Update on the management of open lower limb fractures

M Griffin, M Malahias, W Khan, S Hindocha, M Griffin, M Malahias, W Khan, S Hindocha

Abstract

Open lower limb fractures pose a significant challenging pathology for orthopaedic and plastic surgeons to manage due to the combined soft tissue damage, bone loss and potential vascular compromise. These fracture require extensive team-work and expertise between several surgical specialties and the advice of non-surgical specialties to ensure good clinical outcomes. Extensive research has improved the outcomes of open lower limb fractures and current recommendation on the optimal management is always being updated to enhance patient outcomes. This review serves to provide an overview of the management of open tibial fractures using current evidence and recently updated UK guidelines. The optimal time for surgical debridement, surgical intervention, providing antibiotics and soft tissue coverage will be outlined as well as the indications for amputation.

Keywords: Open tibial fracture; amputation; gustilo and and Anderson score; lower limb fracture; wound debridement..

Figures

Fig. (1)
Fig. (1)
Method of managing open fractures in the accident and Emergency Department [3].

References

    1. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24(8 ):742–6.
    1. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994;76(8 ):1162–6.
    1. British Association of Reconstructive and Aesthetic Surgeons. Standards for treatment of open fractures of the lower leg. 2009.
    1. Court-Brown CM, Rimmer S, Prakash U, Mc Queen mm. The epidemiology of open long bone fracture. Injury. 1998;29:529–34.
    1. Court-Brown CM, Brydone A. Social deprivation and adult diaphyseal fractures. Injury. 2007;38:750–4.
    1. McKenzie EJ, Rivara FP, Jurkovich GJ, et al. A national evaluation of the effect of trauma center on mortality. N Engl J Med. 2006;354:366–78.
    1. Advanced Trauma Life Support student Course Manual. Eight. Chicago: American College of Surgeons; 2008.
    1. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg [Am] 1990;72-A:299–304.
    1. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty five open fractures of long bones. J Bone Joint Surg [Am] 1976;58-A:453–8.
    1. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg. 1990;72-A:299–304.
    1. Gosselin RA, Roberts I, Gillespie WJ. Antibitoics for preventing infections in open limb fractures. (CD003764).Cochrane Database Syst Rev. 2004;1
    1. Jager M, Maier D, Kern WV, Sudkamp NP. Surgical Infection Society guidelines. Prophylatic antibiotic in open fracture: an evidence based guideline. Surg Infect. 2006;7:379–405.
    1. Lee J. Efficacy of cultures in the management of open fractures. Clin Orthop Relat Res. 1997;339:71–5.
    1. Carsenti-Etesse H, Doyon F, Desplaces N, et al. Epidemiology of bacterial infection during management of open leg fractures. Eur J Clin Microbiol Infect Dis. 1999;18:315–23.
    1. Patzakis MJ, Harvey JP, Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am. 1974;56:532–41.
    1. Zalavras CG, Patzakis MJ, Holtom PD, Sherman R. Management of open fractures. Infect Dis Clin North Am. 2005;19:915–29.
    1. Olson SA, Finkemeier CG. Open Fractures. In: Bucholz RW, Heckman JD, Moehring ND, editors. Rockwood and Greene’s fractures in adults. 5th. Philadelphia: Lippincott: Williams and Wilkins; 2001. pp. 285–318.
    1. Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on the management of open fractures of the tibial shaft. Clin Orthop. 1998;350:18–25.
    1. Eckman JB, Jr, Henry SL, Mangino PD, Seligson D. Wound and serum levels of tobramycin with the prophylactic use of tobramycin-impregnated polymethylmethacrylate beads in compound fractures. Clin Orthop Relat Res. 1988;237:213–5.
    1. Ostermann PA, Seligson D, Henry SL. Local antibiotic therapy for severe open fractures. A review of 1085 consecutive cases. J Bone Joint Surg Br. 1995;77:93–7.
    1. Moehring HD, Gravel C, Chapman MW, Olson SA. Comparison of antibiotic beads and intravenous antibiotics in open fractures. Clin Orthop Relat Res. 2000;372:254–61.
    1. Robson MC, Duke WF, Krizek TJ. Rapid bacterial screening in the treatment of civilian wounds. J Surg Res. 1973;14:426–30.
    1. Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. 1995;9:121–7.
    1. Kreder HJ, Armstrong P. A review of open tibia fractures in children. J Pediatr Orthop. 1995;15:482–8.
    1. Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. 1995;9:121–7.
    1. Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma. 2002;16:484–90.
    1. Patzakis MJ, Wilkins J. Factors influencing infectionr rate in open fracture wounds. Clin Orthop Res. 1989;243:36–40.
    1. Naique SB, Pearse M, Manachalal J. Management of severe open tibial fractures: The need for combined orthopaedic and plastic surgical treatment in specialist centers. J Bone Joint Surg Br. 2006;88:351–7.
    1. Crowley DJ, Kanaakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg Br. 2007;89:580–5.
    1. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg. 2001;9:219–26.
    1. Artz CP, Sako Y, Scully RE. An evaluation of the surgeon's criteria for determining the viability of muscle during débridement. AMA Arch Surg. 1956;73(6 ):1031–5.
    1. Park SH, Silva M, Bahk WJ, McKellop H, Lieberman JR. Effect of repeated irrigation and debridement on fracture healing in an animal model. J Orthop Res. 2002;20(6 ):1197–204.
    1. Anglen JO. Comparison of soap and antibiotic solutions for irrigation of lowerlimb open fracture wounds. A prospective randomized study. J Bone Joint Surg Am. 2005;87:1415–22.
