Management of Open Fractures A. Piras Oakland Small Animal Veterinary Clinic, Newry, Northern Ireland, UK.

Open fractures are injuries in which the bone has been exposed to the outside environment either from penetration out through the skin or loss of overlying soft tissues. These fractures are usually contaminated and can be infected. The clinical appearance of an open fracture varies from obvious skin and soft tissue damage with exposure of the bone to a subtle small piercing of the skin created by the protrusion of a spike of bone. The initial treatment of an open fracture is likely to affect the final outcome. An appropriate and systematic operative approach is necessary in order to maximize the chance of a successful outcome. The fundamental goals to consider every time we see an open fracture are to 1) prevent sepsis, 2) promote union, and 3) restore function. CLASSIFICATION OF OPEN FRACTURES The classification of open fractures is based upon the mechanism of injury, the degree of soft tissue damage, the configuration of the fracture, and degree of contamination. This classification scheme provides the emergency clinician with an invaluable guide to open fracture management. Type I These are injuries associated with a fracture where the wound is created from the inside to the outside. A sharp bone fragment penetrates the skin creating a puncture wound. Commonly, the bone retracts back under the skin leaving a wound that usually does not exceed 1 cm in length. The damage to the soft tissues is minimal and there is no soft tissue crushing injury. The fracture configuration is usually short oblique, transverse or spiral with little or no comminution. Any fracture accompanied by a skin damage as a laceration or deep abrasion near the fractured bone should be treated as a Type I open fracture. Probing the wound in the attempt to determine whether or not there is communication of the fracture should be absolutely avoided as this will inevitably lead to an open fracture. Overall complication rate is relatively low for type I injuries with infection rates reported as low as 4% to 5%. Type II With these injuries, the insulting agent generating the fracture is from an exterior source, creating soft tissue damage at the site of the impacted area. The wound is greater than 1 cm long, and there is mild to moderate tissue damage, but relatively little avascular or devitalized tissue. It is important to remember that a mild crushing injury can be associated with moderate contamination of the wound.

With this type of injury there can be a simple or moderately comminuted fracture pattern. Type III These injuries are characterized by extensive soft tissue damage with devitalization and major contamination. The soft tissue damage is full thickness involving skin, muscles, and neurovascular structures. These fractures are often highly comminuted and are generally caused by a high energy trauma. On the basis of the actual tissue loss and presence of arterial injury, type III fractures are divided in to three subtypes. Type III A fractures are characterized by adequate soft tissue coverage of the fractured bone despite extensive laceration or soft tissue flaps. This group includes segmental or severely comminuted fractures resulting from high energy trauma, regardless of the size of the external wound. Type III B injuries are extensive with loss of overlying soft tissues, periosteal stripping, and bone exposure. The wound is highly contaminated with a severe degree of comminution. A local or free flap is required for coverage of the defect. Type III C fractures are associated with arterial damage characterized by absence of distal pulse or perfusion. These cases require immediate repair in order to salvage the limb. The timing of wound classification can be an issue. Because of the progression of soft tissues necrosis over the first 48 to 72 hours, an apparently simple wound may require open irrigation and debridement with progressive loss of soft tissue coverage. For example, a wound classified as Type III A can advance to Type III B injury. Successful management of open fractures is strictly dependent on the ability to providing adequate treatment following a systematic protocol. Failure to appropriately manage these cases initially will dramatically increase the complication rate, can result in impaired limb function, and can diminish the overall outcome. Open fractures must be treated as an emergency. Early in the initial evaluation, is important to decide if the patient should be referred for further care to a specialty center or treated definitively. PATIENT ASSESSMENT The first consideration is the patients general condition. Up to 40% of patients with orthopedic injuries have concurrent thoracic or abdominal injuries and these are the most common cause of death after trauma. The initial assessment consists of rapid evaluation of the respiratory and circulatory function. Treatment of shock and/or respiratory distress is initiated immediately. After this initial stabilization and as soon as the patient can be safely handled, a physical, neurological, and orthopedic examination is performed. Open wounds are covered with sterile dressing in order to prevent nosocomial infections and factures should be splinted to prevent further soft tissue injury and discomfort for the patient. Routine basic bloodwork should be performed as soon as possible in order to obtain a baseline and thoracic and abdominal survey radiographs, a part of the general assessment, should be taken as soon as it is possible to safely handle the patient. Electrocardiography is necessary to detect arrhythmias due to traumatic induced myocarditis.

