  
    Low-pressure pulsatile lavage (14 psi @ 550 pulsations per minute) is equally effective as high pressure pulsatile lavage (70 psi @ 1,050 pulsation per minute) and has less harmful effects on tissues.
X
 
Table 10-15
Principles of Debridement
View Large
Table 10-15
Principles of Debridement
Debridement Principles
  •  
    Must be performed by an experienced team and as early as possible.
  •  
    Orthoplastic approach with involvement of plastic surgeons even at the time of index surgery.
Steps
  •  
    Pre-debridement photographs are taken in different angles.
  •  
    Use of tourniquet allows a clear, bloodless field.
Skin and Fascia
  •  
    Wounds must be longitudinally extended to provide adequate visualization of deeper structures.
  •  
    Margins must be trimmed to bleeding dermis to create a clean wound edge.
  •  
    Gentle handling of the skin and prevention of degloving are essential.
  •  
    All avascular fascia must be excised.
Muscles
  •  
    All muscles in the compartment must be evaluated for viability (“4 C” Color, Consistency, Contractility, Capacity to bleed) and debrided.
Bone
  •  
    Bone ends and medullary cavity must be carefully examined for impregnated paint, mud, and organic material.
  •  
    All fragments without soft tissue attachment must be excised.
Lavage
  •  
    Adequate quantity of fluid with low-pressure pulsatile lavage is preferable.
Completion
  •  
    Deflate tourniquet and evaluate viability of all retained structures.
  •  
    Assess loss of tissues and document with photograph for future reference and planning.
  •  
    Decide on method and timing of wound closure or coverage and bone stabilization.
  •  
    Document sequence of reconstruction.
  •  
    In very severe tissue loss VAC may be used as a bridging procedure till the patient is fit for flap cover.
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The Use of Tourniquets

There is controversy regarding the use of a tourniquet during debridement. The traditional teaching is not to use a tourniquet during debridement as it may injure the already hypoxic tissues and will also interfere with the assessment of muscle viability.166 However, our experience is the opposite and we routinely use a tourniquet as it improves the thoroughness of debridement and prevents unnecessary blood loss. In a limb without vascular deficit there is no proof that application of a tourniquet for the period of debridement, which ranges from 30 to 60 minutes, has any deleterious effects on the retained viable tissues. Without a tourniquet, the injured tissues bleed easily if touched and this disturbing bleeding often hampers the surgeon’s vision and hides contamination, especially in the deeper muscular planes. In contrast, a bloodless field helps to identify contamination, protect the vital structures, explore the joint cavities and also save unnecessary blood loss in a patient who may already be in shock. At the end of the debridement, the tourniquet is released and the viability of all retained tissues can be ascertained reliably. Viable muscles appear pale while under tourniquet and blush immediately on release, whereas avascular muscles appear dark red even while under tourniquet with no change after release of the tourniquet. With experience we have found that it is much easier to identify nonviable muscles under tourniquet than in a bloody field. We attribute our high success rate of early reconstruction with low infection to our routine protocol of performing debridement under tourniquet. The use of loupes also facilitates the identification of dirt and contamination and helps to improve the quality of debridement. 

Superficial Debridement

Debridement of the skin begins with assessment of the orientation of the wound, its margins, the quality of the skin surrounding the wound, and the presence of any flaps or closed degloving. Irrespective of the initial orientation, wounds must be extended using extensile incisions for proper inspection of the deeper tissues. The length of incision depends upon the nature of injury. Typically longer incisions are required for more severely contaminated wounds and wounds over a joint to allow proper inspection of all parts of the joint. Extension of skin incisions must be done without separating the skin from the deep fascia as this may decrease viability and increase hematoma formation. Debridement of the skin must be undertaken without a tourniquet as the extent of skin resection is usually decided by the presence of bleeding skin edges. All nonviable, shredded, and irregular margins of the skin must be gradually trimmed so that only healthy skin remains. Although nonviable skin must not be retained, indiscriminate removal of skin flaps must be avoided. Viable skin flaps can cover exposed bone and help to limit the extent of soft tissue reconstruction that is required. Distally based skin flaps have less vascularity than proximally based skin flaps but flaps with a large base often have sufficient vascularity to allow good healing (Fig. 10-16). Whenever the viability of a flap is in doubt, it is better to retain the skin for debridement during the secondary procedure. Special attention must be paid to debridement of the fascia as retaining nonviable fascia often causes infection. Fascia which is detached, shredded, or even doubtfully nonviable must be excised. 
Figure 10-16
Large skin flaps, especially over the joints, may be viable and can be retained with great benefit.
 
Here, an open injury of the lower end of the femur has a large flap (A, B) which satisfied the requirements for primary closure which was done after suitable internal fixation (C, D). Primary healing of both the skin (E) and bone were achieved.
Here, an open injury of the lower end of the femur has a large flap (A, B) which satisfied the requirements for primary closure which was done after suitable internal fixation (C, D). Primary healing of both the skin (E) and bone were achieved.
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Figure 10-16
Large skin flaps, especially over the joints, may be viable and can be retained with great benefit.
Here, an open injury of the lower end of the femur has a large flap (A, B) which satisfied the requirements for primary closure which was done after suitable internal fixation (C, D). Primary healing of both the skin (E) and bone were achieved.
Here, an open injury of the lower end of the femur has a large flap (A, B) which satisfied the requirements for primary closure which was done after suitable internal fixation (C, D). Primary healing of both the skin (E) and bone were achieved.
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Deep Debridement

Debridement of the muscles and deeper structures must be done with great care. An aggressive approach to muscle debridement must be adopted as retained necrotic muscle is a major growth medium for bacteria and greatly increases the risk of anaerobic infection. Classically muscle viability is assessed by the four C’s: Contractability, Color, Consistency, and Capacity to bleed.148 Different authors have reported differently on the relative importance of these four parameters. We feel that accurate judgment comes with experience but where there is doubt it is better to excise than retain dubiously vascularized muscle. If a tourniquet is used, viable muscles appear pale while under tourniquet and blush immediately on release, whereas avascular muscles appear dark red even while under tourniquet with no change after release of the tourniquet. 
Muscles may be damaged quite extensively even in the presence of a small external wound. Careful examination of all muscles of the different compartments is required to rule out occult muscle damage. Proximal avulsion of entire muscle bellies with complete devascularization of the muscles is common in the forearm and this should be recognized. This will require the excision of the entire muscle bellies but the tendons can be retained and tethered to intact muscles in a later reconstructive procedure. However, the tendons and tendon sheaths are highly susceptible to drying and desiccation and care must be taken to protect them under skin flaps or bury them under muscles. 

Bone

Bone damage varies considerably with the site of the injury and may be independent of the damage to the soft tissues. The decision to retain or discard damaged bone is done on the basis of vascularity and whether the fragments are from the diaphysis, metaphysis, or the articular margins. Retained avascular bone is a rich source of infection and diaphyseal fragments, regardless of their size, which are devoid of soft tissue attachments must be removed (Fig. 10-17). It is not clear how much soft tissue attachment is required for viability but pieces with less than 50% soft tissue attachment should be considered to have poor viability. If preserved, they should be carefully examined during subsequent relook surgery to reassess their viability. Large bone fragments may be used temporarily to achieve length and alignment after thorough cleaning. Once stabilization is complete, they can then be discarded. In contrast to diaphyseal bones, metaphyseal bones, which are purely cancellous, have a higher capacity for revascularization and integration and can be preserved if not grossly contaminated. Cancellous bone involving the articular surface is usually retained so that reconstruction of the joint surface is possible.139 (Fig. 10-18). In the ankle, foot and carpal regions, entire tarsal and carpal bones may sometimes be extruded. We have frequently retained such bones, if not severely contaminated, with good results. If there is metaphyseal comminution adjacent to a joint, the retained bone fragments must be stably fixed so that the complications of secondary loss of bone, joint incongruity, and infection are reduced. 
Figure 10-17
Comminuted cortical bone fragments without soft tissue attachments are avascular and nonviable.
 
(A, B) They must be removed (C) as retaining them may result in infection.
(A, B) They must be removed (C) as retaining them may result in infection.
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Figure 10-17
Comminuted cortical bone fragments without soft tissue attachments are avascular and nonviable.
(A, B) They must be removed (C) as retaining them may result in infection.
(A, B) They must be removed (C) as retaining them may result in infection.
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Figure 10-18
Metaphyseal fragments, with attached articular surfaces, can be retained even if they are devoid of soft tissue attachments.
 
In this case the femoral condylar fragments were found to be freely floating without soft tissue attachments (A, B). The lower end of femur was reconstructed and primary skin closure undertaken. Both bone and soft tissue healing were achieved (C, D).
In this case the femoral condylar fragments were found to be freely floating without soft tissue attachments (A, B). The lower end of femur was reconstructed and primary skin closure undertaken. Both bone and soft tissue healing were achieved (C, D).
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Figure 10-18
Metaphyseal fragments, with attached articular surfaces, can be retained even if they are devoid of soft tissue attachments.
In this case the femoral condylar fragments were found to be freely floating without soft tissue attachments (A, B). The lower end of femur was reconstructed and primary skin closure undertaken. Both bone and soft tissue healing were achieved (C, D).
In this case the femoral condylar fragments were found to be freely floating without soft tissue attachments (A, B). The lower end of femur was reconstructed and primary skin closure undertaken. Both bone and soft tissue healing were achieved (C, D).
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In injuries where the fractured ends of the bones have been exposed, there may be deep impregnation of paint, mud, and other organic material in the fractured bone ends. This is often difficult to completely remove by cleaning and ideally the contaminated bone should be resected to clean the bone. In sports and farmyard injuries, there can be considerable mud and dirt inside the medullary canal which should be carefully curetted and cleaned. If necessary, the bone ends must be delivered out of the wound for proper inspection and cleaning. Otherwise, fulminant deep infection can ensue which may lead to amputation. 
It is important that during debridement, the surgical team should focus only on adequacy of debridement without being concerned about the ease of reconstruction. Modern methods of microvascular soft tissue reconstruction and bone transport allow successful reconstruction but only in the absence of infection. A large, clean wound has a higher chance of successful reconstruction than a smaller but inadequately debrided wound. Errors of judgment by the less experienced at this stage are an important cause of complications and failure. 

Skeletal Stabilization

It is good practice to discard the instruments and table that are utilized during debridement and use a separate set of fresh instruments for skeletal stabilization so that contamination is avoided. In cases of severe organic contamination, it is also advisable to redrape the limb and for the surgical team to rescrub before reconstruction is undertaken. 
Stable skeletal stabilization must be achieved as it helps to alleviate pain and prevent further soft tissue damage. During skeletal stabilization the length of the limb must be restored as this restores the correct tension to the soft tissues and this decreases swelling, improves circulation, and aids venous and lymphatic return. It also increases the comfort of the patient during wound inspection and facilitates early rehabilitation and movement of joints. 
Skeletal stabilization should be undertaken quickly especially in the setting of vascular deficit and it must be designed to allow future soft tissue reconstruction. A variety of stabilization methods are available and the choice depends on the morphology of the fracture and the planned reconstructive procedures. In high-energy injuries associated with contamination, our preference is to use a temporary external fixator device followed by secondary internal fixation at a later operation. 
In situations where there is a good soft tissue envelope as in upper limb and femoral fractures or in situations where soft tissue cover could be achieved within 48 to 72 hours primary internal fixation can be considered. The choice of plate or nailing depends on the location of injury. As a general rule, we have found that plate fixation is preferable for all open upper limb injuries and periarticular injuries with or without articular surface involvement. Lower limb diaphyseal fractures are usually treated by IM nailing either as a primary or secondary procedure. However there are many exceptions to these rules and individual decisions need to be done on a patient to patient basis. 

