The principles and practice of open fracture care, 2018

Amna Diwan, Kyle R Eberlin, Raymond Malcolm Smith, Amna Diwan, Kyle R Eberlin, Raymond Malcolm Smith

Abstract

The principles of open fracture management are to manage the overall injury and specifically prevent primary contamination becoming frank infection. The surgical management of these complex injuries includes debridement & lavage of the open wound with combined bony and soft tissue reconstruction. Good results depend on early high quality definitive surgery usually with early stable internal fixation and associated soft tissue repair. While all elements of the surgical principles are very important and depend on each other for overall success the most critical element appears to be achieving very early healthy soft tissue cover. As the injuries become more complex this involves progressively more complex soft tissue reconstruction and may even requiring urgent free tissue transfer requiring close co-operative care between orthopaedic and plastic surgeons. Data suggests that the best results are obtained when the whole surgical reconstruction is completed within 48-72 h.

Keywords: Bony stabilization; Debridement; Early healthy soft tissue cover; Open fractures.

Copyright © 2018 Daping Hospital and the Research Institute of Surgery of the Third Military Medical University. Production and hosting by Elsevier B.V. All rights reserved.

Figures

Fig. 1
Fig. 1
A grade IIIA tibial fracture. The initial open wound (A) is small but needs extension (B) to display the zone of injury. There is a comminuted segmental fracture with one clearly devitalised fragment requiring debridement. After debridement direct healthy closure with adequate soft tissue was possible allowing classification as IIIA.
Fig. 2
Fig. 2
After nailing there is a complex soft tissue defect over the distal tibia with exposed hardwear (A). This is only suitable for coverage with free tissue transfer. Here a free muscle flap was used (B) and the surface subsequently covered with a split skin graft. A grade IIIB injury. The final result is excellent (C).
Fig. 3
Fig. 3
The final result after a free fasciocutaneous (lateral thigh) flap to the distal leg for a grade IIIB injury.
Fig. 4
Fig. 4
Initial assessment of major de-gloving 3C injury (A) treated by singe stage debridement, revascularisation, internal fixation and free flap cover (B) with a latissimus dorsi flap incorporating the vascular branch to serratus anterior so the limb could be revascularized and the flap vascularized with the same micro vascular anastomosis.

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