Dealing With Open Fractures: The Medical Challenges
Open fractures add potential complications to the trauma of and treatment for broken bones. Defined as involving a direct link between the site of the bone injury and the external environment, open fractures characteristically involve lacerations. They comprise around three per cent of all broken bone injuries.
Classifying open fractures
Medical professionals classify open fractures using the Gustilo-Anderson scale, which takes into account the:
- Size of the wound.
- Extent of damage to surrounding tissues.
- Cause of the fracture and, especially, the level of energy involved.
The least severe is a Type I fracture, while the most complicated is a Type III-C.
Reasonably, one might assume that high energy is necessary to cause an open fracture. However, a surprising proportion of open fractures results from low-energy mechanisms, such as accidental falls. Common injury sites include the forearms, fingers, ankles, toes and the lower leg, often in the tibia.
Treating open fractures
To achieve a satisfactory long-term outcome, prompt medical assessment and effective care management are of the essence. Unfortunately, if left untreated, this type of fracture has high rates of morbidity and mortality.
In the treatment of open fractures, the immediate aims are to stop infection and prevent further injury or damage to the bones and tissues. Care priorities are to clean and seal the wound, realign bones and unify the break(s) to restore normal function.
Treatment and care plans vary according to the patient condition as well as the type of fracture, i.e. the mechanism which caused the injury. The state of the soft tissues in the area of the fracture is of particular importance. It is likely to affect early patient management directly.
Initial treatment involves debriding the site of the injury. Removing dead and damaged tissue will optimise the healing capability of the surrounding healthy areas. Expert debridement is advisable as soon as possible; the procedure ought to be meticulous to prevent unnecessary subsequent tissue breakdown and delays in recovery.
Using traction to repair fractures
If necessary, skeletal traction techniques involve external or internal fixation. However, surgeons employ traction only in limited circumstances because it increases the risk of infection. Its usefulness is in repairing complicated joint fractures, especially in cases where reconstruction of the articular surface is essential.
Alternatively, surgeons might opt for intramedullary nails to fix open fractures involving the femur and tibia.
Wound closure is by surface suturing, skin grafting or the use of muscle flap. Experience has shown that immediate or early closure of the wound – within seventy-two hours – tends to reduce infection rates and the need for additional surgical interventions. In other words, prompt closure promotes overall recovery time to the point of bone union.
Dealing with risk factors
In as many as four in ten Type III open fracture cases, bone union fails, at least at the first attempt. Usually, such problems occur in proportion to the severity of the original trauma. The body’s defences and normal bruising response work well when the fracture is not complicated. However, in open fractures, the haematoma does not congeal around the break, so post-injury healing factors escape to the environment.
Significant risks include infection, principally due to exposure of the damaged bone and tissue to outside organisms. Prompt prophylactic antibiotic treatment is, therefore, almost mandatory in such patients.
Loss of flaps is an additional risk, especially at the tips which are the least vascularised area of skin. Further surgery is almost invariably necessary; in the event of full necrosis, alternative flap coverage procedures are practically unavoidable.
Co-ordinating post-injury care
Surgical techniques and medical technology have improved noticeably over recent years, enabling healthcare professionals to provide efficient treatment, minimise infection risks and achieve good results. Nonetheless, to continue meeting these goals, surgical management and cooperation between orthopaedic, vascular and plastic surgery specialities will continue to be vital. If these different doctors work together, a favourable outcome is more likely for the patient in terms of a prompt return to everyday life.
The British Orthopaedic Association and British Association of Plastic, Reconstructive & Aesthetic Surgeons publish a series of audit standards for trauma, in which they advocate timely, multidisciplinary case management. They aim to ensure optimum recovery and to minimise the consequences to the patient (and the wider community) of infection. Notably, the associations recommend the prompt transfer of patients with open long bone, hindfoot or midfoot fractures to specialist centres that provide orthoplastic care (see below). Nonetheless, patients with injuries to the hand, wrist, forefoot or digits can receive treatment locally where admitted, providing duty staff follow similar principles.
Combining specialities: orthoplastic services
Orthoplastic medical care involves a combination of orthopaedic and plastic surgery consultancy, with sufficient experience from both specialities to allow the effective treatment and timely management of open fractures and flaps. Group responsibilities also include submitting patient data to the national trauma database (TARN) and organising periodic clinical audit meetings.
Specifically, their experts recommend photography of fracture wounds when first exposed during clinical care, before debridement and at other critical stages of management. These records should be kept in each patient’s file. Importantly, plans for fixation and coverage of open fractures should follow the combined orthoplastic approach from initial debridement surgery onwards.
Finally, NICE (The National Institute for Health and Care Excellence) publishes recommendations and information to support patients and family members or carers. A copy is available here.