Plaster Casts and Traction

Plaster casts and traction are now rarely used in open injuries. Wound inspection and dressing is very difficult and cast contamination can be unpleasant and increase the risk of infection. Casts also compromise the early detection of compartment syndrome, skin blistering, and skin necrosis. Puno et al.150 reported an infection rate of >15% and a malunion rate of up to 70% in tibial fractures treated with plaster cast immobilization. Skeletal traction can be used in open pelvic fractures in addition to external fixation or in open femoral fractures for a short time till definitive treatment is planned. 

External Skeletal Fixation

External fixation, especially half pin unilateral frames, is the workhorse for skeletal stabilization in open fractures as it provides a swift versatile method of providing stability without the need for additional exposure or periosteal striping even in demanding situations.11 Ilizarov ring fixators and other ring fixators are used mainly in juxta-articular fractures with soft tissue injury and in fractures with bone loss. 
External fixators are mainly used as temporary stabilizers with conversion to internal fixation being undertaken at an appropriate time. They can be used as a definitive treatment when a stable fracture configuration with good reduction and circumferential contact is achieved (Fig. 10-19). A meta-analysis of the treatment of open tibial diaphyseal fractures by Giannoudis et al.66 reported a union rate of 94% at a mean of 37 weeks and an overall infection rate of 16.2%. Chronic osteomyelitis developed in 4.2% of fractures. External fixators also have a high rate of complications62,172 the most common being pin loosening, infection, and malunion. Pin tract infection is the most frequent complication with external fixation and occurs in up to 32% of patients. This can lead to chronic osteomyelitis and make future conversion to IM nailing difficult. Utmost care should be exercised in the placement of the pins and during follow-up.62 
Figure 10-19
In patients where there is good circumferential bone contact, with a stable reduction, external fixation can be maintained until bone union is achieved.
Rockwood-ch010-image019.png
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The following points need emphasis. 
  1.  
    Whenever external fixation has to be maintained for a long period, pre-drilling should be done to minimize thermal necrosis as this may lead to pin loosening and infection.33,197
  2.  
    The pins must be judiciously placed to allow further soft tissue reconstruction. The availability of a plastic surgeon at the time of debridement is valuable to plan the soft tissue reconstruction and place the pins suitably.
  3.  
    Pins should be placed through intact soft tissues rather than through the open wound.118
  4.  
    In the presence of degloving, further debridement may lead to further secondary loss of skin and the need to change pin sites.
  5.  
    External fixators must be applied with good reduction of the fracture. When the fracture is distant from the open wound small pin incisions may be made in consultation with the plastic surgeons.
  6.  
    Whenever conversion to internal fixation is planned in advance, care must be taken to avoid placing the pins in the line of future surgical incisions.
  7.  
    In fractures with articular surface involvement, especially in fractures around the knee and elbow, joint congruity must be achieved on day 1 with appropriate internal fixation as late reconstruction of the joint surface is often not possible.
  8.  
    Pins must be placed with a thorough knowledge of the regional anatomy so that injuries to the neurovascular structures are avoided.
  9.  
    Pins should avoid joints and the capsular reflections of joints as any infection will lead to septic arthritis.101 For example, proximal tibial pins should be placed 14 mm distal to the articular surface to avoid intra-articular placement.
  10.  
    Muscle and tendon impalement must be avoided as entrapped musculotendinous units restrict movement and cause pain and discomfort.56 Drill sleeves should be used and appropriate dissection of the soft tissues must be done to avoid critical soft tissue impalement.
Meticulous care of pin tracts is very important to avoid infection. The pin tracts must be cleaned with hydrogen peroxide and dressed every day with chlorhexidine solution or povidone iodine. Even a few days of neglect may result in a deep pin tract infection which will complicate the management of the fracture and delay the process of reconstruction. 
Conversion to internal fixation, when needed, must be performed early provided there are no contraindications. In our experience152,154,155 definitive internal fixation either by an interlocking nail or a plate is ideally performed before the stage of definitive soft tissue cover. Once a flap is performed, conversion has to be postponed to accommodate the flap settling time which may be between 3 and 4 weeks. There is a high chance of colonization of bacteria through the pin tracts at this time.7,19,123125 In a meta-analysis16 it was demonstrated that conversion of external fixation to IM nailing in open tibial and femoral fractures within 28 days resulted in a reduced rate of infection of only 3.7% compared to 22% when performed later. In late conversions, an interval of 10 to 14 days between removal of the external fixator and internal fixation has also been advised. 

Primary Internal Fixation

Primary internal fixation was considered unacceptable38,165 even two decades ago due to the fear of increased infection and damage to the blood supply during the process of fixation. However, with refinement of the techniques of debridement, primary bone stabilization by interlocking nails and plate fixations are being increasingly performed with good results.61,107 As a general rule, plate fixation is ideal for fractures of the upper limb. The choice between a locking nail and a plate for the lower limb bones is made depending on the fracture morphology, the instrumentation that is available and the surgeon’s preference. 

Plate Fixation

Internal fixation using plates40,8 has the disadvantages of needing increased soft tissue exposure and periosteal stripping but these can be largely minimized by experience and careful technique. Plate fixation is the method of choice in most open upper limb fractures, femoral fractures involving the periarticular and articular regions, all intra-articular and juxta articular fractures, and in open injuries with vascular involvement (Fig. 10-20). If plate fixation is performed, a critical factor to maximizing the chances of success is achieving wound cover within 3 days. Locking plates provide internal fixation with greater stability but it should be stressed there are no large series reporting the outcome or superiority of locking plates. 
Figure 10-20
Plate fixation is the preferred form of skeletal stabilization in metaphyseal and articular fractures of both the femur and tibia.
 
The figure shows a type IIIb open fracture of the proximal tibia (A, B, C) which was stabilized with a plate (D, E). A medial gastrocnemius flap was used for soft tissue cover (F, G).
The figure shows a type IIIb open fracture of the proximal tibia (A, B, C) which was stabilized with a plate (D, E). A medial gastrocnemius flap was used for soft tissue cover (F, G).
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Figure 10-20
Plate fixation is the preferred form of skeletal stabilization in metaphyseal and articular fractures of both the femur and tibia.
The figure shows a type IIIb open fracture of the proximal tibia (A, B, C) which was stabilized with a plate (D, E). A medial gastrocnemius flap was used for soft tissue cover (F, G).
The figure shows a type IIIb open fracture of the proximal tibia (A, B, C) which was stabilized with a plate (D, E). A medial gastrocnemius flap was used for soft tissue cover (F, G).
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Intramedullary Nails

Intramedullary nails are often the first choice for fixation of lower limb diaphyseal fractures as they provide superior biomechanical conditions and also maintain the length and rotation of the limb (Fig. 10-21). They are ideally suited for Gustilo type I and II injuries and even in type III injuries where contamination isminimal and effective debridement has been performed. Giannoudis et al.66 found a union rate of 95% for unreamed nails and 97% for reamed nails in open tibial fractures proving the safety and superiority of this method of skeletal fixation even in open injuries. Analysis showed that 15.5% of patients required bone grafting and 32% required an additional procedure to achieve bone union. The overall infection rate was 6% to 7%. Kakar and Tornetta105 reported a very low rate of infection of only 3% and there are now many studies proving the advantages of primary nail fixation in open injuries.79,105,119 
Figure 10-21
Tibial diaphyseal fractures are ideally stabilized with interlocking nails as they provide both longitudinal and rotational stability.
 
In this case a comminuted type IIIb fracture (A, B) has been treated with a locking nail and a rotational flap (C, D).
In this case a comminuted type IIIb fracture (A, B) has been treated with a locking nail and a rotational flap (C, D).
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Figure 10-21
Tibial diaphyseal fractures are ideally stabilized with interlocking nails as they provide both longitudinal and rotational stability.
In this case a comminuted type IIIb fracture (A, B) has been treated with a locking nail and a rotational flap (C, D).
In this case a comminuted type IIIb fracture (A, B) has been treated with a locking nail and a rotational flap (C, D).
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The decision to use reamed or unreamed nails was debated but now there are many studies which show the superiority of the reamed nail.75 Some of the stated advantages and disadvantages are listed in Table 10-16. Unreamed nails appear more biologic64 as they cause less devascularization,163 are quicker to perform and have lower incidence of fat embolism and thermal necrosis.142 But they have the disadvantage of an increased rate of implant failure with screw and nail breakages, fracture disruption during surgery and a higher rate of nonunion and malunion. The general consensus is toward the use of reamed nailing, but over-reaming must be avoided to prevent thermal necrosis and infection. Adequate careful reaming allows the use of larger diameter nails that give better stability with reduced rates of hardware failure. The reamed products also stimulate osteogenesis at the fracture site which augments fracture healing. In a canine study, Klein et al.109 documented damage to cortical blood flow of up to 70% in reamed nails but only 31% in unreamed nails. However, many trials including the SPRINT trial13 and different meta-analyses14 have not proved any significant superiority of unreamed over reamed nailing in achieving bony union. 
 
Table 10-16
Reamed versus Unreamed Nailing
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Table 10-16
Reamed versus Unreamed Nailing
Reamed Nailing
  •  
    Reamings function as autologous bone graft
  •  
    Induces a sixfold increase in periosteal blood flow
  •  
    Shorter union time with fewer nonunions
  •  
    Allows insertion of larger nails with increased stability.
Unreamed Nailing
  •  
    Higher rate of secondary interventions
  •  
    Patello-femoral complications are more common
  •  
    Smaller diameter nails with decreased stability
  •  
    Shorter operating time
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Acute Management of Bone Loss

Bone loss of varying degrees can occur due to primary bone loss at the time of accident or during primary or secondary debridement. Considerable experience is often required regarding the retention of comminuted bone fragments as there is no clear indication as to how much soft tissue attachment is required to maintain viability of the fragments. Although a low threshold is advised for retaining cortical fragments, metaphyseal fragments with cancellous bone and fragments containing articular margins are usually retained after adequate cleaning even when there is no soft tissue attachment. Although large bone gaps may tilt the balance toward amputation in many cases, the dictum that a larger bone gap without infection is a preferable to a smaller gap with nonviable bone must also be remembered. 
Bone gaps in the upper limb can generally be managed by bone shortening followed by bone grafting. Whenever there is bone loss, the ends of the bone can be trimmed suitably so that there is a good contact for stable fixation. In the humerus, it is our experience that patients cope with shortening of even 4 cm very easily. There is rarely any residual weakness after adequate therapy. In the forearm, bone shortening must be very carefully done because of the presence of two bones. A differential loss of up to 2 cm in one bone can be easily managed by bone grafting the defect. If there is a very severe loss of either the radius or the ulna, reconstruction to create a single bone forearm is a viable option. In many mangled extremities, this option has not only allowed us quick and early reconstruction but has also made salvage possible avoiding amputation (Fig. 10-22). 
Figure 10-22
This patient presented with a severe mangled injury of the forearm and major bone loss involving both the radius and ulna (A, B).
 
