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The management of open fractures


RB Gustilo, RL Merkow and D Templeman
J Bone Joint Surg Am. 1990;72:299-304.

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Publisher Information The Journal of Bone and Joint Surgery
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Copynght 1990 byThe Journal of Bone andJoint Surgery. lncorporated

Current Concepts Review

The Management of Open Fractures


BY RAMON B. GUSTILO, M.D.*, ROBERT L. MERKOW, M.D.*, AND DAVID TEMPLEMAN, M.D.*,
MINNEAPOLIS, MINNESOTA

From the Department of Orthopaedic Surgery, Hennepin County Medical Center, Minneapolis

The goals of treatment of an open fracture are prevendeal- of comminution and instability. Type-ill fractures are
tion of infection, healing of the fracture, and restoration dividedof into three subtypes. In Type lilA, soft-tissue coy-
function to the extremity. The initial treatment of an erageopen of the fractured bone is adequate, despite extensive
fracture often affects the ultimate outcome. The operativelaceration, flaps, or high-energy trauma. This subtype in-
aspects of management - which include immediate, me-cludes segmental or severely comminuted fractures from
ticulous, and repeated d#{233}bridement; stabilization of the highfrac--energy trauma, regardless of the size of the wound.
ture; coverage of the wound; and early bone-grafting- are The Type-IIIB open fracture is associated with extensive
of paramount importance. Effective antibiotic therapy isinjuryalso to or loss of soft tissue, with periosteal stripping and
a major factor in the prevention of infection in the exposureman- of bone, massive contamination, and severe com-
agement of open fractures. minution of the fracture from high-velocity trauma. After
As approximately 30 per cent of patients who haved#{233}bridementan and irrigation is completed, a segment of bone
open fracture have multiple-system injuries life-threatening ,is exposed and a local or free flap is needed for coverage.
problems must be recognized and addressed before operativeType IIIC includes any open fracture that is associated with
treatment of the open fracture is initiated.
an arterial injury that must be repaired, regardless of the
degree of soft-tissue injury.
Classification of Open Fractures
Open fractures (or open dislocations) that are associ-
Open fractures are classified into three major types ated(one with arterial injuries that must be repaired present the
of which has three subtypes), according to the mechanismgreatest problem: the reported amputation rates for these
of injury, the degree of soft-tissue damage, the configurationpatients have ranged from 25 to 90 per cent36-’4”8”9. The
of the fracture, and the level of contamination”’5. Thetwo in-major causes of amputation have been infectionand the
cidences of infection of the wound, of delayed union failureand to achieve arterial flow to the involved extremity,
non-union, amputation, and ofresidual disability or ultimateparticularly when the arteries have not been repaired within
good function are influenced greatly by the typesix hoursof after injury’8. We strongly recommend arterial
fracture’ 1.12.14.18 repair, with an interpositional graft and adequate prophy-
in a Type-I open fracture, the wound is less than lacticone fasciotomies, within four to six hours. Treatment of
centimeter long. It is usually a moderately clean puncture,aType-IIIC injury calls for a high level of expertiseand
through which a spike of bone has pierced the skin. thusThere shouhd be done by an experienced vascular surgeon.
is little soft-tissue damage and no sign of crushing injuryThe. operation must not be relegated to less experienced
The fracture is usually simple, transverse, or short oblique,staff.
with little comminution. The incidence of infection of the wound in patients
In Type II, the laceration is more than one centimeterwho have an open fracture correlates directly with the extent
long, and there is no extensive soft-tissue damage, flap,of softor-tissue damage3-6-’ 1.15.39 For Type-I fractures, the rate
avulsion. There is a slight or moderate crushing injury,ofinfection has ranged from 0 to 2 per cent; for Type Ii,
moderate comminution of the fracture, and moderate fromcon- 2 to 7 per cent; for Type III over-all, from 10 to 25
tamination. per cent; for Type lilA, 7 per cent; for Type IIIB, from 10
Type III is characterized by extensive damage toto soft50 per cent; and for Type IIIC, from 25 to 50 per cent
tissue, including muscles, skin, and neurovascular (withstruc- a rate of amputation of 50 per cent or I.iSmore)’.30.32#{149}
tures, and a high degree of contamination. The fracture is
often caused by high-velocity trauma, resulting in a great Imperatives inTreatment
When treating an open fracture, it is imperative that
the attending physician follow certain steps, in chronohog-
* Department of Orthopaedic Surgery, Hennepin County Medical
ical order: (1) treat all open fractures as an emergency, (2)
Center, 701 Park Avenue South, Minneapolis, Minnesota 55415. Please

