3. Initial management

We have to be aware of several difficulties when initially treating an open fracture, the antibiotic treatment, the time until debridement and the decision of temporally external fixation versus definitive fixation. Most of the evidence of the management of open fractures in long bones is based on open tibial management because it is the most frequent bone involved in open fractures due to its location and characteristics [1].

### 3.1. Antibiotic prophylaxis

Antibiotic prophylaxis is one of the mainstays of open fracture management. From previous reports, we know that the most common pathogens involved in the colonization of open fractures are Coagulase Negative Staphylococci [15], but depending on the geographic situation, the resistances of these bacteria may change, and orthopedic surgeons should identify the local resistances of the bacteria in their respective area. It is imperative to prescribe antibiotic prophylaxis as soon as possible [16, 17] because early antibiotics diminish infection rates in open fractures [17–19]. This is one of the easiest factors to improve in order to optimize the open fracture management in our clinical practice [20]. The British Orthopedic Association recommends to administering antibiotics within 3 h from the injury. There is also controversy about the perfect antibiotic prophylaxis in the treatment of open fractures. Local or national protocols are of high value if they are adequate to current evidence and population antibiotic resistance. The British Orthopedic Association (BOAST 4) suggests the use of Co-amoxiclav (1.2 g) or Cefuroxime (1.5 g) every 8 h and continue until wound debridement. We should choose clindamycin 600 mg every 6 h if there is a penicillin allergy. Other validated recommendations are the use of cefazolin and gentamicin [21] or piperacillin/tazobactam for 24 h after debridement [22]. Although the use of vancomycin is safe, it is still controversial except for patients allergic to penicillin because it seems that it does not have any benefit in patients with open fractures added to cefazolin [23]. A recent publication suggests a benefit in the use of early vancomycin powder in the wound (locally) to prevent biofilm formation [24]. Other strategies for antibiotic elution in the fracture site are being studied, for example, gentamicin-coated nails are promising, with low infection rates [25], or the use of gentamicin sponges [26].

### 3.2. Time of debridement

that a partial skin or total skin graft is not considered as criteria to classify the fracture as grade IIIB. If we have to face a vascular injury that needs to be repaired, we are talking about grade IIIC. This classification has several utilities: first, it has a prognostic meaning [13], that is, the higher you move in the scale, the chances of infection and complication increase. The second is widespread and used worldwide, and it is clinically useful because it can guide the initial

Table 2. Summary of the different conditions included in the classification of the Orthopedic Trauma Association.

In 2010, in the Journal of Orthopedic Trauma, an article was published proposing a new classification for open fractures based on a meticulous review of the literature made by the Classification Committee of the Orthopedic Trauma Association (OTA) [14]. This classification is useful to classify open fractures of the upper extremity, lower extremity and pelvis in adults and children in a clinically relevant way. This classification proposed five parameters to be measured: skin,

We have to be aware of several difficulties when initially treating an open fracture, the antibiotic treatment, the time until debridement and the decision of temporally external fixation versus definitive fixation. Most of the evidence of the management of open fractures in long bones is based on open tibial management because it is the most frequent bone involved

Antibiotic prophylaxis is one of the mainstays of open fracture management. From previous reports, we know that the most common pathogens involved in the colonization of open

muscle cover, contamination of the wound, arterial injury and bone loss (Table 2) [14].

in open fractures due to its location and characteristics [1].

therapy when facing an open fracture.

26 Trauma Surgery

3. Initial management

3.1. Antibiotic prophylaxis

Time of debridement is also a constant controversy [16]. There was a "6-hour rule" in open fracture for early debridement, but recent publications have put this postulate in doubt. There is enough evidence that supports that time for debridement is not a main factor that conditions infection rates or outcomes [16, 27, 28]. This debridement can be safely performed in the first 24 h, and there is consensus to wait within this 24 h for the best conditions, ideally with an orthoplastic team to plan the reconstruction [6, 29]. Primary early closure of open fractures will improve outcomes and diminish septic complication [30].