A one-bone forearm reconstruction procedure was undertaken and a good result was achieved (C, D).
A one-bone forearm reconstruction procedure was undertaken and a good result was achieved (C, D).
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Figure 10-22
This patient presented with a severe mangled injury of the forearm and major bone loss involving both the radius and ulna (A, B).
A one-bone forearm reconstruction procedure was undertaken and a good result was achieved (C, D).
A one-bone forearm reconstruction procedure was undertaken and a good result was achieved (C, D).
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In the lower limb, the extent of bone loss determines reconstruction options. A loss of less than 2 cm is well tolerated and primary shortening can be safely done. When the loss is due to the removal of a large comminuted fragment, or when the circumferential loss is less than 3 cm, iliac crest bone grafting will usually suffice. The timing of bone grafting is determined by the status of the soft tissue bed and the soft tissue cover. Early or even immediate bone grafting has been reported to give good results depending upon the timing of soft tissue cover. When the loss exceeds 4 cm, a decision is made between primary bone shortening and subsequent lengthening (Fig. 10-23) or bridging the gap by bone transport (Fig. 10-24). Although ring fixators undoubtedly provide excellent stability and versatility of bone transport, they are not usually the primary choice in the acute phase. Loading a frame in the acute setting can be time consuming and cumbersome and can also interfere with future plastic surgical procedures. Unilateral limb reconstruction systems not only offer the advantages of ease and speed of application but they are also more patient and surgeon friendly and are equally effective in bone transport. (See Chapter 15 for further information about the management of bone defects.) 
Figure 10-23
Acute bone shortening and lengthening.
 
This patient presented with a type IIIb open supracondylar femoral fracture with primary bone loss (A, B). The patient was treated with acute shortening with lengthening at the subtrochanteric region (C, D).
This patient presented with a type IIIb open supracondylar femoral fracture with primary bone loss (A, B). The patient was treated with acute shortening with lengthening at the subtrochanteric region (C, D).
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Figure 10-23
Acute bone shortening and lengthening.
This patient presented with a type IIIb open supracondylar femoral fracture with primary bone loss (A, B). The patient was treated with acute shortening with lengthening at the subtrochanteric region (C, D).
This patient presented with a type IIIb open supracondylar femoral fracture with primary bone loss (A, B). The patient was treated with acute shortening with lengthening at the subtrochanteric region (C, D).
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Figure 10-24
Large bone gaps of more than 4 cm cannot be treated by acute shortening.
 
They are ideally treated by bone transport. This patient presented with a type IIIb fracture with extensive soft tissue loss and fracture comminution (A, B). Following debridement there was a considerable bone defect (C). This was treated by bone transport (D, E) and subsequent plating (F).
They are ideally treated by bone transport. This patient presented with a type IIIb fracture with extensive soft tissue loss and fracture comminution (A, B). Following debridement there was a considerable bone defect (C). This was treated by bone transport (D, E) and subsequent plating (F).
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Figure 10-24
Large bone gaps of more than 4 cm cannot be treated by acute shortening.
They are ideally treated by bone transport. This patient presented with a type IIIb fracture with extensive soft tissue loss and fracture comminution (A, B). Following debridement there was a considerable bone defect (C). This was treated by bone transport (D, E) and subsequent plating (F).
They are ideally treated by bone transport. This patient presented with a type IIIb fracture with extensive soft tissue loss and fracture comminution (A, B). Following debridement there was a considerable bone defect (C). This was treated by bone transport (D, E) and subsequent plating (F).
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Wound Cover

Primary Closure of Wounds

Although controversial, good results are being increasingly reported after primary skin closure31,36,50,58,72,76,93,96,130,166,173,184 a concept that was advocated as early as 1948. Hope and Cole97 in a series of tibial fractures in children reported an infection rate of 7.8% with primary closure compared with 14.6% with secondary closure. Cullen et al.47 reviewed the records of 83 children with open fractures of the tibial metaphysis and diaphysis in which 57 wounds were closed primarily. Only two children developed superficial infection. 
Recently Rajasekaran et al.152 reported the results of immediate primary skin closure in Type III injuries using strict inclusion and exclusion criteria which are listed in Table 10-17. They have reported excellent results with only 3% deep infection rate. They emphasized that a GHOIS skin score of 1 or 2, a total score of less than 10, the presence of bleeding wound margins which could be opposed without tension and stable skeletal fixation were important (Fig. 10-25). Successful immediate closure was possible in 32% of the patients but they advised that the wounds be left open whenever there was doubt regarding the fitness for closure. 
A good functional outcome was achieved without any complications (E, F).
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A good functional outcome was achieved without any complications (E, F).
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Figure 10-25
An open tibial fracture with a GHIOS score of 6 (skin 2, bone 2, and MTS 2) (A, B) which has been treated by primary closure and interlocking nail at the index procedure (C, D).
A good functional outcome was achieved without any complications (E, F).
A good functional outcome was achieved without any complications (E, F).
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A good functional outcome was achieved without any complications (E, F).
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Table 10-17
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Table 10-17
Primary Closure of Open Wounds155
Indications
  •  
    Type I and II open injuries and III A and B injuries of limbs without vascular deficit.
  •  
    Wounds without primary skin loss or secondary skin loss after debridement.
  •  
    Ganga Hospital skin score of 1 or 2 and a total score of 10 or less.
  •  
    Injury to debridement interval less than 12 hours.
  •  
    Presence of bleeding wound margins which can be apposed without tension.
  •  
    Stable fixation achieved either by internal or external fixation.
Contraindications
  •  
    Type IIIC injuries.
  •  
    Ganga Hospital skin score of 3 or more and a total score of >10.
  •  
    Wounds in patients with severe polytrauma involving and an injury severity score >25.
  •  
    Sewage or organic contamination/farmyard injuries.
  •  
    Peripheral vascular diseases/thromboangiitis obliterans.
  •  
    Drug-dependent diabetes mellitus/connective tissue disorders/peripheral vasculitis.
X
If primary closure is to be successful, the following points have to be kept in mind. 
  1.  
    When the patient initially presents in the emergency room, almost all open injuries appear to have skin loss. Because of shortening or angulation at the fracture site, the lacerated wound often gapes open exposing deeper structures and bone. In many cases, the margins will oppose easily when the fracture is reduced and limb length restored. (Fig. 10-26). Hence the assessment of skin loss and the ability to oppose the skin without tension should be done only after fracture reduction.
  2.  
    The length of the wound does not correlate with the ease with which the wound can be closed by primary closure. Lacerated wounds without skin loss can be closed, irrespective of the size of the wound, provided the skin can be opposed without tension (Fig. 10-27).
  3.  
    A GHOIS of ≥10 denotes a high-energy injury possibly with a crushing component. The zone of injury may not be obvious on day 1 or during the index procedure. These limbs have a tendency to swell up in the next few days and therefore are not suitable for primary closure.
  4.  
    Careful judgment is required in the presence of skin flaps. Flaps are common especially in wounds around the joints where there is loose skin on the extensor aspect. When the joint is flexed, these flaps retract making the wound appear very large. Many of these flaps, if viable, can be managed by primary closure when the joint is extended.
  5.  
    Flaps must be differentiated from closed degloving as the viability of the skin over degloved tissue is very poor. Lacerations adjacent to closed degloving or associated with extensive bruising of the skin are not suitable for primary closure.
  6.  
    Wounds treated with primary closure should have a deep drain inserted so that an underlying hematoma is avoided. They should be observed carefully for early infection to facilitate early intervention if this is required.
  7.  
    A useful policy is “whenever in doubt, do not close.” Whenever in doubt, delayed primary closure where the decision to close the wound is postponed to the second look surgery 48 to 72 hours later is preferable. Indications for a second look are listed in Table 10-18.
Figure 10-26
Assessment of skin loss requires experience and must be done after the skeletal length is restored.
 
In the emergency room and during debridement, all lacerated wounds appear to have skin loss as they gape due to bone shortening and angulation (A). Once fracture reduction is achieved, the wound margins usually come together and primary closure is possible in nearly one-third of injuries (B).
In the emergency room and during debridement, all lacerated wounds appear to have skin loss as they gape due to bone shortening and angulation (A). Once fracture reduction is achieved, the wound margins usually come together and primary closure is possible in nearly one-third of injuries (B).
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In the emergency room and during debridement, all lacerated wounds appear to have skin loss as they gape due to bone shortening and angulation (A). Once fracture reduction is achieved, the wound margins usually come together and primary closure is possible in nearly one-third of injuries (B).
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Figure 10-26
Assessment of skin loss requires experience and must be done after the skeletal length is restored.
In the emergency room and during debridement, all lacerated wounds appear to have skin loss as they gape due to bone shortening and angulation (A). Once fracture reduction is achieved, the wound margins usually come together and primary closure is possible in nearly one-third of injuries (B).
In the emergency room and during debridement, all lacerated wounds appear to have skin loss as they gape due to bone shortening and angulation (A). Once fracture reduction is achieved, the wound margins usually come together and primary closure is possible in nearly one-third of injuries (B).
View Original | Slide (.ppt)
In the emergency room and during debridement, all lacerated wounds appear to have skin loss as they gape due to bone shortening and angulation (A). Once fracture reduction is achieved, the wound margins usually come together and primary closure is possible in nearly one-third of injuries (B).
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Figure 10-27
An open fracture with tibial comminution and exposure of the articular surfaces (A, B).
 
Although the wound measured 31 cm, there was no loss of skin and bleeding viable skin margins could be opposed without tension (C). Primary wound healing was achieved (D). Leaving the wound open would have carried the risk of severe joint infection and desiccation of the articular cartilage. Soft tissue reconstruction using a flap would have also involved a complicated procedure.
Although the wound measured 31 cm, there was no loss of skin and bleeding viable skin margins could be opposed without tension (C). Primary wound healing was achieved (D). Leaving the wound open would have carried the risk of severe joint infection and desiccation of the articular cartilage. Soft tissue reconstruction using a flap would have also involved a complicated procedure.
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Figure 10-27
An open fracture with tibial comminution and exposure of the articular surfaces (A, B).
Although the wound measured 31 cm, there was no loss of skin and bleeding viable skin margins could be opposed without tension (C). Primary wound healing was achieved (D). Leaving the wound open would have carried the risk of severe joint infection and desiccation of the articular cartilage. Soft tissue reconstruction using a flap would have also involved a complicated procedure.
Although the wound measured 31 cm, there was no loss of skin and bleeding viable skin margins could be opposed without tension (C). Primary wound healing was achieved (D). Leaving the wound open would have carried the risk of severe joint infection and desiccation of the articular cartilage. Soft tissue reconstruction using a flap would have also involved a complicated procedure.
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Table 10-18
Need for Second Look Debridement
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Table 10-18
Need for Second Look Debridement
  •  
    High-energy blast injuries
  •  
    Severe contamination, farmyard, and sewage contamination
  •  
    Delayed presentation >12 hours
  •  
    Evidence of infection during debridement
  •  
    Initial debridement considered unsatisfactory
X

Timing of Wound Cover

After debridement and appropriate skeletal stabilization, the most important factor that determines outcome is the timing and method of wound coverage. Adequate cover of the exposed wound by viable skin or soft tissue at the earliest possible time is essential. Exposure and desiccation can quickly lead to necrosis of many important deeper structures such as periosteum, articular cartilage, paratenon, and fascia. Delay also increases the chances of contamination and infection which can deleteriously affect the reconstruction process and even result in amputation. However there is still considerable controversy regarding the ideal timing and method of wound cover with different definitions being used by different authors. Suggested definitions are given in Table 10-19. It is important to understand the concept of the zone of injury and the sources of infection before discussing the timing of wound cover. 
 
