orthopaedics

CPD article

Management of
open fractures: part 2
Open fractures have been considered one of the true orthopaedic emergencies by some,
however, optimal treatment has not been definitively described. Significant debate has
focused on the most appropriate method by which to manage open fractures, but general
principles of treatment are well established. Principles include fracture classification,
antibiosis, irrigation, debridement, wound management and fracture stabilisation. In
this second in a two-part series on open fracture management, debridement, wound
management and fracture stabilisation will be explored; the initial management of the
patient was discussed in the first article in the series. Debridement should be performed
on an urgent but not emergent basis; adequacy of debridement and timeliness of soft
tissue coverage are probably more important than time from injury to debridement. Once
the wound has been appropriately irrigated and thoroughly debrided, early aggressive
treatment, with rigid bone fixation and soft tissue reconstruction, is widely accepted as
the treatment of choice. Generally, type 1 and 2 open fractures can be stabilised using the
same method of fixation as would be used for a closed fracture of similar configuration,
while the extensive soft tissue damage associated with type 3 fractures may preclude
internal fixation.  10.12968/coan.2016.21.4.196

Karen L Perry BVM&S CertSAS DipECVS FHEA MRCVS, Assistant Professor in Small Animal Orthopaedics,
Veterinary Medical Center, Michigan State University, 736 Wilson Road, East Lansing, Michigan 48824-1314,
USA

Key words: Open fracture | Debridement | Wound management | Internal fixation | External skeletal fixation

I
n the first of this two-part series on open fracture management
(Perry, 2016) the importance of patient stabilisation was
discussed. Following this, current recommendations
regarding classification of the fracture, antibiotic therapy
and irrigation of the wound were detailed and explored. In order to
achieve the ultimate goals in open fracture management, namely
prevention of infection; fracture healing; and full functional
recovery of the limb (Worlock et al, 1994), debridement of the
wound, appropriate wound management and fracture stabilisation
must also be addressed.
in which guinea pigs with contaminated soft-tissue wounds had
lower rates of infection when debridement was performed within
6 hours (Friedrich, 1898), others point to a study by Robson et al
(1973), who reported that 105 organisms per gram of tissue was
the open-fracture infection threshold, which was reached in an
average of 5.17 hours.
To date, two studies in humans have shown a decreased rate of
infection when debridement is performed within 6 hours. In one
study, cases undergoing operative treatment before 5 hours had an
infection rate of 7%, compared to an infection rate of 38% in cases
operated later (Kindsfater and Jonassen, 1995). In the other study,
© 2016 MA Healthcare Ltd

Debridement
Emergency operative treatment has long been the standard of
care for open fractures, with a ‘6 hour window’ often being men-
tioned. The exact origin of this window, however, is unclear. While
some believe that it stems from an 1898 experiment by Friedrich,
cases operated before 6 hours had an infection rate of 12%, com-
pared to 25% in those operated after (Kreder and Armstrong, 1995).
However, the first study may have been biased as severe fractures
were more likely to be treated later in this study, and the second
study had a small sample size, which may have affected results.