### 3.3. Negative pressure wound therapy

The use of negative pressure wound therapy in open fractures that cannot be closed, in the first debridement, is an option that should be considered individually because despite there being evidence that favors its use as a temporary cover until definitive plastic reconstruction [31, 32], there is also a concern about its effect in bacterial growth and local antibiotic effectiveness [33]. Negative wound therapy is an alternative for temporary wound closure in those patients whose condition contraindicates the reconstruction (e.g. polytrauma patients who are not suitable for surgery). In those cases, we should maintain the dressings and change them in short periods of time [32]. A defined limit period of time to use negative pressure wound therapy is not clear, and despite its complications, it is reasonable to extend its use in cases of impossibility of soft tissue coverage because in these situations, it seems to decrease the complications when compared to wet dressings [31]. It is safe to proceed with the conversion from external fixation to internal fixation, in the presence of negative pressure wound therapy, if we hold on the safe interval accepted for conversion from external fixation to internal fixation (less than 2 weeks) [34].

### 3.4. Initial fixation

Another point of conflict is the initial fixation method for open fractures, particularly, in femur and tibia. It is important to obtain an adequate fixation, in order to minimize pain, optimize wound and facilitate patient manipulation. It seems that grades I and II open fractures can be managed in a similar way like close fractures, with the adequate antibiotic prophylaxis and wound debridement and closure [18], and in the case of tibial fractures, the use of reamed intramedullary nails seems to be reasonable [35] and the use of temporary plating can be a trick to achieve anatomic reduction [36]. More controversies exist in grade III open fracture management. In grade IIIA, the use of non-reamed intramedullary nails seems to be a good and safe option (superior), compared to temporary external fixation in fractures with minimum bone defect, with minimized complications and good union rates [37, 38]. Recent reviews suggest that reamed nailing is not inferior to unreamed nailing in terms of function [38, 39] in grade IIIB open tibial fractures. In these fractures, there is evidence that supports the use of similar treatment options than those used for grade IIIA, and in those situations, early wound coverage is done and minimum bone defect is present [5]. If we are in the presence of a bone defect, the use of a protocoled treatment with temporary external fixation may be useful for definitive treatment. In the case of using an external fixator to temporary or definitive management, we should have in mind that future interventions should avoid damaging essential structures or compromise future reconstructive procedures. New modular devices allow us to achieve adequate fixation with different configurations and prevent inadvertent injuries or compromise future approaches.

Early management of IIIC and some IIIB fractures should be first guided by the need of amputation versus limb salvage, and this topic will be shown in a dedicated chapter. In the case of a IIIC open fracture, vascular repair is mandatory, and our efforts should be focused in obtaining a quick and stable fixation to protect the vascular repair (Figure 2). In these cases, we should also consider early preventive fasciotomies to prevent compartment syndrome caused by a revascularized ischemic limb.

seems to be an option for selected patients, but it is not efficient to use routinely in all patients

Figure 2. A complete reconstructive procedure in an open fracture grade IIIB tibial fracture, in a 43-year-old female. Image A: photograph in the emergency department of a grade IIIB open fracture in the emergency department. Image B: photograph in the operative theater, temporary fixation of the fracture with an external fixation. Image C: X-ray of the temporarily stabilized fracture with an external fixator, after soft-tissue and bone debridement. Image D: the final soft tissue coverage of the injury. Image E: an anteroposterior and lateral X-ray, after definitive fixation of the fracture with a nail.

Management of Open Fracture

29

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

If we have to treat a complex open fracture, in a center without the resources to make the reconstruction, it would be a good option to complete antibiotic prophylaxis, immobilize the injury in a proper way after an initial clinical assessment and refer the patient to a trauma center as soon as possible, especially in the presence of a vascular injury that we would not be able to repair. In the case that the patient needs a long transfer to the definitive centre, or the initial debridement surgery would not be performed within 24 h, it is considered a good option to temporary apply an external fixation, perform the irrigation and debridement and then transfer

the patient to a trauma centre to perform the reconstructive procedure.

[43, 44].