Table 10-19
Timing of Wound Closure
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Table 10-19
Timing of Wound Closure
  •  
    Primary Closure: Wound closed by direct skin suturing during the index procedure.
  •  
    Immediate Cover: Soft tissue cover performed within 48 hours.
  •  
    Early Cover: Soft tissue cover performed within 1 week.
  •  
    Delayed Cover: Soft tissue cover performed within 3 weeks.
  •  
    Staged Reconstruction: Soft tissue reconstruction done after 3 weeks.
X

Zone of Injury

Blunt and open injuries with a crushing element have a larger area of impact and tissue destruction than penetrating injuries.74,76,88 The extent of damage, especially to the deeper tissues, may be much wider than it initially appears. This has given rise to the concept of the zone of injury (Fig. 10-28). Three typical zones of injury are described. The direct trauma contact area is the central zone or “zone of necrosis” and is directly beneath the wound. Surrounding this zone is the “zone of injury” which extends into the peripheral uninjured viable zone. The extent of these zones depends on the amount of energy imparted to the tissues at the time of impact and also on the anatomy of the area of impact. This zone of injury is characterized by inflammatory edematous soft tissue with disturbed microcirculation. Following a severe impact, the zone may appear viable at the initial debridement but may show evidence of partial or complete nonviability and loss of tissue over the next few days. It is often difficult to clearly distinguish the zone from adjacent healthy tissues immediately after trauma and during the initial debridement. This has considerable clinical importance because the vascular pedicles of flaps which are based in this zone of injury or microvascular anastomoses performed in this area are associated with an increased rate of failure. Failure to recognize this phenomenon will result in failure of soft tissue reconstruction failures and may make further reconstruction impossible. 
Figure 10-28
This case demonstrates the concept of “zone of injury.”
 
The injury resulted in a comminuted fracture of the femur and tibia. On presentation, the wound was deceptively small (A, B, C). There was extensive skin and tissue over the next 3 days as the zone of injury slowly revealed itself (D). This required secondary debridement (E) and the defect required a latissimus dorsi free flap (F). The fractures were treated by primary plate fixation (G, H).
The injury resulted in a comminuted fracture of the femur and tibia. On presentation, the wound was deceptively small (A, B, C). There was extensive skin and tissue over the next 3 days as the zone of injury slowly revealed itself (D). This required secondary debridement (E) and the defect required a latissimus dorsi free flap (F). The fractures were treated by primary plate fixation (G, H).
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The injury resulted in a comminuted fracture of the femur and tibia. On presentation, the wound was deceptively small (A, B, C). There was extensive skin and tissue over the next 3 days as the zone of injury slowly revealed itself (D). This required secondary debridement (E) and the defect required a latissimus dorsi free flap (F). The fractures were treated by primary plate fixation (G, H).
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Figure 10-28
This case demonstrates the concept of “zone of injury.”
The injury resulted in a comminuted fracture of the femur and tibia. On presentation, the wound was deceptively small (A, B, C). There was extensive skin and tissue over the next 3 days as the zone of injury slowly revealed itself (D). This required secondary debridement (E) and the defect required a latissimus dorsi free flap (F). The fractures were treated by primary plate fixation (G, H).
The injury resulted in a comminuted fracture of the femur and tibia. On presentation, the wound was deceptively small (A, B, C). There was extensive skin and tissue over the next 3 days as the zone of injury slowly revealed itself (D). This required secondary debridement (E) and the defect required a latissimus dorsi free flap (F). The fractures were treated by primary plate fixation (G, H).
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The injury resulted in a comminuted fracture of the femur and tibia. On presentation, the wound was deceptively small (A, B, C). There was extensive skin and tissue over the next 3 days as the zone of injury slowly revealed itself (D). This required secondary debridement (E) and the defect required a latissimus dorsi free flap (F). The fractures were treated by primary plate fixation (G, H).
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Wherever there is suspicion of a severe crush element it is better to stage any soft tissue reconstruction so that the zone of injury will reveal itself over the next few days and all soft tissue reconstruction procedures can then be planned when the extent of the healthy zone is known. In our experience whenever GHOIS is >9, it is preferable to stage the soft tissue reconstruction. 

Source of Infection in Open Injuries

Although infection does result from wound contamination especially if the debridement has been poor, there is now firm evidence that most acute infections after open injuries are the result of pathogens acquired in the hospital rather than from the site of injury.3,13,14,130,155 In a prospective study of 326 open fractures, Gustilo et al.85 reported that eight patients developed infection of which five were acquired secondarily in the hospital. They concluded that “during the long intervals when such wounds were open, secondary infection usually with gram-negative organisms may be a problem since these organisms are usually difficult to control by antibiotics alone.” In a prospective study, Patzakis et al.147 found that only 18% of infections were caused by the organism which was initially isolated in the perioperative period. Since the site of the fracture and soft tissue wound are probably most sterile after an adequate debridement by an experienced surgeon this is an opportune time to provide soft tissue cover. 

The Timing of Soft Tissue Cover

The optimal timing of soft tissue reconstruction in open injuries still remains imprecise, and to date, there are no Level 1 studies that have looked into the timing of soft tissue cover. Traditionally, the protocol in a majority of units is to limit the initial surgical procedure to debridement and skeletal stabilization. The definitive soft tissue and bony reconstruction is postponed to a later date. The argument favoring staged procedures centers around the need for a second look debridement as any uncertainty about the presence of traumatized and devascularized tissue necessitates a second look to allow adequate resection. Godina7274 initiated the trend toward early soft tissue cover and reported a significant difference between wounds reconstructed within 72 hours of injury and those reconstructed later. The rates of infection (1.5%) and free-flap failure (0.75%) in wounds where microvascular reconstruction was performed within 72 hours of injury were significantly lower than the rates (2% infection, 12% flap failure) for wounds reconstructed between 72 hours and 3 months after injury. Recently, the “Fix and Flap” protocol has been described where wounds were reconstructed with muscle flaps as early as within 72 hours of injury.76 In a review of early debridement and muscle flap cover, patients undergoing soft cover within 72 hours had a deep infection rate of only 6%. This was significantly lower than the 29% deep infection rate in patients undergoing soft tissue cover after 72 hours. There is considerable support in the literature for early soft tissue reconstruction. Hertel et al.93 reported on the results of 29 consecutive open tibial fractures (24 type IIIB and 5 type IIIC) of which 14 were reconstructed immediately and 15 were reconstructed with a mean delay of 4.4 days (range: 1 to 9 days). In the delayed reconstruction group the time to full unprotected weight bearing (p = 0.021), the time to definitive union (p = 0.004), the number of reoperations (p = 0.0001), and the infection rate (p = 0.037) were significantly higher. The better outcome in all parameters was related to the fact that bone infection did not occur in the immediate reconstruction group. They advocated that whenever possible and where the condition of the patient allowed, a “zero delay protocol” might be useful to maximize results. 
The practice of debridement that retains only viable tissues and the facility to cover large soft tissue and bone defects by modern microsurgical soft tissue and bone transport procedures have allowed early reconstruction. As Godina73 stated, “Wide, early, experienced debridement to clearly healthy tissue and early rotational or free muscle flap cover may be better in experienced hands than sequential debridement and delayed closure.” 

Type of Cover

In patients with established skin loss there are many options for providing skin cover over the fracture site from releasing incisions to microvascular free tissue transfer. Traditionally it is viewed as a reconstructive ladder starting from simple split skin grafts and progressing to fasciocutaneous flaps, rotational muscle flaps, and free muscle flaps (Fig. 10-29). Each step of the ladder provides a wound cover option of increasing complexity and the traditional advice was to choose the simplest option as the first choice for soft tissue cover. However, this approach has been questioned recently because of extensive advances in microsurgery. Free flaps are now undertaken with a high success rate and they have the advantage of providing versatile skin cover with vascular tissue. Hence, it has been suggested that the reconstructive ladder concept should be replaced by the “reconstructive elevator” concept as the ladder’s top step option is often the one that provides the best wound healing. Rather than adopting a stepwise algorithm for wound cover, surgeons now choose the appropriate method (Fig. 10-30). Recently, a “revised reconstructive ladder”195 has been advocated where newer developments such as vacuum-assisted closure (VAC) therapy, acute bone shortening, and bone transport are incorporated. 
Figure 10-29
The traditional reconstructive ladder proposes a plan for reconstruction where each step of the ladder denotes a reconstruction of increasing complexity starting from primary closure.
 
It was originally suggested that the surgeon must choose the lowest possible step that will suit the defect. However, this concept is not followed now.
It was originally suggested that the surgeon must choose the lowest possible step that will suit the defect. However, this concept is not followed now.
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Figure 10-29
The traditional reconstructive ladder proposes a plan for reconstruction where each step of the ladder denotes a reconstruction of increasing complexity starting from primary closure.
It was originally suggested that the surgeon must choose the lowest possible step that will suit the defect. However, this concept is not followed now.
It was originally suggested that the surgeon must choose the lowest possible step that will suit the defect. However, this concept is not followed now.
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Figure 10-30
The revised reconstructive ladder includes the newer methods of reconstruction such as NPWT and acute shortening/bone transport.
 
