Perspectives on Modern Orthopaedics

Timing of Closure of Open Fractures

Amanda D. Weitz-Marshall, MD, and Michael J. Bosse, MD

Abstract
Traditionally, closure of open fractures after initial dbridement has been
delayed to minimize the risk of complications, particularly infection. This practice developed before the widespread use of systemic antibiotics, local antibiotic
bead pouches, advanced dbridement methods, and improved fracture stabilization techniques. Current evidence indicates that infections after treatment of
open fractures frequently are not caused by initial contaminating organisms but
often are acquired in the hospital. Recent studies comparing primary with
delayed closure have not demonstrated an increased rate of complications.
Considering the improvements in open fracture wound care, the increasing
incidence of resistant nosocomial infections, and the cost implications of a dogmatic delayed-closure strategy, wound care protocols for open fractures should
be reevaluated. Because of lack of data specifically addressing the timing of closure of such wounds, studies comparing primary versus delayed closure are
needed.
J Am Acad Orthop Surg 2002;10:379-384

The widely accepted standard of

care in timing the closure of soft-tissue injury associated with open
fracture is to leave the traumatic
wound open after the initial surgical
dbridement. However, this practice is based on a philosophy established before the advent of current
antibiotics, modern dbridement
methods, and improved fracture
stabilization techniques. Recent
studies challenge the concept of
leaving all open fracture wounds
open after initial dbridement.

Historical Perspective
The open fracture care concept is
based largely on the experiences of
war surgeons, dating back to the
pre-asepsis era. Because of the nature of the wounds sustained on the

battlefield, Trueta in 19391-3 advocated the closed treatment of war

fractures. This referred to open
treatment of the wound with subsequent enclosure of the extremity in
a plaster-of-paris cast. Trueta was
revolutionary in his approach to
handling soft-tissue injury associated
with open fracture. Contrary to the
general opinions held before the
Spanish Civil War, he believed that
the greatest danger of infection lay
not in the bone but in the muscle.
He recommended dbridement of
the wound with excision of bruised
tissue. The wound was drained
with the use of sterile absorbent
gauze and left open to heal by secondary intention. Finally, a plaster
cast was applied to the limb. Instead of windowing the cast to
allow full view of the wound, as
was common for the time, Trueta

Vol 10, No 6, November/December 2002

kept the cast in place unless it became wet and soft, or there was an
intolerable stench, or the patients
condition showed that some complication had developed.3
The method of leaving the
wound open persisted until further
experience was gained during
World War II, a period that produced great advances in the treatment of open wounds. Because of
his work with sulfonamides, Domack
advocated systemic administration
instead of localized application of
antibacterial substances. In 1943,
use of penicillin on the battlefield
quickly reduced the rate of wound
sepsis. However, by relying on the
antibiotics efficiency, surgeons
became too complacent with the
dbridement procedure. Prompted
by the complications of inadequately
dbrided wounds, the concept of
delayed closure was adopted.
Hampton 4 recommended closure
between the fourth and seventh
days, provided the wound was clinically clean. Larger defects continued to be left open to heal by the
established secondary intention.

Dr. Weitz-Marshall is Resident, Department of

Orthopaedic Surgery, Carolinas Medical
Center, Charlotte, NC. Dr. Bosse is Director,
Clinical Research, Carolinas Medical Center,
Charlotte.
Copyright 2002 by the American Academy of
Orthopaedic Surgeons.