3.6. Referral to a trauma center

### 3.5. Compartment syndrome

The suspicion of a compartment syndrome should always be present in high-energy trauma, especially in non-conscious patients. Compartment pressure should be measured in case of doubt in these patients, and if there is an increase, or high clinical suspicion, a fasciotomy should be performed [40, 41]. Compartment syndrome is more frequent in young patients with closed fractures, managed by external fixation and intramedullary nailing, but it can also develop in an open fracture, particularly if we closed the fascial compartment with tension [42]. The use of drains and lax closure (or non-closure) of the fascia will help to prevent the increase of the fascial compartment pressure. The use of continuous pressure monitoring

Figure 2. A complete reconstructive procedure in an open fracture grade IIIB tibial fracture, in a 43-year-old female. Image A: photograph in the emergency department of a grade IIIB open fracture in the emergency department. Image B: photograph in the operative theater, temporary fixation of the fracture with an external fixation. Image C: X-ray of the temporarily stabilized fracture with an external fixator, after soft-tissue and bone debridement. Image D: the final soft tissue coverage of the injury. Image E: an anteroposterior and lateral X-ray, after definitive fixation of the fracture with a nail.

seems to be an option for selected patients, but it is not efficient to use routinely in all patients [43, 44].

### 3.6. Referral to a trauma center

from external fixation to internal fixation, in the presence of negative pressure wound therapy, if we hold on the safe interval accepted for conversion from external fixation to internal

Another point of conflict is the initial fixation method for open fractures, particularly, in femur and tibia. It is important to obtain an adequate fixation, in order to minimize pain, optimize wound and facilitate patient manipulation. It seems that grades I and II open fractures can be managed in a similar way like close fractures, with the adequate antibiotic prophylaxis and wound debridement and closure [18], and in the case of tibial fractures, the use of reamed intramedullary nails seems to be reasonable [35] and the use of temporary plating can be a trick to achieve anatomic reduction [36]. More controversies exist in grade III open fracture management. In grade IIIA, the use of non-reamed intramedullary nails seems to be a good and safe option (superior), compared to temporary external fixation in fractures with minimum bone defect, with minimized complications and good union rates [37, 38]. Recent reviews suggest that reamed nailing is not inferior to unreamed nailing in terms of function [38, 39] in grade IIIB open tibial fractures. In these fractures, there is evidence that supports the use of similar treatment options than those used for grade IIIA, and in those situations, early wound coverage is done and minimum bone defect is present [5]. If we are in the presence of a bone defect, the use of a protocoled treatment with temporary external fixation may be useful for definitive treatment. In the case of using an external fixator to temporary or definitive management, we should have in mind that future interventions should avoid damaging essential structures or compromise future reconstructive procedures. New modular devices allow us to achieve adequate fixation with different configurations and prevent inadvertent

Early management of IIIC and some IIIB fractures should be first guided by the need of amputation versus limb salvage, and this topic will be shown in a dedicated chapter. In the case of a IIIC open fracture, vascular repair is mandatory, and our efforts should be focused in obtaining a quick and stable fixation to protect the vascular repair (Figure 2). In these cases, we should also consider early preventive fasciotomies to prevent compartment syndrome caused

The suspicion of a compartment syndrome should always be present in high-energy trauma, especially in non-conscious patients. Compartment pressure should be measured in case of doubt in these patients, and if there is an increase, or high clinical suspicion, a fasciotomy should be performed [40, 41]. Compartment syndrome is more frequent in young patients with closed fractures, managed by external fixation and intramedullary nailing, but it can also develop in an open fracture, particularly if we closed the fascial compartment with tension [42]. The use of drains and lax closure (or non-closure) of the fascia will help to prevent the increase of the fascial compartment pressure. The use of continuous pressure monitoring

fixation (less than 2 weeks) [34].

injuries or compromise future approaches.

by a revascularized ischemic limb.

3.5. Compartment syndrome

3.4. Initial fixation

28 Trauma Surgery

If we have to treat a complex open fracture, in a center without the resources to make the reconstruction, it would be a good option to complete antibiotic prophylaxis, immobilize the injury in a proper way after an initial clinical assessment and refer the patient to a trauma center as soon as possible, especially in the presence of a vascular injury that we would not be able to repair. In the case that the patient needs a long transfer to the definitive centre, or the initial debridement surgery would not be performed within 24 h, it is considered a good option to temporary apply an external fixation, perform the irrigation and debridement and then transfer the patient to a trauma centre to perform the reconstructive procedure.