The “reconstructive elevator” concept is more popular now where the most appropriate and effective method of cover is chosen as the primary choice, however complex it may be.
The “reconstructive elevator” concept is more popular now where the most appropriate and effective method of cover is chosen as the primary choice, however complex it may be.
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Figure 10-30
The revised reconstructive ladder includes the newer methods of reconstruction such as NPWT and acute shortening/bone transport.
The “reconstructive elevator” concept is more popular now where the most appropriate and effective method of cover is chosen as the primary choice, however complex it may be.
The “reconstructive elevator” concept is more popular now where the most appropriate and effective method of cover is chosen as the primary choice, however complex it may be.
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Type III injuries are associated with wounds of varying size and complexity. Reconstruction should be tailored to the wound and also the surgeon’s expertise. Every surgeon has certain preferences in reconstruction techniques but the following guidelines generally hold true. Lacerated wounds without skin loss, which can be opposed without tension, can be primarily sutured. In small linear vertical wounds, lying over bone, with minimal soft tissue loss cover can be achieved using a parallel releasing skin incision which will allow direct closure of the laceration. The releasing skin incision should be over a good muscle bed or fascia so that it will allow skin grafting of the defect. Wounds which are not directly over the bone and which have a healthy muscle bed can usually be treated by split skin grafting with good results. Small defects in the skin which are directly over bone and are exposing implants can be successfully covered with rotational fasciocutaneous flaps which may have either a proximal or a distal base (Fig. 10-31). The commonly seen defect over the subcutaneous surface of the tibia can be treated by a rotational flap, provided there is no degloving and the zone of injury is not extensive. A distally based flap is commonly performed for a defect in the anterior part of the leg as it creates a donor area over healthy calf muscles that take skin grafts well. Larger defects and injuries exposing the bone and tendons require to be covered with vascularized tissue and the best option is a muscle flap covered with split skin graft. A good example of this is the rotational gastrocnemius flap which is used for injuries around the proximal tibia. The medial gastrocnemius is especially useful as it has a good blood supply from the superior branch of the popliteal artery which is usually uninjured in fractures of the tibia. Even in patients who require an amputation due to severe crushing of the soft tissues in the calf the gastrocnemius is usually viable and can be utilized effectively to cover the amputation stump. Failure of a gastrocnemius flap is very uncommon unless there is an injury to the popliteal vessels or the pedicle blood supply is damaged during dissection. Wounds in which a pedicle flap is not suitable or which are too large to be treated with a pedicle flap require free microvascular tissue transfer (Fig. 10-32). Although demanding and requiring the availability of an experienced microvascular surgeon, it is frequently the best option in complex injuries and may make the difference between amputation and salvage. The workhorse for lower limb injuries is the free latissimus dorsi flap followed by rectus and gracilis flaps. The choice is made depending on the dimensions of the wound and the size of the muscle that is required. Further information on soft tissue reconstruction can be found in Chapter 15
Figure 10-31
An open tibial fracture with soft tissue loss and exposure of the fracture site, and a GHIOS score of 8 (A, B, C).
 
This was nailed and an early fasciocutaneous flap was undertaken (D, E). A low total score allowed successful early flap cover.
This was nailed and an early fasciocutaneous flap was undertaken (D, E). A low total score allowed successful early flap cover.
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Figure 10-31
An open tibial fracture with soft tissue loss and exposure of the fracture site, and a GHIOS score of 8 (A, B, C).
This was nailed and an early fasciocutaneous flap was undertaken (D, E). A low total score allowed successful early flap cover.
This was nailed and an early fasciocutaneous flap was undertaken (D, E). A low total score allowed successful early flap cover.
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Figure 10-32
A severe open injury of leg with a GHIOS score of 13.
 
There was significant soft tissue loss during debridement (A, B). This was managed by secondary debridement and a delayed free flap performed at 1 week (C, D). A score of 10 or more indicates a very severe injury to all compartments of the limb and immediate soft tissue reconstruction is contraindicated.
There was significant soft tissue loss during debridement (A, B). This was managed by secondary debridement and a delayed free flap performed at 1 week (C, D). A score of 10 or more indicates a very severe injury to all compartments of the limb and immediate soft tissue reconstruction is contraindicated.
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There was significant soft tissue loss during debridement (A, B). This was managed by secondary debridement and a delayed free flap performed at 1 week (C, D). A score of 10 or more indicates a very severe injury to all compartments of the limb and immediate soft tissue reconstruction is contraindicated.
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Figure 10-32
A severe open injury of leg with a GHIOS score of 13.
There was significant soft tissue loss during debridement (A, B). This was managed by secondary debridement and a delayed free flap performed at 1 week (C, D). A score of 10 or more indicates a very severe injury to all compartments of the limb and immediate soft tissue reconstruction is contraindicated.
There was significant soft tissue loss during debridement (A, B). This was managed by secondary debridement and a delayed free flap performed at 1 week (C, D). A score of 10 or more indicates a very severe injury to all compartments of the limb and immediate soft tissue reconstruction is contraindicated.
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There was significant soft tissue loss during debridement (A, B). This was managed by secondary debridement and a delayed free flap performed at 1 week (C, D). A score of 10 or more indicates a very severe injury to all compartments of the limb and immediate soft tissue reconstruction is contraindicated.
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Negative Pressure Wound Therapy

A useful treatment option in all injuries where soft tissue cover is not immediately possible is Vacuum-assisted wound closure (VAC) using NPWT. NPWT has largely replaced wet dressing therapy in most centers that treat a large number of open injuries. Wet dressings have to be changed frequently this being labor intensive and costly. Repeated dressings lead to increased exposure and susceptibility to the risk of nosocomial infection. From the time of the first clinical report of NPWT in 1993 by Fleischmann et al.,59,60 its mechanism and beneficial effects in the management of different soft tissue defects, with and without infection, have been reported.178 
Although there are numerous commercially available NPWT systems the basic components include an open pore sponge, a semi occlusive dressing, and a negative pressure source. The commercially available sponges are either made of polyvinyl alcohol or polyurethane ether. The sponges are cut to the correct shape and then secured by adhesive drapes which seal the wound and allow the creation of an effective vacuum. These drapes also stop protein loss, minimize wound desiccation, and prevent additional contamination from the hospital environment. In practice, iodophor-impregnated surgery drapes are useful as they can be cut to accommodate soft tissue defects of various dimensions and also seal wounds around external fixation devices. 
The negative pressure is supplied by commercially available vacuum pumps which allow regulation of the magnitude and duration of the negative pressure. In animal models, it has been shown that a pressure of –125 mm Hg, applied for 5 minutes at intervals of 7 minutes, has the most beneficial effect on the formation of granulation tissue and it increases the blood flow in the surrounding tissues by almost fourfold. Continuous negative pressure increases granulation tissue by only 63% compared to 103% with intermittent negative pressure. The numerous beneficial effects of NPWT are listed in Table 10-20.178 
 
Table 10-20
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Table 10-20
Beneficial Effects of VAC Therapy178
  •  
    Promotes wound contraction and increases the chance of delayed primary closure.
  •  
    Continuously removes excess edematous fluid.
  •  
    Causes reactive increase in blood flow and promotes healing.
  •  
    Removes proteins and electrolytes that are harmful for wound healing.
  •  
    Decreases bacterial burden.
  •  
    Causes cellular microdeformation and favorable electrical fields which stimulate cell response and growth factors.
X

Application of NPWT Device

Before the application of the VAC device, the FDI guidelines and the indications and contraindications for NPWT must be understood178 (Table 10-21). It should be emphasized that VAC is not a replacement for good surgical principles. The wound must be thoroughly debrided of all debris and infected tissues and bleeding should be well controlled before the application of negative pressure. Application of a VAC may be contraindicated in the presence of exposed tendons, surgical anastomosis of a nerve or a vessel or when heavy bleeding or oozing is anticipated. 
 
Table 10-21
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Table 10-21
VAC Therapy178
Indications
  •  
    Severely crushed injuries not amenable for immediate soft tissue cover.
  •  
    Wounds which require dead space management
  •  
    Exposed bone with degloved skin
  •  
    Exposed Tendons and ligaments
  •  
    Open joint injuries with soft tissue loss
Contraindications
  •  
    Presence of necrotic skin with eschar.
  •  
    Untreated osteomyelitis
  •  
    Exposed neurovascular bundle.
  •  
    Exposed vascular anastomosis
X
The sponge is usually pressed against the wound and a template is created on the sponge by the wound exudate or blood. The sponge is then cut to size, applied over the wound and held in place by applying the adhesive dressing in small strips to minimize creases (Fig. 10-33). Keeping the skin dry helps the adhesive drapes to get a firm hold. Circumferential application of the adhesive drapes must be avoided to prevent a tourniquet effect. A 1.5 to 2 cm hole is then cut in the center of the dressing over the sponge and the suction track pad is firmly secured over the hole. The track pad is then connected to the VAC device and any residual leaks are addressed by applying additional adhesive strips. If patients complain of pain with the intermittent suction protocol continuous suction can be used. The VAC device is left in place for 2 or 3 days after which the wound can be inspected and suction continued. 
Figure 10-33
An extensive degloving injury of the buttocks (A) with a pelvic fracture (B) had a large defect following debridement (C).
 
Such large defects are amenable to immediate VAC therapy (D) which facilitated early granulation and treatment by skin grafting.
Such large defects are amenable to immediate VAC therapy (D) which facilitated early granulation and treatment by skin grafting.
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Figure 10-33
An extensive degloving injury of the buttocks (A) with a pelvic fracture (B) had a large defect following debridement (C).
Such large defects are amenable to immediate VAC therapy (D) which facilitated early granulation and treatment by skin grafting.
Such large defects are amenable to immediate VAC therapy (D) which facilitated early granulation and treatment by skin grafting.
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Clinical Effects

Several studies have reported the beneficial effects of NPWT and NPWT has been compared with standard wet dressing in a randomized controlled trial.175 Fractures treated with NPWT needed 0.8 days less to achieve definitive closure status than those treated with standard dressings. Furthermore the infection rate in the NPWT group was only 5.4% compared to 28% in the controlled group this being significantly different. Mouës et al.135 performed a randomized study in 54 patients with full-thickness wounds. They analyzed the time taken for the wound to form a clean granulating wound bed which was “ready for surgical therapy” as determined by an examiner who was not blinded to the treatment modality. No significant difference was observed between the two groups. However, patients in the NPWT group had a wound surface reduction of 3.8% compared to only 1.7% in the control group. This was statistically significant. However it should be noted that the examiner was not blinded to the treatment modality. In another recent study by Dedmond et al.49 reporting on 50 type III open tibial fractures managed by NPWT superficial infection occurred in four patients (8%) and deep infection occurred in 10 patients (20%). The prevalence of infection in type IIIA, IIIB, and IIIC injuries was 8.3%, 45.8%, and 50% respectively which is similar to studies which did use NPWT. Reduction of bacterial wound colonization and clearance of bacteria from the wound are frequently cited as benefits of NPWT. However the literature does not present a uniform view. A few studies have shown a decrease in the bacterial load133 but others have found no difference or an overall increase in the bacterial load.113,135,191 
The rate of infection appears to be related to the timing of coverage as delay affects the capacity of NPWT to reduce infection rates. In a retrospective analysis of 38 patients, patients who underwent definitive cover less than 7 days post injury, had an infection rate of only 12.5% compared to 57% in patients in whom definitive cover was performed after 7 days.17 However studies by Steiert176 and Fleischmann60 did not find the same difference in infection rate. The usage of NPWT should be kept to a minimum and early flap coverage should be performed in a physiologic stable patient. If surgical delay is required for any reason, NPWT can then be continued safely till delayed cover is possible. 
Although there are many encouraging reports, there is no conclusive evidence supporting the superiority of NPWT over standard wet dressings in avoiding wound infection and the requirement for flap cover. There are also no studies that have compared NPWT with other treatment methods such as the use of antibiotic bead pouches which have also been reported to be useful. The overall outcome is affected by the nature of the wound, the adequacy of debridement, the presence of comorbidities, and the health status and nutrition of the patient. 

Complications

Twelve deaths have been reported related to the use of NPWT due to bleeding when used in wounds near the groin or presternal region or when used over vascular grafts.170 NPWT is also contraindicated in patients taking anticoagulants and in those who have significant adhesions between the wound bed and dressings when dressings are removed. Bleeding can be reduced by the use of a nonadherent dressing or polyvinyl alcohol sponges placed in the base of the wound. 
Loss of suction and failure of the VAC system to maintain a vacuum will increase the risk of wound infection. The adhesive dressing must be applied to dry skin to permit adequate sealing and maintenance of suction. Puncture of the occlusive dressing and clogging of the sponge or tubing can result in failure of the suction and therefore continuous monitoring NPWT system is essential. 

