4. Definitive management

There are several options to finally address an open fracture, and we should select the method appropriate for the clinical situation. In the case of polytrauma patients and high-energy trauma, most of the patients are treated with temporally external fixation and later with definitive conversion to internal fixation (Figure 2).

Depending on the situation, we should choose the appropriate moment to perform this conversion to internal fixation. In the case of unstable patients, the best moment for internal conversion is given by patient situation and systemic status, but it is safe to perform this conversion in an interval of time lesser than 14 days [45]. There are several articles that calculate the infection rate of the conversion from external to internal fixation, with percentages that move between 0 and 40, depending on the interval between the injury and the definitive internal fixation with a nail, in long bones of the lower limb (Table 3).

In the case of upper extremity, the use of plates is more common, and in humeral open fractures, it is safe to perform the conversion from external fixation to a plate during the first 2 weeks after the injury, with a reasonable complication rate [56].

In some circumstances, we may have to treat a fracture fixed with an external fixator for a long time (more than 4 weeks). In this situation, it is reasonable to retire the external fixator, use an orthosis or a cast, and wait for 2–4 weeks to perform the definitive internal fixation, if there are no septic complications. Another option is to use an external fixator as the definitive device to treat the fracture; this is a good option in patients who are not amenable for internal fixation.

The use of computer-assisted orthopaedic devices will help to correct and treat sequelae

Figure 3. The treatment of an open grade bifocal IIIB fracture in an 82-year-old female. Image A: initial X-ray of the patient who was treated with an external fixation for 3 months, with no callus formation and development of a malunion. The patient required multiple coverage procedures during this period of time. Image B: initial X-ray after the patient was treated with a Taylor Spatial Frame, correction begun. Image C: X-ray after 6 months since the implantation of the TSF.

Management of Open Fracture

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Most evidence about the decision between limb salvage and amputation is obtained from the lower extremity assessment project (LEAP) study and war-related trauma studies. Several rating scores have been proposed to facilitate the decision, for example, the OTA classification for open fractures, the Mangled extremity severity score or the Ganga Hospital Score [57–60]. Recent publications have demonstrated that these scores should be reviewed to include the new therapeutic advances to prevent amputation and improve the sensitivity and specificity of these scores [61], so these scores alone should not be the only criteria to make our decision.

Because of legal reasons, it is important to include in the clinical records, the anamnesis and graphical documents of the injury, especially in those cases we have decided to perform

caused by temporally external fixation (Figure 3).

The fracture is healed, good alignment and full soft-tissue coverage is achieved.

5. Limb salvage or amputation

amputation.


Table 3. A review of articles is given, which focuses on the complication rate, after conversion from external fixation to internal fixation [34, 46–55].

Figure 3. The treatment of an open grade bifocal IIIB fracture in an 82-year-old female. Image A: initial X-ray of the patient who was treated with an external fixation for 3 months, with no callus formation and development of a malunion. The patient required multiple coverage procedures during this period of time. Image B: initial X-ray after the patient was treated with a Taylor Spatial Frame, correction begun. Image C: X-ray after 6 months since the implantation of the TSF. The fracture is healed, good alignment and full soft-tissue coverage is achieved.

The use of computer-assisted orthopaedic devices will help to correct and treat sequelae caused by temporally external fixation (Figure 3).