address requests for reprints to Dr. Gustilo. perform athorough initial evaluation to diagnose other life-

VOL. 72-A, NO. 2. FEBRUARY 1990 299


300 R. B. GUSTILO, R. L. MERKOW, AND DAVID TEMPLEMAN

threatening injuries, (3) begin appropriate antibiotic therapy The frequent


growth ofPseudomonas aeruginosa and
in the emergency room or (at the latest) in the operatingStaphylococcus
aureus on cultures of specimens from pa-
room and continue the therapy for two or three days only,tients who have an infection contrasts with the infrequent
(4) immediately debride the wound using copious irrigation growth of these organisms in cultures of specimens from
and, for Type-li and Type-Ill fractures, repeat the d#{233}bridethe- site ofthe initial wound. This indicates that the infections
ment in twenty-four to seventy-two hours, (5) stabilize arethe acquired in the hospital’ I.I2.i5#{149} The prominent role of
fracture, (6) heave the wound open for five to seven days,hospital-acquired bacteria in the pathogenesis of infection
(7) perform early autogenous cancehlous bone-grafting, andof the site of the
fracture serves to emphasize the importance
(8) rehabilitate the involved extremity. of early coverage of the open wound6”#{176}. It also suggests
After the preliminary examination is done in the emer-that despite optimum antibiotic therapy, a certain number
gency room, the wound should be covered with sterile dress-of infections, especially those caused by resistant pathogens,
ings. It is important to document the history and physicalmay be inevitable. Therefore, limiting the duration of the
findings properly, particularly with regard to the neurovas- initial antibiotic therapy is important to minimize the emer-
cular status of the limb that has the open fracture. To preventgence of resistant nosocomial bacteria.
additional contamination, the wound must remain covered A cephalosporin (cefazohin or cefamandole) is currently
until the patient is moved into the operating suite, whererecommended for patients who have an open fracture. A
the injured extremity is further examined, with the use singleof dose of 2.0 grams of cephalosporin on admission and
sterile technique, before definitive treatment is undertaken. 1 .0 gram every six to eight hours for forty-eight or seventy-
two hours is recommended for patients who have a Type-I
Appropriate and Effective Antibiotic Therapy
open fracture. For those who have a Type-Il or III open
After specimens are taken for initial culture, antibiotic fracture, combined therapy is essential to cover both gram-
therapy is started immediately. Although the value of positivean- and gram-negative bacteria or a mixed infection.
tibiotic therapy was not universally accepted in the past, Theit patient should receive cephalosporin, 2.0 grams, on
has been well documented’32930. In a prospective, double- admission, as well as aminoglycosides (tobramycin), 1.5
blind, randomized study by Patzakis et al.29, the rate milligramsof per kilogram of body weight on admission and
infection was 13.9 per cent in a group of patients who3.0 to 5.0 milligrams per kilogram of body weight each day
received only phacebos compared with 2.3 per cent inin adivided doses. The dose of aminoglycosides must be
