Introduction
Anatomy
Cause
Treatment
Rehabilitation
Introduction
Open fracture is a fracture in which the broken bone is exposed to the outside environment because the skin and the surrounding soft tissue have been torn. Since the fracture haematoma is a good culture media for bacteria, once the bacteria from the environment enter and stay in the fracture haematoma, they will proliferate and cause infection.
Anatomy
Open fractures can occur in any bones, but it is more common in lower limbs, especially the tibia. The tibia is unique with regard to its poor soft-tissue cover and vulnerability to injury.
Cause
Open fractures can be caused by low-impact injuries such as a simple slip and fall or high-impact injuries such as a fall from height or traffic accidents. The infection and amputation rate is much higher in high-impact injuries because of the likelihood of extensive soft tissue injury accompanying the bone fracture,
The severity of an open fracture is commonly graded with the Gustilo & Anderson Classification. This classification system grades the open fracture in three types according to the impact sustained in an injury, the severity of soft tissue injury and the degree of fracture fragmentation. For the high-impact, type-three fracture, there are three subdivisions. It is based on the adequacy of soft tissue coverage and any vascular injury. For the most severe fracture, or Type 3C, the infection rate can range from 25 percent to 50 percent and the amputation rate can be up to 42 percent.
Treatment
All open fractures require emergency operations.The key is to prevent infection by wound debridement, lavage i.e., repeated and thorough cleaning and removal of all devitalised tissue and fracture fragments; washing and cleaning healthy tissues with physiological solution and a course of appropriate antibiotics to prevent and treat infection. The fractures should be temporarily stabilised with external fixation devices to maintain bony alignment and length. A stable support for the fractured limb will improve the circulation and lymphatic drainage, reduce edema, facilitate wound care and control pain.
The wound should be left open for frequent cleaning and monitoring. The cleaning and irrigation operation might need to be performed every 24- 72 hours until the wound is clean.
Soft tissue procedures with skin grafts or local tissue flaps might be necessary for early coverage of the fractured bones to prevent hospital-acquired infection.
Once the soft tissue envelope on the fracture is stabilised, definite fracture fixation devices could be considered. Internal fixations such as intramedullary nailing and plating are options to consider.
Sometimes, external fixations may be used as a definitive fixation device when the bone or soft tissue condition is not favourable for any internal fixation devices.
Delayed union or non-union is not uncommon in open fractures; bone grafts may be needed to promote bone healing in such cases.
Rehabilitation
Rehabilitation can begin once the soft tissue condition and the wound are stabilised. The aim is to prevent joint stiffness and restore the function of the limb. Since most open fractures need multiple operations, rehabilitation is usually delayed and protracted. However, optimism and persistence are the keys to a satisfactory return of limb function.
Dr. Edmund WONG