Author’s Preferred Treatment151155

 
 

Our Unit treats more than 300 type IIIb injuries every year and our choice of reconstruction pathway is guided by the GHOIS. In an analysis of 965 injuries treated in a 3-year period, we found that the limb reconstruction pathway that was selected followed one of a number of options which are shown in Table 10-22. It must be stressed that an essential requirement for success is a thorough debridement by an experienced “Orthoplastic” team. Bone stabilization is tailored to the fracture requirements and the skin cover is undertaken as early as possible. The individual skin score is used to choose the method of wound cover and the total score guides the time of treatment (Fig. 10-34).

 
Figure 10-34
Treatment algorithm for wound management derived from the Ganga Hospital Open Injury Score.
 
The algorithm assumes that a satisfactory meticulous debridement and stable skeletal fixation has been achieved to allow soft tissue reconstruction.
The algorithm assumes that a satisfactory meticulous debridement and stable skeletal fixation has been achieved to allow soft tissue reconstruction.
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Figure 10-34
Treatment algorithm for wound management derived from the Ganga Hospital Open Injury Score.
The algorithm assumes that a satisfactory meticulous debridement and stable skeletal fixation has been achieved to allow soft tissue reconstruction.
The algorithm assumes that a satisfactory meticulous debridement and stable skeletal fixation has been achieved to allow soft tissue reconstruction.
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Table 10-22
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Table 10-22
Definitive Limb Reconstructive Pathway155
  •  
    “Fix and close” protocol
  •  
    “Fix, bone graft and close” protocol.
  •  
    “Fix and flap” protocol
  •  
    “Fix and delayed flap” protocol
  •  
    “Stabilize, observe, assess and reconstruct” protocol
X
 
Fix and Primary Closure
 

Injuries with a skin Score of 1 and 2 have no skin loss at injury or during debridement. When contamination is low and there has been a satisfactory debridement, these patients are suitable for direct suturing. The total score must be <9 as this indicates low-energy violence and the chances of postoperative swelling or compartment syndrome are low. Stable skeletal fixation and bleeding skin margins which are opposed without tension are the prerequisites for primary closure. It should be noted that the length of the wound is not a criterion (Fig. 10-33).

 
Fix and Delayed Closure
 

Injuries with skin score of 1 or 2, but with either a total score of >9 or with moderate or severe contamination are not treated by primarily closure. A higher score of >9 indicates high-energy violence and a reassessment at 48 or 72 hours is necessary. A delayed closure is performed if the wound characteristics at a second look debridement allow closure. If additional debridement is required at the time of the second look leading to further skin and soft tissue resection, the patient is managed by a staged flap protocol.

 
Fix and Skin Grafting
 

A skin score of 3 indicates skin loss either at injury or during debridement. In skin score 3 the wound either does not expose the fracture site or there is adequate soft tissue cover. A classic example is open fractures of femur where good soft tissue cover is usually present after skeletal stabilization. Here simple wound management by split skin grafting possible.

 
Fix and Early Flap
 

A skin score of 3 or 4 indicates skin loss either at injury or during debridement. If the wound exposes bone, articular cartilage, tendons, or a vascular anastomosis site, a flap is necessary. The type of the flap will be determined by the location and size of the defect and the structures that are exposed. Again timing is guided by the total score of GHOIS. An early flap can be done if the total score is less than 9. This indicates a lower-energy injury and a more definable zone of injury.

 

We do not favor the traditional reconstructive ladder philosophy but rather would choose the most appropriate procedure that best suits the injury as defined by the bone and soft tissue defect. Often a well-performed free tissue transfer gives better functional results and can even make the difference between salvage and amputation.

 
Fix and Delayed Flap
 

A fix and delayed flap protocol is performed whenever there is severe contamination or the total score is >10. The duration of delay will depend on the condition of the wound, the swelling of surrounding soft tissues and the presence of infection. If, during the relook procedure, the wound is not suitable for flap cover the use of NPWT following another debridement is an attractive option.

 
Staged Reconstructions
 

A score of 5 in any of the tissue scores and a total score of >9 indicates a limb that is not suitable for immediate or even early reconstruction. These limbs have considerable associated bony and soft tissue injury or loss. Often the wound may not be ready for reconstruction even after a few weeks. Here the option of immediate or early application of NPWT at the initial procedure must be seriously considered. The expertise of a skilled plastic surgical team with microsurgical reconstruction capability and an orthopedic team capable of bone reconstruction and regeneration techniques is essential. If this is not available, patients must be expeditiously transferred to a center where such facilities are available. The choice and timing of the reconstruction method must be made on an individual patient basis.

