Sie sind auf Seite 1von 5

Current Orthopaedics (1999) 13, 87 91

1999 Harcourt Brace & Co. Ltd

Mini-symposium: Tibial fractures

(i) Open fractures: principles of management

R.M. Smith, S. Gopal

Table 1 The surgical principles of open fracture management

INTRODUCTION

Wound lavageand d~bridement


SkeletaI stabilization
Healthy soft-tissueclosure

The treatment of open fractures is still appropriately


considered a challenge by orthopaedic surgeons.
Severe injuries are rare, limiting personal experience,
and few surgeons work in an environment where the
close support of an experienced plastic surgical team
is available. Accordingly, it is widely recommended
that these severe injuries should be referred to a
regional centre where an experienced multidisciplinary team is available. 1-3 However, the initial
assessment and management of the severe injury and
the entire management of the less severe injury
should be available locally. It is therefore essential
that all receiving surgeons are able to apply the standard initial principles of treatment and know when
and how to communicate with their regional centre.
While open fractures can be devastating injuries,
the risk of complications, particularly infection, and
the persistence of some outdated ideas, have given
these injuries a mystique apart from closed injures. To
avoid an underestimation of the potential complexity
of closed fractures and understand the real problem
of the open fracture, we must first dispense with the
terms 'compound and simple'. While still in common
usage, these confuse the issue; the correct descriptive
words are 'open and closed'.
The definition of an open fracture is: 'a fracture
where a wound leads to a communication between the
fracture haematoma and the outside environment'.
This produces bacterial contamination of the fracture
haematoma and the potential for infection, and

accordingly threatens the limb in the short and the


long term. In a closed injury, there is no contamination, although there may still be a devastating soft-tissue injury within an intact skin envelope. 4 Therefore
the principles specific to open fracture management
are those aimed at preventing infection while facilitating soft-tissue and bony healing (Table 1).

INJURY ASSESSMENT

The initial assessment will usually take place in the


emergency department; the correct diagnosis may be
obvious or quite difficult. While the devastating
injury is obvious, a careful systemic examination is
still essential to reveal small but significant wounds.
Sometimes it is impossible to be sure if a small or distant would truly communicates with a fracture but
initially it should always be assumed that such an
injury is open. Accurate classification of the soft-tissue injury is not possible in the accident and emergency department (see surgical classification). The
injury should be initially generally graded as minor,
moderate or severe, the distal neurovascular status
confirmed, gross contamination removed, the would
covered with a sterile dressing, the limb splinted and
the
appropriate
referral made
immediately.
Antibiotics are only useful if given early and must be
administered immediately.5,6 It is good practice to
take a Polaroid photograph of the wound before it is
covered. While the quality of this image is often poor,
it should stay with the patient and be used to illustrate

R. M. Smith MD FRCS, Consultant Orthopaedic Surgeon;


S. GopalBSc MS(Orth), SpecialistRegistrar, Trauma and
Orthopaedic Surgery,St James's UniversityHospital, Beckett
Street, Leeds LS9 7TF, UK
Correspondence to: Mr R.M. Smith

87

88

Current Orthopaedics
Table2 Open fracture classificationafter Gustilo and Anderson
Grade I
Grade II
Grade IIIA
Grade IIIB
Grade IIIC

Small in-to-out wound (< 1 cm). Low-energyinjury,no soft-tissuecrushing


or stripping, no bony comminution.
Laceration over fracture (1-10 cm wound). Low-energyinjury,minimal soft-tissue
crushing or stripping, no bony comminution.
High-energyinjury,bony comminutionor segmentalfracture, soft-tissuecrushing
stripping or serious contaminationbut adequatesoft-tissuecoverafter d6bridement.
High-energyinjury,bony comminutionor segmentalfracture, soft-tissuecrushing
stripping or serious contamination, inadequatesoft-tissuecoverafter d6bridement
Any open fracture associated with a local vascular injury requiring repair.

the severity of the wound to other clinicians and thus


prevent repeated and potentially contaminating
wound examinations outside of a sterile environment.