379

Timing of Closure of Open Fractures

This approach to wound management is still advocated by many
authors.5-12

Advances in Open Fracture

Management
The basic objectives in the management of open fractures are the same
today as in the time of Trueta: to
prevent infection, achieve bony
union, and restore function. During
the past half century, however, the
development and availability of
broad-spectrum antibiotics, antibiotic-impregnated polymethylmethacrylate beads, pulse lavage, and a
choice of various fracture stabilization devices have improved standards of treatment. Yet despite the
great effectiveness of antibiotics, no
principle is more important in the
care of an open fracture than aggressive irrigation and dbridement. Penetration of antibiotics into
necrotic tissue still is under investigation. Theories range from decreased penetrance secondary to an
interruption in the blood supply to
an increased penetrance related to
local inflammatory mediators.13,14
In either case, the use of antibiotics
is not a substitute for thorough surgical dbridement. Antibiotics are
adjuvants best used in conjunction
with surgical management.
In a prospective, randomized
clinical trial, Patzakis et al15 found
that the infection rate decreased sixfold, from 13.9% to 2.3%, when the
administration of appropriate antibiotics was compared with placebo.
Moehring et al16 prospectively compared antibiotic beads with intravenous antibiotics and found no statistically significant difference in the
two delivery methods. Despite
these findings, they concluded that
antibiotic beads may be useful in
preventing infection in open fractures. Ostermann et al17 reported a
significant decrease in the rate of
wound infection with the combined

380

use of systemic antibiotics and an

antibiotic bead pouch for grade IIIB
and IIIC fractures (IIIB, 7% for combined treatment versus 41% for systemic antibiotics alone [P < 0.001],
and IIIC, 5% versus 25% [P < 0.05]).
The overall infection rate for the systemic antibiotic group was 12%,
compared with 3.7% for the combined-treatment group (P < 0.001).
In accordance with Moehring et al,16
Ostermann et al 17 recommended
using antibiotic beads in conjunction
with conventional intravenous
antibiotics.
Jet lavage has been instrumental
in removing contaminants from
wounds and is clearly an advance in
wound therapy. Anglen et al 18
found that the use of power irrigation increased the removal of bacteria by a factor of at least 100 over
bulb syringe irrigation of the same
volume. This was consistent with
the findings of Gross et al 14 in a
study of contaminated crushed
muscle in animals, where pulsatile
lavage irrigation was compared
with that of a bulb syringe. The
wounds irrigated with pulsatingpower lavage had fewer bacteria as
well as less wound inflammation
and debris up to 12 days postoperatively. Necrosis was markedly
higher for the wounds treated with
bulb syringe up to 6 days postoperatively. Although the threshold volume of irrigation is unknown, the
recommended volume is between 3
and 9 L, often based on the severity
of the injury (grade I, 3 L; grade II,
6 L; and grade III, 9 L).19 Pressure
at the tissue level appears to be
the most important determinant in
successful decontamination of the
wound. 20 Increased pressure removes more debris and bacteria;
however, higher pressure settings
(70 psi) have detrimental effects on
bone healing.21 Low- to moderatepressure settings (15 psi to 25 psi)
appear to balance the potential
bone-damaging effects with the
proven contaminant-clearing prop-

erties of jet lavage.19,22 Investigations are ongoing to develop a new

delivery system aimed at optimizing both volume and flow while
minimizing the deleterious effects
on soft tissue and bone.
Alternatives now exist for fracture stabilization, including external
fixators and intramedullary devices,
that are marked improvements
compared with balanced skeletal
traction or cast immobilization.
Modern methods of early surgical
fixation provide excellent stabilization of the injury zone, early joint
range of motion, and a decreased
incidence of pulmonary complications in the multiply injured patient. 23,24 Rigid fixation also has
been shown to promote healing and
facilitate rehabilitation.8,25
Most acute infections after open
fractures are caused by pathogens
acquired in the hospital.26,27 Gustilo
and Anderson 28 reported in 1976
that most of the infections (5 of 8) in
their prospective study of 326 open
fractures developed secondarily. If
left open for an extended period
(2 weeks), wounds were prone to
nosocomial contaminants such as
Pseudomonas species and other
gram-negative bacteria. During the
past 25 years, it has become increasingly difficult to predict a subsequent infecting pathogen on the
basis of initial wound cultures. In a
recent study, Patzakis et al29 found
that only 18% of infections were
caused by the same organism initially isolated in the perioperative
cultures, in contrast with a 73% correlation in an earlier study.15 This
emergence of hospital-acquired bacteria and their prominent role in the
pathogenesis of infection emphasizes the importance of early wound
coverage. Considering the potential
consequences of having an open
wound in the hospital environment,
the fracture site and surrounding
soft tissue may be cleanest after the
initial aggressive dbridement and
wound irrigation.

