2. Classification

Several classifications have been used to classify open fractures. We have chosen two from all of them because of the utility and spread through the orthopaedic community. The first one was described by Gustilo [10–12]. He distinguished three scales according to the energy of the mechanism of injury. The full description is reviewed in Table 1.

We can see in this classification that grade I injuries are simple fractures, usually with the skin disrupted from the inside because of the spike of the fracture, with limited contamination and good soft tissue coverage. Grade II injuries are usually the effect of a moderate trauma, with more soft tissue contusion and a more complex fracture pattern. Grade III injuries are the consequence of a high-energy trauma; we can find comminution and contamination in the fracture and an extensive soft tissue injury associated with periosteal striping. If the wound can be adequately covered and has no vascular injury, it is sub-classified as A. If the fracture cannot be covered by a soft tissue envelope, and we perform a rotational or free flap procedure to achieve coverage, we are talking about grade B injuries (Figure 1). It is important to underline


due to a high decrease in the number of open fractures in the occupants of motor vehicles probably because of the improvement of vehicles and traffic road security. This situation is in contrast with an increase, in the last years, in the incidence of open fractures in cyclist, motorcyclists and pedestrian accidents [2]. There is also a trend to see an increased incidence of open fractures in the elderly due to all mechanisms (high- and low-energy trauma) [1, 3, 4]. The presence of an open fracture is challenging because of several reasons. First of all, it is a complicated situation because of the generation of a bone defect or the presence of complex fracture patterns; second, we have to solve soft tissue coverage, and in some cases, we also

The management of open fracture has evolved during the last few years, with the introduction of algorithms and the integration of the "orthoplastic" management, in several trauma units in hospitals all over the world [5, 6]. We can see in countries, like United Kingdom, the presence of national protocols to favor an early transfer of patients with these injuries to a trauma center, in order to improve the final outcomes (British Orthopedic Association Standards for Trauma 4

In the case of multiple traumatized patients, open fractures should be individually addressed in order to minimize the general complications of a prolonged reconstructive procedure, minimizing the second-hit phenomenon in unstable patients [7–9]. The decision of limb salvage can be difficult to achieve, but in these situations, if we follow a validated protocol, we

In this chapter, we present the most recent evidence associated with the management of open fractures, with the objective of optimizing the management in these injuries, applying validated protocols in order to maximize the final outcomes obtained in patients with an open

Several classifications have been used to classify open fractures. We have chosen two from all of them because of the utility and spread through the orthopaedic community. The first one was described by Gustilo [10–12]. He distinguished three scales according to the energy of the

We can see in this classification that grade I injuries are simple fractures, usually with the skin disrupted from the inside because of the spike of the fracture, with limited contamination and good soft tissue coverage. Grade II injuries are usually the effect of a moderate trauma, with more soft tissue contusion and a more complex fracture pattern. Grade III injuries are the consequence of a high-energy trauma; we can find comminution and contamination in the fracture and an extensive soft tissue injury associated with periosteal striping. If the wound can be adequately covered and has no vascular injury, it is sub-classified as A. If the fracture cannot be covered by a soft tissue envelope, and we perform a rotational or free flap procedure to achieve coverage, we are talking about grade B injuries (Figure 1). It is important to underline

have to recover the blood flow to the extremity.

can optimize the chances of a favorable outcome.

fracture.

24 Trauma Surgery

2. Classification

[BOAST 4]: The management of severe lower limb fractures).

mechanism of injury. The full description is reviewed in Table 1.

Table 1. Summary of the Gustilo and Anderson classification, with the division of grade III fractures (red) in grade IIIA, IIIB and IIIC.

Figure 1. Image A: Clinical picture of an open IIIC fracture of the humerus. Image B: Photograph in the operative theater of the early and initial management, by temporary fixation with an external fixator, to facilitate vascular reconstruction and protection of the repair.


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

Management of Open Fracture

27

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

are promising, with low infection rates [25], or the use of gentamicin sponges [26].

improve outcomes and diminish septic complication [30].

3.3. Negative pressure wound therapy

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

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

3.2. Time of debridement

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

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 therapy when facing an open fracture.

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