AAOS Bulletin - December 2006

Pearls and Pitfalls: Open fractures

By Douglas W. Lundy, MD

Severe open fractures are among the most dramatic injuries seen in emergency departments. Because they often result from a significant mechanism of injury such as motor vehicle accident, fall or gunshot, their presentation quickly mobilizes the triage team. As the treating orthopaedist, you are confronted with an injury that is likely far worse than an equivalent closed fracture. Under such stressful circumstances, the expectations you place on yourself—as well as the expectations of the patient, the family, the system and the other providers—can weigh heavily.

Close-up view of an antibiotic bead pouch used to treat an open proximal tibial fracture.

Adjacent to the bead pouch are traumatic arthrotomy and fasciotomy wounds that have been closed.

Liability risks
The fact that open fractures are associated with a greater potential for liability litigation can create additional stress. There are several reasons for the higher percentage of lawsuits. As a rule, open fractures carry a greater risk of infection and take longer to heal than comparable closed fractures. Therefore, patients may become frustrated and impatient with their seemingly slow recovery process. Patients may also inhibit their healing by smoking cigarettes or not complying with the surgeon’s protocols.

Fortunately, open fractures can be successfully treated with aggressive modern operative fracture techniques. Below are some “pearls and pitfalls” to assist you in caring for these common, but dramatic injuries.

Prophylactic antibiotics
Administering appropriate antibiotics is paramount when treating an open fracture. Numerous studies have demonstrated the benefit of early antibiotic treatment. Although orthopaedic trauma surgeons still differ on the ideal duration of antibiotic treatment, there is substantial agreement that intravenous antibiotics should be given as soon as possible after a patient arrives at the treating facility. The choice of antibiotic agent is also somewhat controversial, but cefazolin and gentamycin (when appropriate) have been used successfully for years.

Tetanus vaccination
The patient’s tetanus immunization status should also be determined because contaminated open fractures are susceptible to tetanus infection. Administer a tetanus vaccination if the patient’s last vaccination was 10 or more years ago. If the wound is very contaminated, the patient should be revaccinated if the last vaccination was more than five years ago. Document all of this information—including the use of antibiotics—in the medical record.

A survey of Web sites dedicated to soliciting medical liability lawsuits emphasizes this need for documentation. These sites are inundated by unhappy patients—many of whom experienced postoperative infections. The sites advise patients to obtain their medical records to determine if they received perioperative antibiotics.

Timing of operative debridement
The timing of operative debridement has been the subject of investigation in recent years. In the 1990s, studies suggested that surgical irrigation and debridement of open fractures should take place within five to six hours from injury. Over the past several years, however, new studies have suggested that there is no increase in the rate of infection among patients whose surgery takes place after six hours. Nonetheless, irrigation and debridement of open fractures should occur within a reasonable amount of time, allowing for the variables influencing the patient’s care. Include a clear method and plan in the medical record, integrating reasons for any delay in operative management. In case of litigation, this written explanation of your thought process is invaluable.

Diagnosing an open fracture
Properly diagnosing an open fracture is imperative to proper treatment of the injury. Unfortunately, open fractures can be missed if a patient is not adequately examined. At minimum, every patient who presents with a fracture and a laceration of the same limb segment should be examined to determine the presence of an open fracture. When appropriate, dressing and splints should be removed to examine the skin and soft-tissue injury. A small puncture distant from the fracture site may indicate an open fracture, and should be carefully evaluated.

A patient who presents with a “pin-hole” wound over a fracture may, in fact, have an open fracture. Do not let the minimal extent of the skin injury tempt you to simply observe the wound and treat the patient nonoperatively. Failure to treat these wounds with surgical irrigation and debridement may result in a claim of negligence. To fully assess the severity of the soft-tissue injury and the amount of the contamination, surgically extend the laceration and inspect the entire zone of injury. If the injury can be treated without operative debridement, carefully document this decision process along with a summary of the detailed discussion with the patient.

Wound VAC, antibiotic beads
Type III B open tibial fractures require rotational or free flap coverage. A 2003 survey distributed to members of the Orthopaedic Trauma Association revealed that when temporizing open-fracture wounds until flap coverage could be achieved, 43 percent of respondents preferred a “wound VAC” (vacuum-assisted closure) device, and 39 percent utilized an antibiotic bead pouch.1

The wound VAC uses negative pressure through a controlled suction device to close wounds and promote faster healing. An antibiotic bead pouch produces bactericidal levels of antibiotics at the fracture site until flap coverage can be performed. The pouches—which are comprised of a chain of polymethyl methacrylate (PMMA) beads that deliver antibiotics such as vancomycin or tobramycin into a specific area—are isolated with an impervious dressing.