Journal of the American Academy of Orthopaedic Surgeons

Amanda D. Weitz-Marshall, MD, and Michael J. Bosse, MD

Timing of Wound Closure

The literature on open fracture management exhibits wide discrepancies in terminology. Definitions of
nonunion/union, osteomyelitis,
deep infection, and superficial infection vary considerably. In addition,
the Gustilo and Anderson classification,30 which is used almost univer-

sally for open fracture severity, has

been shown to have poor interobserver agreement.31 Thus, comparing results is difficult.
Only a few North American studies have focused on the timing of closure of open fracture wounds (Table
1). In a double-blind prospective
study, Benson et al34 assessed the
benefit of delaying primary closure

of wounds associated with open

fractures. Eighty-two fractures were
divided into primary-closure (44
wounds) and delayed-closure (38
wounds) groups a mean of 6 days
after injury. Internal fixation was
used in 38% of the cases. Only three
superficial wound infections were
reported; these occurred in the primary-closure wounds. There were

Table 1
Studies of Timing of Wound Closure
Fracture Grade
(Number/Total)

Wound
Closure

Infection
Rate (%)

Delayed/
Nonunion (%)

1961-1968/Retrospective

III
III

(16/21)
(5/21)

Primary
Delayed

7/16 (44)
1/5 (20)

Gustilo and
Anderson28

1969-1973/Prospective

I
II
III

(78/326)
(181/326)
(67/326)

Primary
Primary
Delayed

0
2/181 (1)
6/67 (9)

Caudle and
Stern32

1979-1983/Retrospective

IIIA
IIIB*
IIIB

(11/62)
(24/62)
(18/62)

Flap in <1 wk
Flap >1 wk or
secondary intent

0
2/24 (8)
10/17 (59)

3/11 (27)
5/22 (23)
10/13 (77)

4/7 (57)

5/5 (100)

Hope and
Cole33

1981-1989/Retrospectivell

Primary, 11
Primary, 35
Delayed, 14

0
6/51 (12)
4/19 (21)

5/22 (23)
9/51 (18)
8/19 (42)

Benson
et al34

1983/Prospective

Primary, 44
Delayed, 38

3/44 (7) (all superficial)

2/38 (5) (all deep)

Cullen
et al35

1983-1993/Retrospectivell I

(24/83)

(40/83)

(19/83)

Primary, 20
Delayed, 4
Primary, 30
Delayed, 10
Primary, 7
Delayed, 12

0
0
1/30 (3)
0
1/7 (14)
0

Primary, 22
Delayed, 3
Primary, 37
Delayed, 6
Primary, 24
Delayed, 8
Primary, 4
Delayed, 8
Delayed, 6**

0
0
2/37 (5)
0
1/24 (4)
1/8 (13)
0
1/8 (13)
3/6 (50)

1/22 (5)
0
4/37 (11)
2/6 (33)
4/24 (17)
2/8 (25)
1/4 (25)
3/8 (38)
2/6 (33)

Study

Year(s)/Design

Gustilo and
Anderson28

IIIC (9/62)
I
II
III

II
III
DeLong
et al36

1984-1987/Retrospective

(22/92)
(51/92)
(19/92)

(25/118)#

II
(43/118)

IIIA (32/118)

IIIB (12/118)

IIIC (6/118)

Secondary amputation required in *2/24 (8%), 4/17 (24%), 7/9 (78%), and **1/7 (14%).
One patient required early amputation and was excluded from analysis.
ll Pediatric population
No grading indicated
# One additional patient in this series with a grade IIIC fracture and delayed wound closure had a primary below-knee amputation.