group that was treated with cephalothin. Experimental studadjusted- ifthe patient has renal insufficiency. This antibiotic
ies have also demonstrated the efficacy of antibiotics therapyin is continued for three days. Ten million units of
preventing infection when they were administered just bepenicillin- is added if the patient sustained the injury on a
fore, or shortly after, bacterial contamination42. farm. Antibiotics are given again for three days when an-
Since 1969, in clinical studies of open fractures, miother- major operation, such as delayed primary or secondary
crobiological investigation has revealed that at least 70 perclosure of the wound, elective open reduction, and internal
cent of open fractures are contaminated with bacteria at fixationthe and bone-grafting, is performed. Prolonging anti-
time of injury’329. Both gram-negative and aerobic gram-biotic therapy for more than three days has been reported
positive bacteria are major pathogens in infections that arenot to prevent infection of the wound”’3’30.
associated with fractures”-’2-’4-’530, and the reported change
Adequate and Repeated Operative
from findings of gram-positive bacterial flora to those of
D#{233}bridement and Copious Irrigation
gram-negative bacteria or mixed infections since 1979 die-
tates combined antibiotic therapy for the treatment of open Adequate d#{233}bridement of the wound, accompanied by
fractures, related infections, and the effects of nosocomial copious intermittent lavage, is the most important step in
pathogens’4-’5. The risk of infection at the site of an openmanagement. Small puncture wounds or small lacerations
fracture depends greatly on the severity of the soft-tissue must be extended to allow adequate exposure. Both small
injury’ I-I5.29.3O and large fragments or segments of devitalized, unattached
Initial cultures of specimens from open fracture wounds cortical bone should be discarded. We do not recommend
have revealed mostly normal skin flora(Staphylococcus ep- putting back any large bone or segment of bone that was
idermidis, Propionibacterium acnes, Corynebacterium spe- taken from the scene of the accident. For Type-Il or Type-
cies, and Micrococcus) or environmental contaminants III open fractures, copious irrigation with 5,000 to 10,000
(Bacillus species and Clostridium species), which infremilliliters- of normal saline solution or distilled water is
quently cause infection’9. However, when more virulentrecommended. For final irrigation, 2,000 milliliters of bac-
pathogens, especially gram-negative bacilli, are also present itracin-pohymyxin solution is used34. Even when the initial
initially, the risk of infection appears to be higher’920. Sped#{233}bridement- of the wound is aggressive, it is very difficult
cific pathogens are also associated with certain types toof determine the viability of marginal tissue at that time.
environmental exposure; for example, gas gangrene, causedRepeated d#{233}bridement in forty-eight to seventy-two hours
by Clostridium perfringens, can follow farm-related inju- is essential to establish a viable environment for soft-tissue
ries, and exposure to fresh water is associated with infections coverage. Early soft-tissue reconstruction (in five to seven
by Pseudomonas aeruginosa and Aeromonas hydrophila. days) is recommended if a clean, stable wound has been