References

Abramson D, Hitchcock R, Trooskin S, et al. Lactate clearance and survival following injury. J Trauma. 1993;35:584–588.
Adams CI, Keating JF, Court-Brown CM. Cigarette smoking and open tibial fractures. Injury. 2001;32:61–65.
Al-Arabi YB, Nader M, Hamidian-Jahromi AR, et al. The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: A 9-year prospective study from a district general hospital. Injury. 2007;38:900–905.
Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg. 2001;9:219–226.
Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lower-limb open fracture wounds. A prospective, randomized study. J Bone Joint Surg Am. 2005;87:1415–1422.
Anglen JO, Apostoles PS, Christensen G, et al. Removal of surface bacteria by irrigation. J Orthop Res. 1996;14:251–254.
Antich-Adrover P, Marti-Garin D, Murias-Alvarez J, et al. External fixation and secondary intreamdullary nails of open tibial fractures. A Randomised, prospective trial. J Bone Joint Surg Br. 1997;79:433–437.
Bach AW, Hansen ST Jr. Plates versus external fixation in severe open tibial shaft fractures. A randomized trial. Clin Orthop Relat Res. 1989;241:89–94.
Bakker J, Gris P, Coffernils M, et al. Serial blood lactate levels can predict the development of multiple organ failure following septic shock. Am J Surg. 1996;171:221–226.
Baue AE. Multiple organ failure, multiple organ dysfunction syndrome, and the systemic inflammatory response syndrome-where do we stand? Shock. 1994;2:385–397.
Behrens F, Searls K. External fixation of the tibia. Basic concepts and prospective evaluation. J Bone Joint Surg Br. 1986;68:246–254.
Bhandari M, Adili A, Lachowski RJ. High pressure pulsatile lavage of contaminated human tibiae: An in vitro study. J Orthop Trauma. 1998;12:479–484.
Bhandari M, Guyatt G, Tornetta P 3rd, et al. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. Study to prospectively evaluate reamed intramedullary nails in patients with tibial Fracture. J Bone Joint Surg Am. 2008;90:2567–2578.
Bhandari M, Guyatt GH, Swiontkowski MF, et al. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br. 2001;83:62–68.
Bhandari M, Schemitsch EH, Adili A, et al. High and low pressure pulsatile lavage of contaminated tibial fractures: An in vitro study of bacterial adherence and bone damage. J Orthop Trauma. 1999;13:526–533.
Bhandari M, Zlowodzki M, Tornetta P 3rd, et al. Intramedullary nailing following external fixation in femoral and tibial shaft fractures. J Orthop Trauma. 2005;19:140–144.
Bhattacharyya T, Mehta P, Smith M, et al. Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg. 2008;121:1263–1266.
Billroth. Clinical Surgery. London: The new Sydenham Society; 1881.
Blachut PA, Meek RN, O’Brien PJ. External fixation and delayed intramedullary nailing of open fractures of tibial shaft. A sequential protocol. J Bone Joint Surg Am. 1990;72:729–735.
Blow O, Magliore L, Claridge JA, et al. The golden hour and the silver day: Detection and correction of occult hypoperfusion within 24 hours improves outcome from major trauma. J Trauma. 1999;47:964–969.
Bonanni F, Rhodes M, Lucke JF. The futility of predictive scoring of mangled lower extremities. J Trauma. 1993;34:99–104.
Bosse MJ, MacKenzie EJ, Kellam JF, et al. A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores. J Bone Joint Surg Am. 2001;83-A:3–14.
Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347:1924–1931.
Brennan SS, Leaper DJ. The effect of antiseptics on the healing wound: A study using the rabbit ear chamber. Br J Surg. 1985;72:780–782.
British Orthopaedic Association and British Association of Plastic Surgeons. The Early Management of Severe Tibial Fractures: The Need for Combined Plastic and Orthopaedic Management: A Report by the BOA/BAPS Working Party on Severe Tibial Injuries, 1993; London.
British Orthopaedic Association recommendations (Open fractures of lower limb). Online Recommendations September 2009.
Brohi K, Cohen MJ, Davenport RA. Acute coagulopathy of trauma: Mechanism, identification and effect. Curr Opin Crit Care. 2007;13:680–685.
Brown LL, Shelton HT, Bornside GH Jr. Cohn I. Evaluation of wound irrigation by pulsatile jet and conventional methods. Ann Surg. 1978;187:170–173.
Brown PW, Kinman PB. Gas gangrene in a metropolitan community. J Bone Joint Surg Am. 1974;56:1445–1451.
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.
Byrd HS, Spicer TE, Cierney G 3rd. Management of open tibial fractures. Plast Reconstr Surg. 1985;76:719–730.
Calhoun JH. Optimal timing of operative debridement: A known unknown: commentary on an article by Mara L. Schenker, MD, et al.: “Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review”. J Bone Joint Surg Am. 2012;94:e90.
Carroll EA, Koman LA. External fixation and temporary stabilization of femoral and tibial trauma. J Surg Orthp Adv. 2011;20:74–81.
Carsenti-Etesse H, Doyon F, Desplaces N, et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:315–323.
Castillo RC, Bosse MJ, MacKenzie EJ, et al. Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures. J Orthop Trauma. 2005;19:151–157.
Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Bone Joint Surg Am. 1987;69-A:801–807.
Chapman M. Role of bone stability in open fractures. Instr Course Lect. 1982;31:75–87.
Chapman MW. The use of immediate internal fixation in open fractures. Orthop Clin North Am. 1980;11:579–591.
Chung KC, Saddawi-Konefka D, Haase SC, et al. A cost-utility analysis of amputation versus salvage for Gustilo IIIB and IIIC open tibial fractures. Plast Reconstr Surg. 2009;124:1965–1973.
Clifford RP, Beauchamp CG, Kellam JF, et al. Plate fixation of open fractures of the tibia. J Bone Joint Surg Br. 1988;70:644–648.
Conroy BP, Anglen JO, Simpson WA, et al. Comparison of castile soap, benzalkonium chloride, and bacitracin as irrigation solutions for complex contaminated orthopaedic wounds. J Orthop Trauma. 1999;13:332–337.
Cooney WP, Fitzgerald RH Jr, Dobyns JH, et al. Quantitative wound cultures in upper extremity trauma. J Trauma. 1982;22:112–117.
Court-Brown CM, Cross AT, Hahn DM, et al. The Management of Open Tibial Fractures. in BOA/BAPS Working Party September 1997: London.
Court-Brown CM, Rimmer S, Prakash U, et al. The epidemiology of open long bone fractures. Injury. 1998;29:529–534.
Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury. 2007;38:879–889.
Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg Br. 2007;89:580–585.
Cullen MC, Roy DR, Crawford AH, et al. Open fracture of the tibia in children. J Bone Joint Surg [Am]. 1996;78-A:1039–1047.
Dabezies EJ, D’Ambrosia RD. Treatment of the multiply injured patient: Plans for treatment and problems of major trauma. Instr Course Lect. 1984;33:242–252.
Dedmond BT, Kortesis B, Punger K, et al. The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma. 2007;21:11–17.
DeLong W, Born CT, Wei SY, et al. Aggressive treatment of 119 open fracture wounds. J Trauma. 1999;46:1049–1054.
Di Pasquale DJ, Bhandari M, Tov A, et al. The effect of high and low pressure pulsatile lavage on soft tissue and cortical blood flow: a canine segmental humerus fracture model. Arch Orthop Trauma Surg. 2007;127:879–884.
Dirschl DR, Wilson FC. Topical antibiotic irrigation in the prophylaxis of operative wound infections in orthopedic surgery. Orthop Clin North Am. 1991;22:419–426.
Dollery W, Driscoll P. Resuscitation after high energy polytrauma. Br Med Bull. 1999;55:785–805.
Draeger RW, Dahners LE. Traumatic wound debridement: A comparison of irrigation methods. J Orthop Trauma. 2006;20:83–88.
Durham RM, Mistry BM, Mazuski JE, et al. Outcome and utility of scoring systems in the management of the mangled extremity. Am J Surg. 1996;172:569–573.
Edwards CC, Simmons SC, Browner BD, et al. Severe open tibial fractures. Results treating 202 injuries with external fixation. Clin Orthop Relat Res. 1988:98–115.
Emami A, Mjoberg B, Ragnarsson B, et al. Changing epidemiology of tibial shaft fractures. 513 cases compared between 1971–1975 and 1986–1990. Acta Orthop Scand. 1996;67:557–561.
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.
Fleischmann W, Becker U, Bishoff M, et al. Vacuum sealing: Indication, technique and results. Eur J Orthop Surg Traumatol. 1995;5:37–40.
Fleischmann W, Strecker W, Bombelli M, et al. Vacuum sealing as treatment of soft tissue damage in open fractures. Unfallchirurg. 1993;96:488–492.
Franklin JL, Johnson KD, Hansen ST. Immediate internal fixation of open ankle fractures. Report of thirty-eight cases treated with a standard protocol. J Bone Joint Surg Am. 1984;66:1349–1356.
French B, Tornetta P 3rd. High energy tibial shaft fractures. Orthop Clin North Am. 2002;33:211–230.
Giannoudis PV. Current concepts of the inflammatory response after major trauma: An update. Injury. 2003;34:397–404.
Giannoudis PV, Furlong AJ, MacDonald DA, et al. Reamed against unreamed nailing of the femoral diaphysis: A retrospective study of healing time. Injury. 1997;28:15–18.
Giannoudis PV, Hildebrand F, Pape HC. Inflammatory serum markers in patients with multiple trauma. Can they predict outcome? J Bone Joint Surg Br. 2004;86:313–323.
Giannoudis PV, Papakostidis C, Roberts C. A review of the management of open fractures of the tibia and femur. J Bone Joint Surg Br. 2006;88:281–289.
Giannoudis PV, Perry S, Smith RM. Systemic response to trauma. Curr Orthop. 2001;15:176–183.
Giannoudis PV, Smith MR, Evans RT, et al. Serum CRP and IL-6 levels after trauma. Not predictive of septic complications in 31 patients. Acta Orthop Scand. 1998;69:184–188.
Giannoudis PV, Smith RM, Banks RE, et al. Stimulation of inflammatory markers after blunt trauma. Br J Surg. 1998;85:986–990.
Gilmore OJ, Sanderson PJ. Prophylactic interparietal povidone-iodine in abdominal surgery. Br J Surg. 1975;62:792–799.
Glass GE, BS, Sanderson F, Pearse MF, et al. The microbiological basis for a revised antibiotic regimen in high-energy tibial fractures: Preventing deep infections by nosocomial organisms. J Plast Reconstr Aesthet Surg. 2011;64:375–380.
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285–292.
Godina M. The tailored latissimus dorsi free flap. Plast Reconstr Surg. 1987;80:304–306.
Godina M, Arnez ZM, Lister GD. Preferential use of the posterior approach to blood vessels of the lower leg in microvascular surgery. Plast Reconstr Surg. 1991;88:287–291.
Gopal S, Giannoudis PV. Prospective randomized study of reamed versus unreamed femoral intramedullary nailing: An assessment of procedures. J Orthop Trauma. 2001;15:458–460.
Gopal S, Majumder S, Batchelor AG, et al. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br. 2000;82:959–966.
Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;(1):CD003764.
Gregory CF, Chapman MW, Hansen ST. Open fractures. In: Rockwood CA, Green DP eds. Fractures in Adults. Philadelphia, PA: J.B. Lippincott; 1984: 169–218.
Grosse A, Christie J, Taglang G, et al. Open adult femoral shaft fracture treated by early intramedullary nailing. J Bone Joint Surg Br. 1993;75:562–565.
Gustilo RB. Management of open fractures. An analysis of 673 cases. Minn Med. 1971;54:185–189.
Gustilo RB. Use of antimicrobials in the management of open fractures. Arch Surg. 1979;114:805–808.
Gustilo RB. Management of infected fractures. Instr Course Lect. 1982;31:18–29.
Gustilo RB. 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. 1995;77:1291–1292.
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;58:453–538.
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.
Gustilo RB, Corpuz V, Sherman RE. Epidemiology, mortality and morbidity in multiple trauma patients. Orthopedics. 1985;8:1523–1528.
Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics. 1987;10:1781–1788.
Guthrie HC, Clasper JC. Historical origins and current concepts of wound debridement. J R Army Med Corps. 2011;157:130–132.
Guyette F, Suffoletto B, Castillo JL, et al. Prehospital serum lactate as a predictor of outcomes in trauma patients: A retrospective observational study. J Trauma. 2011;70:782–786.
Hansen ST Jr. The type-IIIC tibial fracture. Salvage or amputation. J Bone Joint Surg Am. 1987;69:799–800.
Hansen ST Jr. Overview of the severely traumatized lower limb. Reconstruction versus amputation. Clin Orthop Relat Res. 1989:17–19.
Has B, Nagy A, Pavic R, et al. External fixation and infection of soft tissues close to fracture localization. Mil Med. 2006;171:88–91.
Hertel R, Lambert SM, Muller S, et al. On the timing of soft tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg. 1999;119.
Hildebrand F, Giannoudis PV, Kretteck C, et al. Damage control: Extremities. Injury. 2004;35:678–689.
Hoff WS, Reilly PM, Rotondo MF, et al. The importance of the command-physician in trauma resuscitation. J Trauma. 1997;43:772–777.
Hohmann E, Tetsworth K, Radziejowski MJ, et al. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop Trauma Surg. 2007;127.
Hope PG, Cole WG. Open fractures of the tibia in children. J Bone Joint Surg Br. 1992;74-B:546–553.
Horn BD, Rettig ME. Interobserver reliability in the Gustilo and Anderson classification of open fractures. J Orthop Trauma. 1993;7:357–360.
Howard M, Court-Brown CM. Epidemiology and management of open fractures of the lower limb. Brit J Hosp Med. 1997;57:582–587.
Howe HR Jr, Poole GV Jr, Hansen KJ, et al. Salvage of lower extremities following combined orthopedic and vascular trauma. A predictive salvage index. Am Surg. 1987;53:205–208.
Hyman J, Moore T. Anatomy of the distal knee joint and pyarthrosis following external fixation. J Orthop Trauma. 1999;13:241–246.
Jawa RS, Anillo S, Huntoon K, et al. Interleukin 6 in Surgery, Trauma, and Critical Care–Part II: Clinical Applications. J Intensive Care Med. 2010.
Jawa RS, Anillo S, Huntoon K, et al. Analytic review: Interleukin-6 in surgery, trauma, and critical care: part I: basic science. J Intensive Care Med. 2011;26:3–12.
