J Korean Orthop Assoc.  2018 Feb;53(1):9-18. 10.4055/jkoa.2018.53.1.9.

The Current Concepts in the Management of Open Fractures

Affiliations
  • 1Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, Korea. kcpark722@gmail.com

Abstract

Open fractures require infection prevention, injured soft tissue management, and fracture fixation. Moreover, it should be treated according to the emergency surgery. The main goals of treatment are life preservation, limb preservation, infection prevention, and functional restoration. Treatment procedure is carried out in the following order. Early diagnosis and management in the emergency room, appropriate antibiotic treatment, adequate irrigation and thorough debridement, fracture fixation and wound restoration (temporary stabilization of the fracture and covering of the wound, definite fixation of the fracture and soft tissue coverage). Herein, we discuss the current trends in each treatment phase to be helpful to other clinicians regarding the applicability of these steps in clinical practice.

Keyword

open fractures; debridement; external fixators; internal fixators

MeSH Terms

Debridement
Early Diagnosis
Emergencies
Emergency Service, Hospital
External Fixators
Extremities
Fracture Fixation
Fractures, Open*
Internal Fixators
Wounds and Injuries

Figure

  • Figure 1 Low-pressure wound irrigation using intravenous line with normal saline.

  • Figure 2 (A, B) A 61-year-old male with a right shaft fracture of the tibia and (C) open wound (Gustillo-Anderson classification type II). (D–F) Planning of pin placement is essential to avoid a compromise of definitive internal fixation. (G) External fixator was used as a reduction tool.

  • Figure 3 (A) A 42-year-old male with a right shaft fracture of the tibia and open wound (Gustillo-Anderson classification type 3B). (B) External fixator and vacuum-assisted closure was applied. (C) After 5 days of injury, large bone defect was observed when definitive plate fixation was performed. (D) Polymethylmethacrylate was filled in bone defect. (E) Soft tissue defect was reconstructed by gastrocnemius flap. (F) The fibula fracture was fixated at the same time to increase stability. (G) After 6 weeks, the wound was healed without complications. (H, I) Autogenous bone graft was performed using the Masquelet technique. (J) After 7 months, the fracture was united without complications.

  • Figure 4 (A) A 53-year-old male with a right shaft fracture of the tibia and (B) open wound (Gustillo-Anderson classification type 3B). (C) The fracture was fixated using the minimally invasive plate osteosynthesis technique. (D) At the same time, soft tissue defect was reconstructed by gastrocnemius flap. (E, F) After 1 year, the fracture united and (G) the wound healed without complications. (H) Function of the right limb was normal (images courtesy of CW Oh, M.D.).

  • Figure 5 (A) A 10-year-old male with a shaft fracture of the right tibia and fibula. (B) The open wound (Gustillo-Anderson classification type 3B) was approximated using a surgi loop. (C) Using surgical gel to prevent skin maceration. (D) The sponge was applied using the OPSITE® (Smith & Nephew). (E) After 6 days, the open wound became smaller. (F) The wound was sutured. (G) The fractures were fixated using a plate at the same time. (H) After 2 weeks, the wound healed without complications.

  • Figure 6 (A) A 48-year-old male with a right shaft fracture of the tibia and fibula and (B) open wound (Gustillo-Anderson classification type 3B). (C) External fixator was applied and fibula fracture was fixated with a plate. (D) The sponge was applied. (E) After 5 days, the fracture was fixated with intramedullary nail. (F) After 2 months, bone defect was observed. (G) Autogenous iliac bone graft was performed. (H) After 18 months, the fracture was united.

  • Figure 7 (A) The same patient in Figure 6 with a combined right shaft segmental fracture of the femur and (B) open wound (Gustillo-Anderson classification type 3A). (C) The fracture was fixated with intramedullary nail. (D) After 2 months, the fracture was in union. (E) After 6 months, the fracture was in union. (F) After 18 months, the fracture was united.


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