THE JOURNAL OF BONE AND JOINT SURGERY


THE MANAGEMENT OF OPEN FRACTURES 301

achieved, and it is the key to reducing the incidence intramedullaryof nailing with reaming was done following
infection after a Type-Ill open fracture6-’#{176}’4-”#{176}The. wound removal ofthe external fixator 3. We recommend either leav-
must be kept moist until definite coverage is accomplished ing the fixator in place until the fracture is stable enough
in five to seven days. Recent studies6-’#{176}have demonstrated for continued immobilization in a cast or continuing the
markedly reduced rates of infection in Type-Il! fracturesexternal fixation until the fracture has united. Angulation,
when early coverage of the wound is accomplished. leading to mahunion, may follow early removal of an ex-
ternal-fixation device. However, the incidence of pin-site
Stabilization of the Fracture infection can be reduced considerably with proper insertion
Technical advances in the operative stabilization andof care’.
certain fractures have improved the rate of union and the
functional results compared with those obtained by non- Intramedullary Nailing
operative methods. Achieving osseous stability in open frac- The management of closed tibial fractures by intra-
tures reduces the rate of infection and protects the integrity meduhlary nailing with reaming usually avoids infection.
of the remaining soft tissues, thereby promoting wound-However, in the largest reported series of Type-I open frac-
healing. Stability of the site of the fracture also facilitates tures, this method was associated with a 6 per cent incidence
care of the wound when patients must be transferred manyof infection’7, in contrast to the 0 to 1 per cent incidence
times for repeated operative d#{233}bridement, and it allows mothat- is usually associated with the management of Type-I
bilization of patients who have multiple injuries. open fractures’3. For this reason, intramedullary nailing with
The appropriate timing of operative stabilization mustreaming has not been recommended for the early stabihi-
be determined for each patient by the surgeon. Immediate zation of open tibial fractures’7-28. In the treatment of Type-
reduction and fixation is especially advantageous in the manII- and Type-Ill open fractures of the tibia, nailing without
agement of intra-articular fractures, for which anatomical reaming has been reported to be associated with rates of
reconstruction of the surfaces of the joint followed by earlyinfection of 3 to 7 per cent, probably because the disruption
motion improves the prognosis. An open intra-articular fracof- the endosteal blood supply is not as great as when reaming
ture can be fixed during the initial management of istheused39’4’ However, nailing
. without reaming does not pro-
wound, to avoid the technical problems that are inherent videin as much stability for severely comminuted fractures of
hate articuhar reductions. Immediate stabilization is also benthe- proximal or distal third of the tibia, so many patients
eficial for patients who have multiple injuries, as they wereare excluded from the clinical studies on the use of this
at risk for pulmonary complications. In these patients, fractechnique39- -4’ .Interlocking nailing without reaming is a po-
ture of a long bone should be stabilized during the initialtential solution to these mechanical problems, but, to our
operative d#{233}bridement4. knowledge, there have been no reports on the rates of union,
non-union, and infection that are associated with this
Devices for Stabilizing the Fracture
method.
Devices for stabilizing an open fracture can be divided Most open fractures ofthe femoral shaft are either Type
into external and internal fixators. The choice is guided I byor Type II, and they can be managed successfully with
the anatomical site ofthe injury, the degree of comminution, intramedullary nailing with reaming. Immediate intramed-
the wound, the associated injuries, and the expertise of ullarythe nailing with reaming must be considered for the treat-
surgeon. No one method of stabilization is optimum for mentthe of such a fracture in a patient whose life is threatened
management of all open fractures. by multiple injuries (Abbreviated Injury Scale Injury -

Severity Score of more than 20) #{176}- However,. nailing with


External Fixation
reaming of a Type-Ill open fracture of the femur is asso-
External fixation is a safe and reliable method ciatedof with a higher rate of infection, and the reported ex-
achieving osseous stability. The advantages of this techperience- has been too limited to allow us to recommend a
nique are versatility, ease of application with minimum opsingle- form of fixation for this type of fracture. Treatment
erative trauma, and maintenance of access to the wound.must be individualized on the basis of the severity of the
External fixation is therefore an excellent method for stasoft--tissue injury, the extent of contamination, the location
bilization of Type-Ill open fractures of the tibia’’6-’7. and the configuration of the fracture, and any associated
The incidence of infection of the wound after external injuries.
fixation of a Type-Ill tibial fracture has been reported to
range from 7 to 14 per cent’-6’439. The rate of non-union Fixation with a Plate and Screws
has been high (20 to 30 per cent), reflecting the character- Use of a plate and screws, external fixation, and in-
istics of the fracture: a high-energy injury with severe losstrameduhlary nailing have all been reported to achieve com-
of soft tissue and comminution. Early soft-tissue coverage, parable results in the management of open fractures of the
timely bone-grafting, and gradual destabilization are curupper- extremity7-9-26. Rigid internal fixation with a plate
renthy done to enhance fracture-healing’’4. One major disoffers- early mobilization of the affected ipsihateral joints,
advantage of external fixation of open fractures of the tibialso this method is preferred except when the presence of
shaft is the high rate of infection that has been reported aftersevere contamination or extensive comminution (such as