Johansen K, Daines M, Howey T, et al. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990;30:568–572.
Kakar S, Tornetta P 3rd. Open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: A prospective study. J Orthop Trauma. 2007;21:153–157.
Kashuk JL, Moore EE, Millikan JS, et al. Major abdominal vascular trauma–a unified approach. J Trauma. 1982;22:672–679.
Ketenjian AY, Shelton ML. Primary internal fixation of open fractures: A retrospective study of the use of metallic internal fixation in fresh open fractures. J Trauma. 1972;12:756–763.
Klein MB, Hunter S, Heimbach DM, et al. The Versajet water dissector: A new tool for tangential excision. J Burn Care Rehabil. 2005;26:483–487.
Klein MP, Rahn BA, Frigg R, et al. Reaming versus non-reaming in medullary nailing: Interference with cortical circulation of the canine tibia. Arch Orthop Trauma Surg. 1990;109:314–316.
Kocher MS. Early limb salvage: Open tibia fractures of Ambroise Pare (1510-1590) and Percivall Pott (1714-1789). World J Surg. 1997;21:116–122.
Kreder HJ, Armstrong P. The significance of perioperative cultures in open pediatric lower-extremity fractures. Clin Orthop Relat Res. 1994:206–212.
Krishna U, Joshi SP, Modh M. An evaluation of serial blood lactate measurement as an early predictor of shock and its outcome in patients of trauma or sepsis. Indian J Crit Care Med. 2009;13:66–73.
Lalliss SJ, Stinner DJ, Waterman SM, et al. Negative pressure wound therapy reduces pseudomonas wound contamination more than Staphylococcus aureus. J Orthop Trauma. 2010;24:598–602.
Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop Relat Res. 1989:92–99.
Lee EW, Dirschl DR, Duff G, et al. High-pressure pulsatile lavage irrigation of fresh intraarticular fractures: Effectiveness at removing particulate matter from bone. J Orthop Trauma. 2002;16:162–165.
Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997:71–75.
Lenz A, Franklin GA, Cheadle WG. Systemic inflammation after trauma. Injury Int J Care Injured. 2007;38:1336–1345.
Lethaby A, Temple J, Santy J. Pin site care for preventing infections associated with external bone fixators and pins. Cochrane Database Syst Reviews. 2008;(4):CD004551.
Lhowe DW, Hansen ST. Immediate nailing of open fractures of the femoral shaft. J Bone Joint Surg Am. 1988;70:812–820.
Lineaweaver W, McMorris S, Soucy D, et al. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg. 1985;75:394–396.
Lu WH, Kolkman K, Seger M, et al. An evaluation of trauma team response in a major trauma hospital in 100 patients with predominantly minor injuries. The Aust N Z J Surg. 2000;70:329–332.
Mannikis P, Jankowski S, Zhang H, et al. Correlation of serial lactate levels to organ failure and mortality after trauma. Am J Emerg Med. 1995;13:619–622.
Marshall PD, Saleh M, Douglas DL. Risk of deep infection with intramedullary nailing following the use of external fixators. J Roy Coll Surg Edin. 1991;36:268–271.
Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing of severe open tibial fractures initially treated with external fixation. J Bone Joint Surg Am. 1989;71:835–828.
McGraw JM, Lim EV. Treatment of open tibial-shaft fractures. External fixation and secondary intramedullary nailing. J Bone Joint Surg Am. 1988;70:900–911.
McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the Mangled Extremity Severity Score (MESS). J Orthop Trauma. 1994;8:81–87.
McNelis J, Marini CP, Jurkiewicz A, et al. Prolonged lactate clearance is associated with increased mortality in the surgical intensive care unit. Am J Surg. 2001;182:481–485.
McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome: Who is at risk? J Bone Joint Surg Br. 2000;82:200–203.
Merritt K. Factors increasing the risk of infection in patients with open fractures. J Trauma. 1988;28:823–827.
Moola F, Jacks D, Reindl R, et al. Safety of primary closure of soft tissue wounds in open fractures. J Bone Joint Surg Br. 2008;90-B:94.
Moore TJ, Mauney C, Barron J. The use of quantitative bacterial counts in open fractures. Clin Orthop Relat Res. 1989:227–230.
Morgan BW, Read JR, Solan MC. Photographic wound documentation of open fractures: An update for the digital generation. Emerg Med J. 2007;24:841–842.
Morykwas MJ, Argenta LC, Shelton-Brown EI, et al. Vacuum-assisted closure: A new method for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg. 1997;38:553–562.
Mosti G, Iabichella ML, Picerni P, et al. The debridement of hard to heal leg ulcers by means of a new device based on Fluidjet technology. Int Wound J. 2005;2:307–314.
Mouës CM, Vos MC, van den Bemd GJ, et al. Bacterial load in relation to vacuum-assisted closure wound therapy: A prospective randomized trial. Wound Repair Regen. 2004;12:11–17.
Murray MJ. We can’t go home again: Advances in the resuscitation of patients with polytrauma. Anesth Analg. 2012;115:1263–1264.
Nusem I, Otremski I. Prophylactic antibiotics in orthopedic practice. Part II: Closed and open fractures. Harefuah. 1999;136:316–317.
Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006;88:2739–2748.
Olson SA, Schemitsch EH. Open fractures of the tibial shaft: An update. Instr Course Lect. 2003;52:623–631.
Pape HC, Griensven MV, Hildebrand FF, et al. Systemic inflammatory response after extremity or truncal fracture operations. J Trauma. 2008;65:1379–1384.
Pape HC, Grimme K, Van Griensven M, et al. Impact of intramedullary instrumentation versus damage control for femoral fractures on immunoinflammatory parameters: Prospective randomized analysis by the EPOFF Study Group. J Trauma. 2003;55:7–13.
Pape HC, Regel G, Dwenger A, et al. Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma. J Trauma. 1993;35:709–716.
Pape HC, Schmidt RE, Rice J, et al. Biochemical changes after trauma and skeletal surgery of the lower extremity: Quantification of the operative burden. Critical Care Med. 2000;28:3441–3448.
Pape HC, Tornetta P 3rd, Tarkin I, et al. Timing of fracture fixation in multitrauma patients: The role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17:541–549.
Pape HC, van Griensven M, Rice J, et al. Major secondary surgery in blunt trauma patients and perioperative cytokine liberation: Determination of the clinical relevance of biochemical markers. J Trauma. 2001;50:989–1000.
Paré A. The Works of That Famous Chirurgion Ambrose Paré. London; 1634.
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;14:529–533.
Patzakis MJ. Orthopedics-epitomes of progress: The use of antibiotics in open fractures. West J Med. 1979;130:62.
Pollak AN. Timing of debridement of open fractures. J Am Acad Orthop Surg. 2006;14:S48–S51.
Puno RM, Teynor JT, Nagano J, et al. Critical analysis of results of treatment of 201 tibial shaft fractures. Clin Orthop Relat Res. 1986;212:113–121.
Rajasekaran S. Early versus delayed closure of open fractures. Injury. 2007;38:890–895.
Rajasekaran S, Dheenadhayalan J, Babu JN, et al. Immediate primary skin closure in type-III A and B open fractures: Results after a minimum of five years. J Bone Joint Surg Br. 2009;91:217–224.
Rajasekaran S, Giannoudis PV. Open injuries of the lower extremity: issues and unknown frontiers. Injury. 2012;43:1783–1784.
Rajasekaran S, Naresh Babu J, Dheenadhayalan J, et al. A score for predicting salvage and outcome in Gustilo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg Br. 2006;88:1351–1360.
Rajasekaran S, Sabapathy SR. A philosophy of care of open injuries based on the Ganga hospital score. Injury. 2007;38:137–146.
Raman R, Pape HC, Giannoudis PV. Cytokines in orthopaedic practice: A review. Curr Orthop. 2003;17.
Raunest J, Derra E. Clostridium perfringens infection following intramedullary nailing of an open femur shaft fracture. Aktuelle Traumatol. 1990;20:254–256.
Rennekampff HO, Schaller HE, Wisser D, et al. Debridement of burn wounds with a water jet surgical tool. Burns. 2006;32:64–69.
Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426–430.
Rosenstein BD, Wilson FC, Funderburk CH. The use of bacitracin irrigation to prevent infection in postoperative skeletal wounds. An experimental study. J Bone Joint Surg Am. 1989;71:427–430.
Russell WL, Sailors DM, Whittle TB, et al. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg. 1991;213:473–480.
Saveli CC, Belknap RW, Morgan SJ, et al. The role of prophylactic antibiotics in open fractures in an era of community-acquired methicillin-resistant Staphylococcus aureus. Orthopedics. 2011;34:611–616.
Schemitsch EH, Turchin DC, Kowalski MJ, et al. Quantitative assessment of bone injury and repair after reamed and unreamed locked intramedullary nailing. J Trauma. 1998;45:250–255.
Schenker ML, Yannascoli S, Baldwin KD, et al. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012;94:1057–1064.
Schmidt AH, Swiontkowski MF. Pathophysiology of infections after internal fixation of fractures. J Am Acad Orthop Surg. 2000;8:285–291.
Scully RE, Artz CP, Sako Y. An evaluation of the surgeon’s criteria for determining the viability of muscle during debridement. Arch Surg. 1956;73:1031–1035.
Shafi S, Kauder DR. Fluid resuscitation and blood replacement in patients with polytrauma. Clin Orthop Relat Res. 2004:37–42.
Shanmuganathan R. The utility of scores in the decision to salvage or amputation in severely injured limbs. Indian J Orthop. 2008;42:368–376.
Shapiro MB, Jenkins DH, Schwab CW, et al. Damage control: Collective review. J Trauma. 2000;49:969–978.
Silver S. Update on Serious Complications Associated With Negative Pressure Wound Therapy Systems. US Food and Drug Administration: FDA Safety Communication February 24, 2011.
Simons R, Eliopoulos V, Laflamme D, et al. Impact on process of trauma care delivery 1 year after the introduction of a trauma program in a provincial trauma center. J Trauma. 1999;46:811–815.
Sims M, Saleh M. Protocols for the care of external fixator pin sites. Prof Nurse. 1996;11:261–264.
Sinclair JS, McNally MA, Small JO, et al. Primary free-flap cover of open tibial fractures. Injury. 1997;28:581–587.
Solan MC, Calder JD, Gibbons CE, et al. Photographic wound documentation after open fracture. Injury. 2001;32:33–35.
Stannard JP, Robinson JT, Anderson ER, et al. Negative pressure wound therapy to treat hematomas and surgical incisions following high-energy trauma. J Trauma. 2006;60:1301–1306.
Steiert AE, Gohritz A, Schreiber TC, et al. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy: Worse or worth? J Plast Reconstr Aesthet Surg. 2009;62:675–683.
Stensballe J, Christiansen M, Tonnesen E, et al. The early IL-6 and IL-10 response in trauma is correlated with injury severity and mortality. Acta Anaesthesiol Scand. 2009;53:515–521.
Streubel PN, Stinner DJ, Obremskey WT. Use of negative-pressure wound therapy in orthopaedic trauma. J Am Acad Orthop Surg. 2012;20:564–574.
Stubig T, Mommsen P, Krettek C, et al. Comparison of early total care (ETC) and damage control orthopedics (DCO) in the treatment of multiple trauma with femoral shaft fractures: Benefit and costs. Unfallchirurg. 2010;113:923–930.
Suedkamp NP, Barbey N, Veuskens A, et al. The incidence of osteitis in open fractures: an analysis of 948 open fractures (a review of the Hannover experience). J Orthop Trauma. 1993;7:473–482.
Sugrue M, Seger M, Kerridge R, et al. A prospective study of the performance of the trauma team leader. J Trauma. 1995;38:79–82.
Svoboda P, Kantorova I, Ochmann J. Dynamics of interleukin 1, 2, and 6 and tumor necrosis factor alpha in multiple trauma patients. J Trauma. 1994;36:336–340.
Swiontkowski MF. Commentary on an article by Christopher J. Lenarz, MD, et al.: “Timing of wound closure in open fractures based on cultures obtained after debridement”. J Bone Joint Surg Am. 2010;92:e12.
Templeman DC, Gulli B, Tsukayama DT, et al. Update on the management of open fractures of the tibial shaft. Clin Orthop Relat Res. 1998:18–25.
Tkachenko SS, Rabinovich IM, Poliak MS, et al. Use of antibiotics in open fractures of the bones of the extremities. Voen Med Zh. 1975:20–23.
Tscherne H. [Management of open fractures]. Hefte zur Unfallheilkunde. 1983;162:10–32.
Tschoeke SK, Hellmuth M, Hostmann A, et al. The early second hit in trauma management augments the proinflammatory immune response to multiple injuries. J Trauma. 2007;62:1396–1403; discussion 1403–1404.
Valenziano CP, Chattar-Cora D, O’Neill A, et al. Efficacy of primary wound cultures in long bone open extremity fractures: Are they of any value? Arch Orthop Trauma Surg. 2002;122:259–261.
Wangensteen O, Wangensteen S. The Rise of Surgery from Empiric Craft to Scientific Discipline. Minneapolis: University of Minnesota Press; 1978.
Webb LX, Bosse MJ, Castillo RC, et al. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am. 2007;89:923–928.
Weed T, Ratliff C, Drake DB. Quantifying bacterial bioburden during negative pressure wound therapy: Does the wound VAC enhance bacterial clearance? Ann Plast Surg. 2004;52:276–280.
Weitz-Marshall AD, Bosse MJ. Timing of closure of open fractures. J Am Acad Orthop Surg. 2002;10:379–384.
Werner CM, Pierpont Y, Pollak AN. The urgency of surgical debridement in the management of open fractures. J Am Acad Orthop Surg. 2008;16:369–375.
Yannascoli S. The Urgency of Surgical Debridement and Irrigation in Open Fractures: A Systematic Review of the 6-hour Rule. University of Pennsylvania Orthopaedic Journal (UPOJ). 2011;21.
Yehuda U, et al. The Revised Reconstructive Ladder and its applications for high energy injuries to the extremities. Ann Plast Surg. 2006;56:401–405.
Yokoyama K, Uchino M, Nakamura K, et al. Risk factors for deep infection in secondary intramedullary nailing after external fixation for open tibial fractures. Injury. 2006;37:554–560.
Ziran BH, Smith WR, Anglen JO, et al. External fixation: how to make it work. J Bone Joint Surg Am. 2007;89:1620–1632.