Open fractures

Classification, Management and Evidence

Outline

• Definition• Classification• Management• Complications

Definition of open fracture

• A broken bone that is in communication through the skin with the environment

Classification

• Gustilo and Anderson classification of open #

– Based on1. Size of wound2. Amount of soft tissue injury3. Presence/absence of NV injury4. Degree of contamination

Classification - I– Clean wound <1 cm in diameter– Simple # pattern with minimal

comminution– Minimal soft tissue injury

Classification - II• Laceration >1 cm

diameter• Moderate soft tissue

damage (no flaps, degloving, or contusion)

• # pattern may be more complex

• Moderate contamination

Classification - III– An open segmental # or a single # with

extensive soft-tissue injury. Also included are injuries older than 8 hours• >10cm long• Highly contaminated• Usually comminuted

– IIIA, IIIB, IIIC• Depends on soft tissue injury

Classification - IIIA• Severe soft tissue injury• Adequate soft-tissue

coverage of the # is likely (despite high-energy trauma or extensive laceration or skin flaps)

Classification - IIIB• Inadequate soft-tissue

coverage with periosteal stripping

• Soft-tissue reconstructive surgery is necessary

Classification - IIIC

• Associated vascular injury that requires repair• Reconstructive surgery for skin coverage

Management aims– Prevent infection– Ensure # healing– Restore function

Management• Analgesia• Fluid/blood replacement• Splinting• Antibiotics• Tetanus prophylaxis• Take photo• Cover wound• Surgical debridement• Stabilise #

Use of antibiotics

• Cochrane review 2009 – “Antibiotics for preventing infection in open limb fractures”– 1106 participants– 8 studies (5 RCT, 3 quasi-randomised)– Use of antibiotics had a protective effect

against early infection compared with no antibiotics or placebo (risk ratio 0.43, 95% CI 0.29 to 0.65)

Which antibiotics?

• BOA/BAPRAS guidelines for lower limb open # (2009):– IV co-amoxiclav 1.2g TDS until 1st

debridement (if penicillin allergic IV clindamycin 600mg QDS)

– At induction of anaesthesia• Gentamicin 1.5mg/kg• Plus teicoplanin 800mg or vancomycin 1g

– Post op continue IV augmentin 1.2g TDS until wound closure or max. of 72 hours

Timing of debridement

• Kindsfater et al 1995– 47 tibia fractures (25 grade II, 22 grade III)– Jan 1988 to Jan 1992– Initial debridement:

• < 5 hours - 7% infection rate• > 5 hours - 38% infection rate• Overt manifestations of infection - 4.8 months

Timing of debridement

• BOA/BAPRAS guidelines lower limb open # (2009)– Within 24 hours if solitary open # by senior

plastic & ortho surgeons on scheduled list– However immediately if:

• gross contamination• compartment syndrome• devascularised limb• multi-injured pt

Complications

• Wound infection• Osteomyelitis• Non-union• Tetanus infection• Neurovascular injury• Compartment syndrome

Risk of infection (Sorger, 1999)

Grade of open fracture (Gustilo-Anderson)

Risk of infection (%)

I 0 – 12

II 2 -12

III 9 - 55

Summary

• Gustilo-Anderson classification• Grade I, II, III (A/B/C) dependent on

wound size, amount of soft tissue injury, degree of contamination & NV injury

• Take photo & cover wound• Antibiotics & early debridement

References1. Gustilo RB, Anderson JT “Prevention of infection in the treatment of 1025

open fractures of long bones: Retrospective and Prospective” Journal of Bone and Joint Surgery, 1976, Vol. 58-A (4): pg 453–458

2. Gosselin RA, Roberts I, Gillespie WJ “Antibiotics for preventing infection in open limb fractures” Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003764. DOI: 10.1002/14651858.CD003764.pub2

3. BOA/BAPRAS “Standards for the management of open fractures of the lower limb – A short Guide” September 2009

4. Kindsfater K, Jonassen EA “Osteomyelitis in grade II and grade II open tibia fractures with late debridement” Journal of Orthopaedic Trauma 1995, Apr;9(2): pg 121-7

5. http://www.eorif.com/General/Open%20Fx%20Class.html6. Royal College of Surgeons of Edinburgh

http://www.rcsed.ac.uk/fellows/lvanrensburg/classification/commonfiles/open.htm