VOL. 72-A, NO. 2, FEBRUARY 1990


302 R. B. GUSTILO, R. L. MERKOW, AND DAVID TEMPLEMAN

may occur in distal radial fractures) indicates timethat forexternalcoverage with a flap. If there is any doubt abou
fixation is more appropriate. the presence of infection of the wound, repeat d#{233}bridement
In general, fixation with a plate and screws quantitativeisindicated cultures of specimens from the wound, and
for displaced intra-articular and metaphyseal fracturesappropriate of theantibiotic therapy may be necessary. The choice
lower extremity and for open fractures of the upperof theextremflap- depends on numerous factors, including the ag
ity. and needs of the patient; the location, size, and condition
of the defect; the likelihood that subsequent reconstruction
Splints, Casts, and Traction will be needed; the associated zone of soft-tissue injury;
A plaster splint may be used for a stable, isolatedthe tissuesType- that are available for the flap. A flap can
I fracture until the wound is healed. After this,fasciocutaneous3138,thelimbis a transposed muscle pedicle22-24, or
immobilized in a cast2. However, a circular castfree mustmicrovascularbe muscle flap5-25-36, with or without cuta
avoided in the acute stage of treatment of an openneous fracture,transfer.
as compartment syndrome is not an uncommon compliThe- gastrocnemius or soleus muscle is used most fre-
cation2. quently as the local flap for coverage of an open tibia
After the initial d#{233}bridement and delayed closurefracture. of anThe gastrocnemius is most useful for defects
isolated Type-I or Type-Il fracture of the femoralthe proximalshaft, third of the tibia22. The distance that can
temporary skeletal traction through the proximal coveredpart ofby thethat muscle can be increased by converting it
tibia is an option, followed by intramedulhary a nailingtrue islandwith flap, by dividing its proximal origin from
reaming ten to fourteen days after closure of thefemoralwound37condyle. . The soheus is used primarily for covering
mid-tibial defects, although occasionally the muscle extend
Coverage and Closure of the Wound distally and can be used to cover defects in the distal th
The goals of soft-tissue coverage of open fracturesofthe tibia43are. Although the extensor digitorum communis
to achieve a safe, early closure of the wound withinissmallerseven and is used less frequently, it is a useful musc
to ten days after injury, to avoid infection and thatoptimizecan be ‘reversed’the to cover
‘ ‘ a defect in the distal third
milieu for healing, to obliterate dead space ofand theestablishtibia2’.
durable coverage, and to facilitate future reconstructionTransfers. of free microvascular muscle flaps have been
ForType-I and Type-Il open fractures, delayedusefulprimaryin providing early coverage of large defects, parti
closure or closure using mesh skin grafts can ularlyusuallyin thebe distal tibial region5-25-36. The use of free musc
done five to seven days after injury’3’5. In Typetransfers-lilA openhas helped to avoid multiple reoperations. Su
fractures (when exposed bone is not a problem), transfersclosure canprovide durable vascular coverage of the site
usually be done in five to seven days by the same themethods’5fracture,. allow subsequent reconstructive procedures,
Open wounds must be kept moist until they are diminishclosed, tothe rate of infection, and ultimately shorten
avoid desiccation of the soft tissues, periosteum, time andfor bonehealing. . The latissimus dorsi25-36 and the vertica
Type-IIIB or IIIC open fractures that are rectusassociatedabdominis muscle5 are transferred most frequently.
with major loss of soft tissue and exposed bone In mustthe preoften-tibial region, the rate of survival for a free mus
be debrided two, three, or four times to achievetransfer chean,has been approximately 85 to 95 per cent25’27’36 ’#
stable wound. These severe fractures are associatedFailure ofwithfree microvascular flaps has been primarily relat
high incidences of infection and non-union6 dueto topre-theexisting- vascular damage within the zone of injury,
creased devitahization of the soft tissues and andtheto commifriability- of the recipient vessel, due to either chro
nution of bone. Because of the severe soft-tissuegranulationinjury, or infection.
contamination, and compromised vascularity, more Splitaggres-thickness- skin-grafting is usually delayed for t
sive d#{233}bridement and subsequent coverage with to a fiveflap daysare after injury. The graft is meshed ( 1 .5: 1 or 3
needed for these fractures. If such a wound is toleftallowopen forforswelling and exudation of serum from the trans-
more than two weeks, colonization with bacterial ferredflora musclefrom.
the hospital is common, frequently resulting in infection of
Compartment Syndrome
the wound and failure ofthe flap3-8’4’35. In patients who have
an open fracture early soft-tissue
, coverage of exposed Thebone possibility that a compartment syndrome may de-
(within five to ten days after injury) considerablyvelop afterreduces an open fracture of the tibia should not be ove
the risks of infection and of failure of thelookedsoft.-tissueWhile one or more compartments may be decom-
flap6’#{176}’4.Although early muscle transfer to coverpressedexposedas a result of the open injury, the remaining com
bone is strongly advocated, one must avoid the partmentstransfer areof still at risk. At our institution, 2.7 per
severely injured muscle27. of the patients who had an open tibial fracture have needed
The wound must be kept moist between serial fasciectomyirrigation for compartment syndrome. Bhick et al. re
and d#{233}bridement until soft-tissue coverage canportedbe accom-9. 1 per cent incidence of compartment syndrome
phished. The wound must be chean and stable beforein patientsitcan who had an acute open tibial fracture2. For p
be covered with a flap. Experience and sound clinicaltients whojudg- have an altered mental thatstatusis, those -