SURGICAL CLASSIFICATION
Formal classification of the open fracture occurs after
surgical debridement. The most widely used system is
that attributed to Gustilo and Anderson. 7,8 This classifies the injury into three types, with the high-energy
injuries subdivided into three further groups (Table 2).
This system has stood the test of time and is widely
understood. The essential elements being the differentiation between high- and low-energy injuries and the
concept of adequacy of soft-tissue cover in the highenergy injuries.
The site of the fracture has an important effect on
the injury grade, particularly with regard to quantity
of local muscle cover and the vulnerability of the local
soft tissue to injury. A fracture in the normal femur
has to be high-energy because of the intrinsic strength
of the bone; accordingly all open femur fractures
must be grade III, although the thick muscle cover of
the thigh usually provides adequate soft-tissue cover.
In comparison, the tibia is unique with regard to its
poor soft-tissue cover and particular vulnerability to
injury. Accordingly, it is difficult to have a grade IIIa
injury to the tibial diaphysis where most high-energy
diaphyseal and distal tibial fractures are grade IIIb
and require complex reconstructive surgery. The most
severe injury (IIIc) is the open fracture associated with
a vascular injury that requires repair. These can occur
with either a severe or very a relatively 'minor' would.
The high grading is because of the primary risk to the
limb associated with the arterial disruption and the
susceptibility of ischaemic muscle to infection.
A similar classification system for closed fractures
has been proposed by Tscherne. 4 This also describes
the range of soft-tissue injuries from essentially no
significant injury to major vascular disruption, severe
muscle revitalization or compartment syndrome, all
within a closed skin envelope, a fuller classification
system considering both injury types is provided by
the comprehensive classification from the AO. 9 This
individually classifies the integument, nerve and vascular tissues producing a more comprehensive and
detailed system that has much to recommend it.

Scoring systems for limb salvage


After life-saving issues have been considered, the primary issue in the management of serious open fractures is the decision as to whether the limb is
salvageable or not. This decision can often be quite
difficult, depending on a number of factors which
include the condition of the patient, the limb and
availability of reconstructive surgery. Many surgeons
are sceptical about a number of more heroic limb-salvage procedures, citing an earlier return to activity
after amputation rather than protracted reconstructive surgery. 1~12 While occasionally the early decision
to amputate is correct, this can never be taken lightly.
Unless mandated by a life-threatening situation or the
most extreme geographical situations such a decision
should always involve at least two senior surgeons
experienced in modern limb-salvage techniques.
Several scoring systems have been developed in an
attempt to aid this decision, the best known of which
the Mangled Extremity Severity Score or MESS. 13
This system scores the injury 1-4, the ischaemia time
1-3, the presence of shock 0-2 and the patient' age
0 ~ . In the initial work, a score of 7 or more may predict the need for a primary amputation. While this
makes a reasonable attempt to rationalize a very difficult decision-making process, more intrinsic difficulties have been identified and the system is not in
widespread use. 14

SURGICAL M A N A G E M E N T

History
Much open-fracture surgery has developed in response
to the stimulus of war. Historically, an open fracture
was a mortal injury and rapid amputation the surgeon's primary mode of treatment. 15'~6Eventually, the
practice of d6bridement and antisepsis developed I7
and, together with delayed wound closure, entered
normal practice during World War I. At the same time,
the application on skeletal stability by the introduction
of the Thomas splint reduced the wartime mortality of
open femur fractures from 80% to 15%. ~5 Trueta
soundly established these principles during the
Spanish Civil War, TM while World War saw the introduction of antibiotics. More recently, military surgery
in Korea and Vietnam saw the development of rapid

Open fractures: principles of management


transport, efficient wound ddbridement, a planned secondary closure and more efficient skeletal stabilization
that progressed to the management protocols practised
today.
Current management

The current principles of management (Table 1) are


aimed at preventing bacterial contamination from
developing into frank infection. 19 This is achieved by
removing the inoculated bacteria by tissue cleansing
with profuse lavage and d6dbridement of all devitalized tissue to remove the culture medium for bacterial
growth. The skeleton is stabilized to allow soft-tissue
healing and to allow healthy soft-tissue cover to be
obtained early enough to prevent further tissue desiccation and obliterate the residual dead space, which
can act as a reservoir for infection.

