Principles of management of open fractures

Abstract

Background: Open fractures are known orthopedic emergencies associated with risk of infection and healing problems. They also present as part of the spectrum in multiply injured patients in a third of cases. The cases of open fractures are common in our environment because of motor vehicle and motorbike accidents, falls from height and sometimes gun-shot wounds. They do carry significant morbidity and subsequent disability, if not managed appropriately. The initial management of Open fractures usually affects the ultimate outcome. A closer look at principles of evaluation and management of open fractures is necessary if they are to be managed appropriately.

Methods: An English literature survey done using different search engines and databases like Google, Pubmed, Medline, EMBASE, and Cochrane library concentrating on major review articles, prospective randomized trials, selected instructional courses, current concept reviews on principles of evaluation and management of open fractures to optimize outcome.

Results: Open fractures occur isolated or as part of spectrum of injuries patients in multiply injured patients. Initial evaluation according to Advanced Trauma Life Support principles and exclusion of life threatening injuries take priority. The goals of management of open fractures are prevention of infection, appropriate management of bone and soft tissue with resultant bone healing, and restoration of function to the injured extremity. Adjuncts to management include antibiotic therapy and anti-tetanus prophylaxis and management. Classification of open fracture depends on the fracture type, the related soft tissue injury and level of contamination. In severe cases like mangled extremities clinical assessment and use Mangled Extremity Severity Score may aid in management. Definitive management includes early and through debridement, generous lavage and soft tissue closure or reconstruction, and bone stabilization. There is still controversy on timing of closure, type of fluid or method of irrigation. Extensive soft tissue injury requires the collaboration between the orthopedic and plastic surgeons and mode of fixation of the fracture will depend on fracture characteristics, anatomic location and other supplemental procedures like flaps and bone grafting.

Conclusion: Open fractures managed by following management principles heal well with decreased morbidity and extremity function is restored.