ment are the best guides for determining the whoappropriatehave a head injury or have sustained multiple trauma

ThE JOURNAL OF BONE AND JOINT SURGERY


THE MANAGEMENT OF OPEN FRACTURES 303

that necessitated prolonged anesthesia - the risk


that the delayed until six weeks after the wound has healed.
diagnosis of compartment syndrome may be
missed or de-
Indications for Amputation
layed is particularly high. Decompressive fasciotomies of
all four compartments in the leg should be done in anyThe decision to amputate an extremity as the primary
patient in whom the clinical diagnosis of compartment formsyn- of treatment for an open fracture should be guided by
drome is made. The same is true for unconscious patientswhether a functional, viable extremity can reasonably be
who have elevated intercompartmental pressures (thirty achievedmil- by any other form of treatment and whether the
limeters of mercury or more). time and expense of what will almost surely be multiple
attempts at saving the extremity can bejustified, particularly
Bone-Grafting when a below-the-knee amputation can be done. We believe
The two essential prerequisites for fracture-healing thatare there are two absolute indications for a primary am-
blood supply and stability. The rate of non-union is diminputation:- (1) a Type-IIIC injury accompanied by disruption
ished when bone-grafting is done after the optimum bloodofthe posterior tibial nerve, and (2) a Type-IIIC injury with
supply around the site of the fracture has been attained6’4loss. of soft tissue, massive contamination, severely com-
The vascular environment around Type-I and Type-Il minutedopen segmental fracture, or massive loss of bone that
fractures is minimally impaired. In these fractures, ifwill au-likely result in marked impairment of function. We also
togenous cancellous bone-grafting is indicated because believeof that a Type-IIIC injury that has remained untreated
loss of bone or marked comminution, it can be done forearly eight hours is a relative indication for amputation.
- that is, when the wound is closed or two to three weeks Delayed amputation has been shown to be two to three
after the wound has healed. In a Type-Ill open fracture, timesthe more expensive than immediate amputation, and often
periosteal and soft-tissue envelope is severely compromised, the delay necessitates a more proximal level of amputation3.
and a local or free flap is often needed for soft-tissue Also,coy- the patient and surgeon can often accept an immediate
erage. In such patients, autogenous bone-grafting should amputationbe with less emotional trauma.

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