ANTIBIOTIC THERAPY An open fracture is contaminated by definition and should be considered infected after eight hours of exposure. Appropriate antibiotic therapy reduces infection rates in open fractures and should be initiated on admission of the patient. Recommended antibiotics for patients with Type I open fractures should cover the anaerobic gram- positive bacteria spectrum. A first-generation cephalosporin is appropriate and should be injected intravenously every 6 to 8 hours. For patients with Type II or III injuries, a first- or second-generation cephalosporin can be used alone or in combination with an aminoglycoside. Alternatively, a combination of a synthetic penicillin with an aminoglycoside is equally acceptable. When additional surgical procedures are required, such as either delayed open reduction or delayed secondary or primary wound closure, antibiotic therapy is continued for an additional 72 hours following the procedure. In humans, antibiotic therapy extended for more of three or four days postoperatively has not been reported to decrease the infection. WOUND MANAGEMENT Open fractures are surgical emergencies and should be treated, whenever possible, without delay. Wound management, following the principles of any other open wound, consists of adequate surgical debridement with copious lavage, followed by application of a sterile bandage. These fundamental steps must be followed carefully. Aggressive debridement of subcutaneous tissue and fat is accompanied by copious lavage with warm balanced electrolyte solution. Skin debridement should be conservative at first, trying to preserve those areas of questionable viability as skin coverage is a frequent problem in these patients. Devitalized tissue, debris, and small bone fragments devoid of soft tissues attachments should be discarded. Dirt, stone, and hair ground into the bone can be removed with a swab or a sterile surgical scrub. In certain cases a curette or bone rongeurs is necessary for the removal of deep embedded material. Very large bone fragments that can significantly contribute to the stability of the repair should be cleaned but not removed. During debridement of a wound a priority list should be kept in mind; fascia and fat are expendable, muscles and skin should be managed in a conservative manner, and ligaments, tendons, and bone should be left unless otherwise is absolutely necessary. The irrigation is maintained throughout the debridement procedure. Although a minimum of 1 to 2 liters is generally required, severely contaminated wounds will require a considerably larger amount of lavage solution. Soft tissue reconstruction can be often be performed as early as 7 days after the initial debridement as far as a clean and stable granulating wound has been achieved. In severely contaminated open fractures it is better to leave the wound open to allow drainage of fluids and progression of second intention healing.

FRACTURE REPAIR The timing of definitive fracture fixation remains controversial. The decision of immediate fixation versus delayed fixation is affected by the condition of the patient and possible referral to a specialist. Human orthopedic surgeons advocate immediate stabilization for intra-articular fractures, severely traumatized limbs, in presence of vascular compromise, in polytraumatized patients, and geriatric patients. Early repair of open fractures increases the survival of soft tissues which hastens healing and facilitates the treatment of the wound. In the veterinary patients, Type III fractures, some Type II fractures, and articular fractures are ideally treated with immediate stabilization. Fracture fixation is undertaken immediately after an aggressive debridement has converted the contaminated or infected wound into a clean contaminated wound. The wound area should be rescrubbed, replacing the gowns, the gloves, the drapes and the instruments before proceeding to the repair of the fracture. If a surgical approach is made to the bone, avoid whenever possible contact with the traumatic wound. Open fractures can be repaired with either internal fixation by plates or interlocking nails or external fixation (ESFs) with either linear hybrid or ring fixators. Intramedullary pins and cerclage wiring should be avoided. Internal fixation requires some consideration; it is not uncommon to hear that internal fixation should be avoided to prevent the introduction a foreign body that will increase the likelihood of infection. As numerous authors have shown, this not true and it is safe to perform internal fixation on open fractures after appropriate debridement (Chapman, Orthop Clin North Am, 1980). The external fixation offers definite advantages for the management of many open fractures and is probably the method of choice for fractures distal to the elbow and stifle. In particular, the use of ESFs is beneficial in the management of open fractures especially Type III A and B. The advantages are easy access to the wound for continued management and excellent stability achieved with fixation pins at sites distal to the wound. WOUND CLOSURE The closure should be planned on a case-by-case basis. It would be foolhardy to make statements as to which wounds should be closed and which should be left open without an intimate knowledge of the individual case. However, in general, Type I open fractures may be closed primarily but most open fractures are left completely open to allow healing by second intention. Operative debridement can be repeated together with lavage and application of wet to dry bandages until the wound is covered by a healthy granulation bed. In some cases, the wound does not heal because it is too large, located in an area of active motion, or over a pressure point. In these situations, skin reconstruction with a skin flap or graft should be considered. In cases with severe tissue loss and vast bone exposure, early wound coverage with healthy viable tissue is of supreme importance, even if only partial coverage can be achieved. Muscle flaps or axial pattern flaps can be used for this purpose. AUTOGENOUS CANCELLOUS BONE GRAFTING

In open fractures with adequate soft tissue coverage, autogenous cancellous bone grafting can be considered at the time of initial fracture stabilization. In Type III open fractures the graft may fail due to the poor soft tissue coverage. Additional bone grafting can be replaced 4 to 6 weeks after stabilization as soon as soft tissue coverage and blood supply of the fracture site are improved. POSTOPERATIVE CARE Appropriate postoperative care is mandatory to prevent and control infection. Wound management will depend on the extent of the soft tissue damage, the location of the injury, and the type of definitive fracture repair. The wound should be covered with sterile bandages; daily care include abundant lavages with sterile saline or lactate Ringers solution and frequent bandage changes until the development of a healthy granulation bed indicates the resolution of infection and the success of the healing process. The goal of the wound treatment is to establish a good bed of granulation tissue for either a delayed closure or secondary healing or the application of a skin flap or graft. The patients activity should be restricted depending on the type of fracture and type of fracture repair. The use of an Elizabethan collar is highly recommended in order to prevent the patient from removing or damaging the bandage and from licking the wound. Frequent and regular follow-up rechecks to assess limb function and radiography to monitor the bone healing are necessary in order to plan the timing and level of rehabilitation and physical therapy. Complete and early return to function of the injured limb is the ultimate goal in the management of open fractures. Muscles and tendons heal following the principle of "one wound one scar." For this reason early physiotherapy and rehabilitation represent the best way to optimize joint and soft tissue function during the healing period. References available from the author upon request.