Lavage and dbbridement


The removal of the bacterial inoculum and any contaminated and devitalized tissue is essential. Initially,
copious lavage with warm Hartman's solution (Ringer
lactate) is necessary, with 10 litres or more of lavage
required for a large wound. Formal wound ddbridement requires experience. In our practice, cases referred
after initial treatment are rarely adequately ddbrided
and devitalized tissue is often left in the wound. In most
centres, a stages ddbridement with a second-look procedure is planned. An accurate and adequate d6bridement is ideally performed by a surgeon with specific
experience of the relevant techniques of soft-tissue
reconstruction. In our practice, an experienced
orthopaedic trauma surgeon and a senior plastic surgeon will d6bride the wound. This allows appropriate
placement of wound extensions and excision of doubtful tissue to the edge of the zone of injury with the confidence that the resulting defect can be reliably filled.
After ddbridement, the traumatic wound should be
left open and a second-look procedure with delayed
soft-tissue cover planned. This facilitates the reassessmerit of issue viability, allows for potential swelling
and for additional tissue loss. The primary closure of
the open wound is contraindicated. If the soft tissues
are healthy and provide adequate cover at the second
look then closure, without tension, an be performed.
On occasions, a further 'second look' may be scheduled or formal soft-tissue reconstruction planned.
Any high-energy open fracture has a significant
potential for a compartment syndrome which can still
occur despite the open wound. Accordingly it is essential that a wide fasciotomy is incorporated in to the
d6bridement.
The bone

There is strong evidence from both clinical and animal


work that the stabilization of the skeleton reduces the
incidence of infection2 and facilitates soft-tissue

89

healing. The international standard for many years


has been the stabilization of the skeletal injury with
an external fixator rather than internal fixation
because of concerns regarding the implantation of
metal into a contaminated field. However, this opinion has been widely challenged over recent years. 21-24
While there remain enthusiasts for external fixation
techniques, in many centres there has been a progressive change from external to internal fixation devices
in recent years. Both larger hollow nails inserted with
a reamed technique and thinner solid nails inserted
without reaming have become more popular and each
technique has its advocates. While nailing techniques
were initially applied only to lower grades of soft-tissue injury, more severe injuries have been treated in
this way as good results have emerged. However, until
recently, most reports of primary nailing describe the
technique in grade 1 to IIIA fractures only and
include very few IIIB injuries, 25,26where most surgeons
would still apply an external fixator.
With access to early plastic surgical support] 3,24 a
more radical protocol has developed for the highgrade soft-tissue injury. Reliable early soft-tissue
cover allows stabilization of every open fracture by
the technique applicable to the bone injury alone,
without consideration of the soft-tissue defect. This
includes the liberal use of both unreamed nails and
plates where appropriate. This is only applicable
where there is support from a plastic surgery department experienced in reconstructive microsurgery. In
our experience, the use of nails and plates for skeletal
stabilization in even the most severe injuries produce
consistently excellent results with a very low infection
rate and high rate of primary bone-healing without
recourse to bone-stimulating techniques. In our
hands, the use of external fixators is a prominent
source of the infective problems we are trying to
avoid and produces less reliable bone-healing? 4
The soft-tissue defect

In lower-grade injuries (1,2, or IIIa) there is an adequate soft-tissue envelope after d6bridement. These
wounds should not be closed primarily so as to allow
for swelling and reassessment but can be closed at a
second look at 48-72 hours. 19,27
More severe injuries (IIIB) have deficient soft tissues associated with significant areas of degloving,
periosteal stripping and contamination (Fig. 1).
Modern plastic surgery has progressed from the difficulties of the tube pedicle to the scope provided by fasciocutaneous flaps and finally modern microvascular
techniques for free tissue transfer (as initially championed by Marco Godina] 8 see the next article by Simon
Knight). The use of these techniques has revolutionized our reconstructive potential, rapidly converting
the open to a closed injury and facilitating the use of
any appropriate implant. Our experience and that of
others suggests that, in very experienced units, a protocol of repeated d6bridements and delayed closure for

90

Current Orthopaedics

Fig. 1 A: Severe III-c open fracture of the tibia; B: immediate flap coverage; C: final soft-tissue result; D: final bony consolidation after
plate removal.

the more severe injury may not be the best treatment.