Low-pressure irrigation
Because several studies suggest that pressure pulsatile lavage may actually drive contamination further into the soft tissues rather than mobilizing and removing the debris, it may be preferable to irrigate wounds adequately with a low-pressure irrigation system. Alternate irrigation with sharp debridement to ensure that the totality of the zone of injury is examined and cleared of all necrotic tissue and foreign debris.

Internal vs. external fixation
Another controversial aspect of open fracture treatment is the method used to stabilize the fracture, in part because the outcome depends on multiple factors—including which bone is fractured, where it is broken, the degree of the soft-tissue injury, and the status of the patient, including co-morbidities and the presence of other injuries. Many open fractures treated with antibiotics and aggressive irrigation/debridement can be successfully stabilized with internal or intramedullary fixation—a previously prohibited practice.

The thought process leading to the decision to fixate should be carefully explained in the medical record prior to or immediately after surgery. In the event of a lawsuit, sound thought processes—well documented in the record and carefully explained to the patient—will greatly facilitate a surgeon’s defense.

If the operating surgeon feels that internal or intramedullary fixation is not indicated, fractures associated with severe soft-tissue injuries or significant contamination should be stabilized with external fixation. Uniplanar or circular external fixation can stabilize the fracture without placing metal within the zone of injury, thereby reducing the risk of infection. The external fixator may be removed within a reasonable time period and the fracture can be stabilized with another form of fixation with minimal risk of infection.

If the open fracture shows signs of sepsis, do not hesitate to perform a thorough workup. The patient may need to return to the operating room for open biopsy of the infected site, and the internal or intramedullary fixation may need to be removed. It is essential to identify the pathogen responsible for the infection so that appropriate antibiotics can be initiated. In this situation, “look for disease, do not hope for wellness.” Ignoring an infection after an open fracture will complicate the patient’s course and hinder his or her care.

Compartment syndrome
One last pitfall in the treatment of open fractures is the failure to diagnose compartment syndrome—a condition that occurs when pressure within the muscles builds to dangerous levels. Do not assume that the patient’s compartments were released during the injury, or that open fractures cannot be associated with compartment syndrome. In fact, the mechanism of injury resulting in an open fracture involves enormous forces, and this energy can cause significant muscle injury.

In their study of open tibial fractures, Blick et al2 found that the incidence of compartment syndrome was directly proportional to the degree of injury, and that compartment syndromes occurred most often with comminuted, type III open tibial fractures in pedestrians. Therefore, remain vigilant for the presence of a compartment syndrome, and be ready to operate if this situation arises.

Photograph the injury
Because open fractures are often dramatic in appearance, photographs that document the contamination and the soft-tissue injury present in severe open fractures may aid in the defense of a subsequent lawsuit in which the plaintiff claims the injury “wasn’t really all that bad.” Such photographs may certainly be helpful when primary amputation is advisable due to the severity of an injury. The need to practice such defensive medicine is unfortunate, but this is the reality of the climate in which many orthopaedic surgeons work today.

Classifying open fractures
In any discussion of open fractures, it is important to note that these injuries exist on a continuum, and may not easily fit into categories in a classification system. Brumback and Jones3 demonstrated that fellowship-trained orthopaedic trauma surgeons agreed on the classification of open fractures only 66 percent of the time. Because many open fractures cannot be classified consistently, comparisons of different study groups have inherent errors.

Although researchers in orthopaedic trauma continue to improve the care of the injured patient, it is important to understand the intrinsic problems in studying traumatic injuries. In summary, a surgeon treating an open fracture should:

  • Ensure that the patient is administered peri-injury antibiotics as soon as possible.
  • Determine the status of the patient’s tetanus immunization and, if necessary, revaccinate as soon as possible.
  • Irrigate and debride the injury, and stabilize it by appropriate fixation within a reasonable time frame.
  • Be vigilant for signs of infection and compartment syndrome.
  • Document the injury with photographs
  • Clearly outline the thought process resulting in treatment decisions in the medical record.

Douglas W. Lundy, MD, is a member of the AAOS Medical Liability Committee.

References

  1. Smith JM, Volgas D: Logistics of Coverage of Open Tibia Fractures: OTA Survey. Orthopaedic Trauma Association. Fall 2003.
  2. Blick SS, Brumback RJ, Poka A, Burgess AR, Ebraheim NA: Compartment syndrome in open tibial fractures. J Bone Joint Surg 1986;68-A:1348-1353.
  3. Brumback RJ, Jones AL: Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg 1994;76-A:1162-1166.

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