Vol 10, No 6, November/December 2002

381

Timing of Closure of Open Fractures

two deep wound infections, both in
delayed-closure wounds. Statistical
analysis revealed infection to be
independent of method of closure.
In a retrospective review of 83
pediatric open tibia fractures, Cullen
et al35 had done primary closure in
57 cases (69%). There were 24 grade
I, 40 grade II, 13 grade IIIA, 6 grade
IIIB, and no grade IIIC fractures.
The type of wound closure was chosen on the basis of soft-tissue injury
and wound contamination. Four
grade I, 10 grade II, and 12 grade III
fractures underwent delayed closure
or soft-tissue flap closure. Two of
the 57 primarily closed wounds
(3.5%) demonstrated a superficial
infection, with neither wound progressing to a deep infection or osteomyelitis. Both wounds were
grossly contaminated at the time of
surgery, and in retrospect, not suitable for primary wound closure.
The authors supported the use of primary wound closure in the treatment of open fractures in children,
with the obvious exceptions being
gross contamination of the wound
or any concern regarding the adequacy of the dbridement.
DeLong et al,36 in a review of 119
open fracture wounds, sought to
determine whether immediate primary closure of open fracture
wounds could be done without
increasing the incidence of infections
and delayed unions or nonunions.
All patients received preoperative
cefazolin, plus gentamycin for
severe soil contamination. These
drugs were continued for 2 to 3 days
after the last surgical procedure.
The wounds underwent aggressive
surgical dbridement and irrigation
with pulse lavage. The fractures
were stabilized with a variety of
methods including external fixation,
plaster, internal fixation, traction,
intramedullary nailing, and external
fixation with limited internal fixation. Closure depended on the
attending surgeons appraisal of the
wound after dbridement and bony

382

fixation. Six wound management

techniques were used. (1) Immediate primary closures were loosely
approximated at both the traumatic
and surgical extension portions of
the wound. (2) Second-look primary closures underwent primary closure with a planned reexploration,
dbridement, and closure 48 to
72 hours after the initial closure.
(3) Delayed primary closures were
packed open initially and then approximated loosely after a subsequent dbridement. (4) Delayed
skin grafts and (5) delayed flaps
were used in patients whose wounds
were initially managed open. The
last category (6) was primary amputation. Eighty-seven fractures underwent primary closure, with 11 returning for a second-look procedure
and subsequent closure. Thirty-one
fractures were managed by delayed
closure, with skin grafts needed in
three and flap coverage in eight.
One of the 119 cases had a primary
below-knee amputation. Primary
closure was used in 88% of grade I,
86% of grade II, 75% of grade IIIA,
33% of grade IIIB, and no grade IIIC
fractures. The aggressive approach
resulted in an overall 7% infection
rate (8/118) and 16% delayed/
nonunion rate (19/118). Statistical
analysis revealed no significant difference in delayed/nonunion and
infection rates between immediate
and delayed closures. The authors
concluded that immediate primary
closure (with or without a second
look) is a viable option when carried out by an experienced fracture
surgeon.36
Some authors advocate early, if
not immediate, flap coverage. The
microsurgical reconstruction techniques promoted by Godina37 revolutionized the concept of free tissue
transfer for trauma. Free flaps transformed an open fracture acutely into
a well-vascularized closed fracture.
Godina 37 evaluated 532 patients
undergoing microsurgical reconstruction at three different intervals

after injury. Group I (early) received

the free flap within 72 hours of the
injury, group II (late) between 72
hours and 3 months, and group III
(delayed) between 3 months and 12
years. Infection occurred in 1.5% of
group I, 17.5% of group II, and 6% of
group III. Time to bone healing was
7 months, 12 months, and 29 months,
respectively. Flap failure rate was
0.75% for group I, 12% for group II,
and 10% for group III. Of the 134
early flaps, 63 were performed in the
first 24 hours. The results led the
author to conclude that coverage
within the first 72 hours after injury
provided superior results, with earlier bone healing and decreased
rates of infection. In addition, the
average length of hospital stay was
notably diminished for the earlyflap (27 days) versus the delayedflap (256 days) coverage. Delaying
definitive reconstruction resulted in
extensive fibrosis, which complicated the microvascular anastomoses and in many instances led to
an additional loss of soft tissue and
bone.
In a more recent series of earlyflap coverage, Gopal et al38 reported
the results of their fix and flap
approach for grade IIIB and IIIC
injuries of the tibia. Over an 8-year
period, 84 fractures were treated
with immediate meticulous wound
dbridement with lavage, skeletal
stabilization, and definitive soft-tissue coverage with a vascularized
muscle flap and split-thickness skin
graft. The goal was to obtain coverage within 72 hours of the injury.
Sixty-three fractures were treated
with early (<72 hours) flap coverage. Twenty-one patients underwent late (>72 hours) soft-tissue
coverage. The deep infection rate
was 6% for patients with early flaps
and 30% for those with late flaps.
Flap failure rate was 3.5%. The
authors suggested that delay in coverage is not necessary if healthy soft
tissue can be imported reliably into
the zone of injury.