Evidence is mounting that, in the very severe injury
(IIIb or IIIc), with extensive exposed tissue, repeated
procedures may lead to additional tissue loss through
desiccation and increased infection due to the delay in
soft-tissue cover.2~31 Advanced tissue-transfer techniques can be applied immediately with outstanding
results. Using these techniques, our group has developed a protocol of immediate radical d6bridement by
an experienced team, skeletal stabilization by the
implant most appropriate to the bony anatomy and
early, often .immediate, soft-tissue reconstruction with
a muscle flap subsequently covered by a spilt skin
graft. We have been able to demonstrate functional
limb-salvage rates of > 95% in IIIB and IIIC injuries.
Leeds Protocol for open fractures
D6bridement, skeletal stabilization (internal fixation
if possible), secondary wound closure.
D~bridement, skeletal stabilization (internal fixation
Grade 2
if possible), secondary wound closure.
Grade IIIA D~bridement, skeletal stabilization (internal fixation
if possible), secondary would closm'e.
Grade IIIB D6bridement, skeletal stabilization (internal fixation
if possible), wound closure by free tissue transfer
within 72 h (immediate if possible).
Grade IIIC Immediate revascularization (?shunt), d6bridement,
immediate skeletal stabilization, wound closure by
free tissue transfer within 72 h (immediate if possible).

Grade 1

OVERVIEW

A logical approach to the management of open fractures is focused on the prevention of infection, with a
clear route of referral of the more serious injuries.
The treatment of the open wound is essential.
Obtaining early skeletal stability is critical and can be
achieved with both internal and external fixation
devices. The aims in management of these injuries
should be considered in a logical sequence. The first is
limb salvage by obtaining soft-tissue healing without

infection, followed by bony union. Fortunately, both


aims are often met with the same device and technique but a clear understanding of these priorities is
essential.
Problems arise from inadequate d6bridement, poor
skeletal stabilization and poor soft-tissue techniques.
All treating surgeons should be aware of the reconstructive capabilities of an experienced department
combining the skills of experienced orthopaedic surgeons with a plastic surgery department experienced
in microvascular surgery. Early referral of these
injuries to such a service is mandatory.

REFERENCES

1. Kaye JC. Management protocols in high-energy tibial fracture.


Ann R Coll Surg Eng 1994; 76: 363-364.
2. Green RA. The courage to co-operate: the team approach to
open tibial fractures of the lower limb. Ann R Coll Surg Eng
1994; 76:365 366.
3. British Orthopaedic Association and British Association of
Plastic Surgeons: a working party report. The management of
open tibial fractures. September 1997.
4. Tscherne H, Gotzen L. Fractures with soft tissue injuries.
Berlin: Springer-Verlag, 1994.
5. Gustilo RB. Use of antimicrobials in the management of open
fractures. Arch Surg 1979; 114: 805-808.
6. Worlock P, Slack R, Harvey L, Mawhiney R. The prevention
of infection in open fractures. J Bone Joint Surg 1988; 70-A:
1341-1347.
7. Gustilo RB, Anderson JT. Prevention of infection in the
treatment of one thousand and twenty five open fractures of
long bones. J Bone Joint Surg 1976; 58-A: 453M59.
8. Gustilo RB, Mendoza RM, Williams DN. Problems in the
management of type-III (severe) open fractures: a new
classification of type-III open fractures. J Trauma 1984; 24:
742-746.
9. Muller ME, Nazarian S, Koch P, Schatzker J. The
comprehensive classification of fractures of long bones.
Berlin: Springer-Verlag, 1990.
10. Hansen ST Jr. The type-IIIC tibial fracture- salvage or
amputation. J Bone Joint Surg 1987; 69-A: 799-800.
11. Georgiadis GM, Behrens FF, Joyce M J, Earle S, Simmons AL.
Open tibial fractures with severe soft tissue loss-limb salvage
compared with below the knee amputation. J Bone Joint Surg
1993; 75-A: 1431 1441.

