5. Limb salvage or amputation

4. Definitive management

30 Trauma Surgery

internal fixation [34, 46–55].

definitive conversion to internal fixation (Figure 2).

internal fixation with a nail, in long bones of the lower limb (Table 3).

2 weeks after the injury, with a reasonable complication rate [56].

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

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

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

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.

Table 3. A review of articles is given, which focuses on the complication rate, after conversion from external fixation to

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 amputation.

From previous studies, we know that in case of limb conservation, we will face a secondary amputation rate of 3.9%, a complication rate near 40% (10% infections), a 24% non-union rate and an 8% of long-term osteomyelitis. In the case of amputation, we have to consider a reamputation rate of 5.4% and a 25% complication rate in the first 3 months (1/3 infections). At 7 years post-injury, patients treated with amputation or limb salvage procedure were found to have similarly poor outcomes [62], but costs were higher for amputee patients because of the cost of the prostheses [63].

7. Conclusions

Acknowledgements

Conflict of interest

Author details

and Jesús Pino-Mínguez1,3

Santiago de Compostela, Spain

Santiago de Compostela, Spain

Pontevedra, Spain

Open fractures can produce a huge disability in patients. The use of evidence-based protocols and treatments will help us to optimize patient's outcomes. Centers used to manage highenergy trauma with an "orthoplastic" team will achieve the best results in open fractures, specially grade III, and will be prepared to manage the devastating complications that will

The authors' research is supported by research grants from the Fondo de Investigación Sanitaria funded by the Instituto de Salud Carlos III and FEDER (PI16/01870, CP15/00007). R.G. is funded by the Instituto de Salud Carlos III through a Miguel Servet programme. R.G. is a member of the RETICS Programme, RD12/0009/0008 Instituto de Salud Carlos III (ISCIII).

appear during the reconstructive steps of these fractures.

Authors declare that they do not have conflict of interest.

Cristina López-Del Teso1,3, Rodolfo Gómez2

\*Address all correspondence to: aljmora@gmail.com

Alberto Jorge-Mora1,2,3\*, Samer Amhaz-Escanlar1,3, Iván Couto González1,4,

1 Hospital Clínico Universitario de Santiago de Compostela, Orthopaedic Department,

4 Hospital Clínico Universitario de Santiago de Compostela, Plastic Surgery Department,

5 Complexo Hospitalario de Pontevedra, Physical Medicine and Rehabilitation Department,

2 Musculoskeletal Pathology Group, Institute IDIS, Santiago de Compostela, Spain

3 University of Santiago de Compostela, Santiago de Compostela, Spain

, Teresa Jorge-Mora<sup>5</sup>

, José Ramón Caeiro-Rey1,3

Management of Open Fracture

33

http://dx.doi.org/10.5772/intechopen.74280

The factors that can modify outcomes, in patients with mangled extremities, are numerous: tobacco consumption is one of the most important, with an increase of 37% in the non-union rate, an increase higher than two times in infection and almost four times in osteomyelitis. Ceasing smoking will improve the union rate, the infection rate and the risk of osteomyelitis, but patients will never have the same risk as a non-smoker. Personal status, education level, gender, age, economic status and patient self-esteem are pre-lesional factors, and worker compensations, depression, SIP score, walking speed, pain and aggressive physiotherapy are post-lesional factor that will modify the outcomes [64–68].