Journal of the American Academy of Orthopaedic Surgeons

Amanda D. Weitz-Marshall, MD, and Michael J. Bosse, MD

Despite studies supporting early

closure, the major argument against
primary wound closure is its association with the occurrence of gas gangrene. Brown and Kinman39 documented 27 patients between 1963
and 1973 with clostridial wound
infections treated with a variety of
antibiotic regimens. Thirteen patients
were involved in contaminated waterrelated accidents. Two patients involved in motor vehicle crashes had
apparent fecal contamination secondary to rectal lacerations. The
wounds were severely contaminated
but were all closed primarily, some
in the emergency department. In
many cases, foreign material such
as dirt or vegetable matter was
noted throughout the tissues at the
time of wound breakdown, indicating incomplete dbridement. Only
five patients received initial coverage for anaerobic organisms, and
four received no antibiotics at all.
The authors stated that antibiotics
in various combinations and dosages
were changed from day to day without any apparent pattern or rationale.39 Although these 19 cases of
gas gangrene and 8 of anaerobic cellulitis were attributed to the timing
of closure, perhaps the more logical
common denominator was the inadequacy of dbridement and inappropriate selection for early wound closure treatment.

Surgical Judgment as a
Factor in Wound Closure
Although the term is not easy to
define, adequate dbridement
remains a difficult technical problem.28 All nonviable tissue must be
removed while as much functional
tissue as possible is spared. Likewise, proper tissue-closure tension
and optimal wound-closure technique are difficult to define but can
be summarized as the methods that
are not anticipated to cause additional tissue necrosis. When the possibility of progressive tissue necrosis
is uncertain, the wound can be
closed initially and subsequently
opened, if necessary, for a second
exploration.
Surgical judgment, typically
gained with experience, is required
to successfully use an immediate
wound-closure protocol. Obvious
exceptions to immediate closure
include wounds containing gross
contamination with feces, dirt, or
stagnant water, as well as farmrelated injuries or freshwater boating accidents. Other contraindications are a delay in the initiation of
antibiotics beyond 12 hours postinjury or questionable tissue viability
at the time of the initial surgery. If a
doubt exists concerning the adequacy
of the dbridement, or in a patient
with confounding comorbidities,

the wound should not be closed

regardless of fracture type or antibiotic coverage.

Summary
Advances in initial wound dbridement and irrigation, access to
broad-spectrum antibiotic coverage,
and experience with modern fracture stabilization techniques enable
a more aggressive approach to be
taken to open fracture wound care.
Considering the many improvements in all aspects of open fracture
wound care, the increasing incidence of resistant nosocomial infections, and the cost implications of a
dogmatic delayed-closure strategy,
wound care protocols for open fractures should be reevaluated. A
large, multicenter, randomized,
prospective study is required. A
pilot study under the auspices of
the Orthopaedic Trauma Association is underway. Until better data
are available, the best clinical practice may be the adoption of a treatment plan that allows for the earliest possible soft-tissue coverage
over a clean, stable, viable zone of
injury. If these parameters are
achieved at the time of initial dbridement, primary wound closure
appears to be a reasonable treatment option.

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Journal of the American Academy of Orthopaedic Surgeons