Open fractures: principles of management

12. Fairhurst MJ. The function of below knee amputees versus the
patient with salvaged grade-III tibial fracture. Clin Orthop
1994; 301: 227-232.
13. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr.
Objective criteria accurately predict amputation following
lower limb extremity trauma. J Trauma 1990; 30:568 573.
14. Robertson PA. Prediction of amputation after severe lower
limb trauma. J Bone Joint Surg 1991; 73-A: 816-818.
15. Russell TA. General principles of fracture treatment. In:
Campbell's Operative Orthopaedics, 8th edn. Grenshaw AH:
Mosby Year Book 1992: 768, vol. 2.
16. Kocher MS. Early limb salvage: open tibial fractures of
Ambroise Par6 (1510-1590) and Percival Pott (171 4-1789).
World J Surg 1997; 21: 116-122.
17. Wangesteen OH, Wangensteen SD. Carl Reyher - his
demonstration of the role of debridement in gunshot wounds
and fractures. Surgery 1973; 74: 641-649.
18. Trueta J. War surgery of the extremities; treatment of war
wounds and fractures. Br Med J 1942; 1: 616.
19. Hansen ST. In Hansen ST, Swinotowski MF, eds.
Traumatology at Harbour View Medical Center 3-8.
Orthopaedic Trauma protocols. New York: Raven Press, 1993.
20. Worlock P, Slack R, Harvey L, Mawhiney R. The prevention
of infection in open fractures: an experimental study of the
effect of fracture stability. Injury 1994; 25(1): 31 38.
21. Court-Brown CM, McQueen MM, Quaba AA, Christie J.
Locked intramedullary nailing of open tibial fractures. J Bone
Joint Surg 1991; 73-A: 959 964.
22. Tornetta PIII, Bergman M, Watnik N, Berkowitz G, Steuer J.
Treatment of grade-IIIB open tibial fractures. J Bone Joint
Surg 1994; 76-B: 13 19.
23. Hertel R, Lambert SM, Muller S, Ganz R. Rebuilding severe
open fractures of the leg: immediate is better than early soft

24.

25.
26.
27.
28.
29.

30.

31.

91

tissue reconstruction for open fractures of the leg. Injury 1998;


29(2): 154-155.
Gopal S, Majumder S, Batchelor AG, DeBoer P, Smith RM.
Fix and flap: the radical management of open tibial fractures.
Presentation at the British Trauma Society meeting London,
October 1998. Injury 1998; in press.
Tu Y-K, Lin C-H, Su J-I, Hsu D-T, Chert R-J. Unreamed
interlocking nail versus external fixator for open type-III tibial
fractures. J Trauma 1995; 39:361 367.
Keating JF, O'Brien PJ, Blachut PA, Meek RN. Locking
intramedullary nailing with and without reaming for open
fractures of tibial shaft. J Bone Joint Surg 1997; 79-A: 334-341.
Gustilo RB, Merkow RL, Templeman D. Current concepts
review: the management of open fractures. J Bone Joint Surg
1990; 72-A: 299-304.
Godina M. Early microsurgical reconstruction of complex
trauma of the extremities. Plast Reconstr Surg 1986; 78:
285-292.
Byrd HS, Cierny G, Tebbett JB. The management of open
tibial fractures with associated soft tissue loss: external pin
fixation with early flap coverage. Plast Reconstr Surg 1985; 76:
719-728.
Yaremchuk M J, Brumback RJ, Manson PN, Burgess AR,
Poka A, Weiland AJ. Acute and definitive management of
traumatic osteocutaneous defects of the lower extremity. Plast
Reconstr Surg 1987; 80:1 12.
Francel TJ, Vander Kolk CA, Hoopes JE, Manson PN,
Yaremchuk MJ. Microvascular soft tisue transplantation of
acute open tibial fractures: timing of coverage and long term
functional results. Plast Reconstr Surg 1992; 89: 478-487.

Das könnte Ihnen auch gefallen