    1. Bollero D, Carnino R, Risso D, Gangemi EN, Stella M. Acute complex traumas of the lower limbs: a modern reconstructive approach with negative pressure therapy. Wound Repair Regen. 2007;15(4 ):589–94.
    1. De Franzo AJ, Argenta LC, Maks A, et al. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg. 2001;108:1184–91.
    1. Stannard JP, Volgas D A, Robinson J, De Los Santos C. Topical negative pressure therapy for soft tissue management of open fractures, preliminary results. Second World Union of Wound Healing Societies Meeting Paris. 2004.
    1. Court-Brown CM, McQueen MM, Quaba AA, Christie J. Locked intramedullary nailing of open tibial fractures. J Bone Joint Surg [Br] 1991;73-B:959–64.
    1. Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma. 1994;8:45–9.
    1. Giotakis N, Narayan B. Stability with unilateral external fixation in the tibia. Strategies Truam Limb Reconstr. 2006;2:13–20.
    1. Nayagam S. Safe corridors in external fixation: The lower Left (tibia, fibula hindfoot, and forefoot) Strategies trauma limb reconstruct. 2007;2:105–10.
    1. Bone LB, Kassman S, Stegemann P, France J. Prospective study of union rate of open tibial fractures treated with locked, unreamed intramedullary nails. J Orthop Trauma. 1994;8:45–9.
    1. Williams MM, Askins V, Hinkes EW, Zych GA. Primary reamed intramedullary nailing of open femoral shaft fractures. Clin Orthop. 1995;318:182–90.
    1. Dabezies E J, D’Ambrosia R, Shoji H, Norris R, Murphy G. Fractures fo the femoral shaft treated by external fixation with the Wagner device. J Bone Joint Surg. 1984;66-A:360–4.
    1. Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg. 2000;82-A:781–8.
    1. Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia: a systematic overview and meta-analysis. J Bone Joint Surg. 2001;83-B:62–8.
    1. Utvag SE, Grundnes O, Reikeras O. Effects of degrees of reaming on healing segmental fractures. J Orthop Trauma. 1998;12:192–9.
    1. Grundnes O, Utvag SE, REikeras O. Restoration of bone flow following fracture and reaming in rat femora. Acta Orthop Scand. 1994;65:185–90.
    1. Hupel TM, Aksenov SA, Schemitsch EH. Cortical bone blood flow in loose and tight fitting locked intramedullary nailing: a canine segmental tibia fracture model. J Orthop Trauma. 1998;2:127–35.
    1. Giannoudis PV, Papakostidis C, Roberts C. A review of the management of open fractures of the tibia and femur. J Bone Joint Surg Br. 2006;88(3 ):281–9.
    1. Keating JF, O’Brien PJ, Blachut PA, et al. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft: a prospective randomized study. J Bone Joint Surg. 1997;79-A:334–41.
    1. Antich-Adrover P, Marti-Garin D, Murias-Alvarez J, Puente-Alonso C. Externalfixation and secondary intramedullary nailing of open tibial fractures: a randomised, prospective trial. J Bone Joint Surg. 1997;79-B:433–7.
    1. Sarmiento A, Gersten LM, Sobol PA. Tibial Shaft fractures treated wit functional braces: experience with 780 fractures. J Bone Joint Surg. 1989;71-B:602–9.
    1. Blachut PA, Meek RN, O’Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft: a sequential protocol. J Bone Joint Surg. 1990;72-A:729–35.
    1. McGraw JM, Lim EVA. Treatment of open tibial-shaft fractures: external fixation and secondary intramedullary nailing. J Bone Joint Surg. 1988;70-A:900–11.
    1. Maurer DJ, Merkow RL, Gustilo RB. Infection after intramedullary nailing o severe open tibial fractures initially treated with external fixation. J Bone Joint Surg. 1989;71-A:835–8.
    1. Inan M, Halici M, Ayan A, et al. Treatment of type IIIA open fractures of tibial shaft with Ilizarov external fixator versus unreamed tibial nailing. Arch Orthop Trauma Surg. 2007;127:617–23.
    1. Bach AW, Hansen ST., Jr Plates versus external fixation in severe open tibial shaft fractures: a randomized trial. Clin Orthop. 1989;241:89–94.
    1. Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Bone Joint Surg Am. 1987;69:801–7.
    1. Small JO, Mollan RA. Management of open tibial fractures. Acta Orthop. 1996;62:188–92.
    1. Sinclair JS, MC Nally MA, Small JO, Yeates HA. Pimary free flap cover of open tibial fractures. Injury. 1997;28:581–7.
    1. Hertel R, Lambert SM, Müller S, Ballmer FT, Ganz R. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg. 1999;119(1-2 ):7–12.
    1. Glass GE, Pearse MF, Nancchalal J. Improving lower limb salvage following fractures with vascular injury: A systematic review and new management algorithm. J Plast Recontr Aesthet Surg. 2009;62:571–9.
    1. Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Join Surg. 1990;72:571–9.
    1. Mc Henry TP, Holcomb JB, Aoki N, Lindsey RW. Fractures with major vascular injuries from gunshot wounds: Implications of surgical sequence. J Trauma. 2002;53:717–21.
    1. Dickson K, Katzman S, Delgado E, Contreras D. Delayed unions and nonunions of open tibial fractures. Correlation with arteriography results. Clin Orthop Relat Res. 1994;302:183–93.
    1. Khali IM, Livingston DH. Intravascular shunts in complex lower limb trauma. J Vasc Surg. 1986;62:582–7.
    1. MacKenzie EJ, Bosse MJ, Kellam JF, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma. 2002;52:641–9.
    1. Esquenazi A, Meier RH., 3rd Rehabilitation in limb deficiency 4 Limb amputation. Arch Phys Med Rehabil. 1996;77:S18–28.
    1. Dougherty PJ. Long term follow up of unilateral transfemoral amputees form the Veitnam War. J Trauma. 2003;54:718–23.

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