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 orthopaedics
Figure 1. An example of a shearing injury affecting the medial aspect of the tibio-
tarsal joint in a domestic short-haired cat where the viability of tissue was difficult
to assess on presentation. Excessive debridement was not felt to be desirable as
this would complicate future wound reconstruction. In the absence of certainty
regarding adequacy of debridement, the wound was managed open.
Many studies have called the ‘six hour window’ into question
(Patzakis and Wilkins, 1989; Harley et al, 2002; Khatod et al,
2003; Charalambous et al, 2005; Skaggs et al, 2005), having
found no significant difference in infection rates between
fractures treated operatively before or after six hours (Bednar
and Parikh 1993; Ashford et al, 2004; Spencer et al, 2004)
and no correlation between time to first debridement and
rate of infection (Pollack et al, 2003). It is interesting to note
however that in the study by Pollack et al, patients who had been
admitted to a hospital within 6 hours after the injury had a lower
prevalence of infection than those who had been admitted after
6 hours (22% compared with 9%, p<0.01). Caution should be
employed when drawing conclusions from these reports however,
as cases were not randomised and in many studies the sample
sizes were small. In conclusion, it is not possible to argue for
or against a firm ‘6  hour window’ in the management of open
fractures. In the prevention of infection after open fracture, the
time from injury to debridement is probably less important than
other factors such as adequacy of debridement and timeliness
of soft tissue coverage (Okike and Bhattacharyya, 2006).
Treatment decisions and prognosis of open fracture wounds
should be based on assessment of soft tissue damage, viability,
contamination and infection ­— not on a time interval (Millard
and Towle, 2012). Patients with an open fracture should be
taken to the operating room on an urgent basis, with the stability
of the patient, the preparation of the operating room and the
availability of appropriate assistance taken into account (Okike
and Bhattacharyya, 2006).
Wound management
Once the wound has been appropriately irrigated, cleaned and
thoroughly debrided, early aggressive treatment with rigid bone
fixation and soft tissue reconstruction where possible is widely
198
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accepted as the treatment of choice (Byrd et al, 1981; Esterhai,
1990; Tukiainen and Asko-Seljavaara, 1993; Moucharafieh et al,
1996; Hertel et al, 1999).
Historically, the closure of open fracture wounds has been
delayed to prevent infection with contaminating organisms.
While this strategy remains the generally accepted approach
in settings characterised by substantial contamination, many
orthopaedic surgeons have begun to consider earlier closure
of open fracture wounds that have been adequately debrided
(Okike and Bhattacharyya, 2006). Several studies in humans
have documented significantly better outcomes with early
closure (within 7 days) than with late closure (Cierny et al, 1983;
Byrd et al, 1985; Caudle and Stern 1987; Fischer et al, 1991).
Also, a number of studies have demonstrated excellent outcomes
with closure performed within 3  days of injury (Godina 1986;
Sinclair et al, 1997). A number of authors have also investigated
the feasibility of immediate closure (within 24 hours of injury).
DeLong et al (1999) did not find immediate closure to be
associated with a higher rate of infection or nonunion when
compared with delayed closure, and two studies have shown
lower infection rates in type  3b and type  3c tibial fractures
following immediate wound closure and fracture fixation (Hertel
et al, 1999; Gopal et al, 2000). Based on the human literature,
early closure of thoroughly debrided wounds is safe and can
improve outcomes (Okike and Bhattacharyya, 2006).
As mentioned above, however, assessing the adequacy of de-
bridement can be difficult, and if there is any doubt in the sur-
geon’s mind as to whether all non-viable tissue has been removed
then the wound should not be closed regardless of the type of
open fracture (Gustilo and Anderson, 1976), as this can lead to
future complications (Figure 1). There are multiple options for
the treatment of the wound prior to closure; these include the
placement of antibiotic beads using the ‘bead-pouch technique’,
as mentioned in the first article in this series, and negative pres-
sure wound therapy (NPWT). In humans, other techniques that
have been used for wound coverage include the application of a
synthetic skin substitute, Epigard (Parke-Davis, Detriot, Michi-
gan) (Levin, 2006); Adaptic gauze (Johnson and Johnson, Rayn-
ham, Massachusetts); or porcine allograft (Zalavras et al, 2007).
While a full discussion of open wound management is out-with
the scope of this article, dependent upon individual wound char-
acteristics other options may include polyurethane foam dress-
ings, wet-to-dry dressings and hydrocolloid dressings. The goals
of wound coverage are to prevent desiccation of tissue, optimise
antibiotic delivery, optimise patient comfort and seal the wound
from the external environment (Zalavras et al, 2007). Once the
bone is covered by healthy tissue, or a healthy bed of granulation
tissue, local skin or transposition flaps can often be used for clo-
sure. Axial pattern flaps and free skin grafts are other treatment
options (Millard and Towle, 2012). While this does not adhere
to the principle of early soft tissue reconstruction, once a healthy
© 2016 MA Healthcare Ltd
bed of granulation tissue has formed the wound becomes rela-
tively resistant to infection, therefore, for smaller wounds, allow-
ing healing by second intention is also an option.
Recently, NPWT has emerged as a useful method of accel-
erating wound-healing, by reducing chronic oedema, increasing
Companion animal | April 2016, Volume 21 No 4
 orthopaedics
Figure 2. Photographs demonstrating the use of negative pressure wound
therapy on a Maine Coon cat that had suffered open fractures of multiple
metatarsal bones.
local blood flow and enhancing granulation tissue formation (Ar-
genta and Morykwas, 1997; Morykwas et al, 1997) (Figure 2). A
small number of reports have documented the use of NPWT in
the management of orthopaedic wounds, with generally favoura-
ble results (Mooney et al, 2000; DeFranzo et al, 2001; Herscovici
et al, 2003; Labler et al, 2004). Beneficial effects have included
reduced tissue oedema, shrinking wound size, granulation tissue
formation stimulation (DeFranzo et al, 2001) and lower infec-
tion rates (Labler et al, 2004). The negative pressure device is
typically applied at the end of each irrigation and debridement
until the wound is considered clean. After that point, the dress-
ing can be changed every 2–3 days. Negative pressure wound
therapy was used for an average of 10–20 days in the studies
described above. While NPWT appears to be a promising mo-
dality in the management of musculoskeletal wounds, additional
studies are required before a definitive recommendation can be
made (Okike and Bhattacharyya, 2006).
Fracture stabilisation
Controversy regarding the most appropriate method of fixation is
vast in the human and veterinary literature. A number of stabili-
sation methods are available and success has been reported with
both internal fixation methods (bone plates, bone plate and IM
pin, cerclage wire and interlocking nails), and with external fixa-
tion methods (linear, circular and hybrid external skeletal fixation
(ESF)) (Egger et al, 1985; Nunamaker and Berg, 1985; Aron,
1988; Johnson et al, 1989; Martin, 1990; Foland and Egger,
1991; Houlton, 1996; Johnson et al, 1996; Dudley et al, 1997;
Tsur and Christie, 1999). If internal fixation is elected, however,
it is important to warn owners that the implants used may require
removal in the future (Houlton, 1996). In any given situation, the
best option for fixation depends on a number of factors including
the bone involved, the fracture site and type, the wound loca-
tion, the skin vascularity and the condition of the patient (Nuna-
maker and Berg, 1985; Okike and Bhattacharyya, 2006). Ideally,
a surgical approach away from the initial open fracture wound is
selected (Houlton, 1996; Piras, 2007).
External coaptation is not normally recommended as the
definitive method of fixation for any open fracture in our
veterinary patients. Frequent removal of casts and splints is
required to appropriately evaluate and assess most open fracture
wounds, and this makes adequate stabilisation difficult to achieve
(Nunamaker and Berg, 1985).
200
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Conventionally, the use of metallic implants to stabilise open
fractures was avoided because of the supposedly higher risk of
infection (Epps and Adams, 1961; Gustilo and Anderson, 1976).
However, McLaughlin (1956) suggested that treatment by trac-
tion or cast, even when it did not have to be removed frequently,
was usually associated with constant small movement of the frac-
tured bone ends, causing further soft tissue necrosis. This necro-
sis was considered to constitute a greater infection risk than
ensuring stability with a sterile implant. Various workers have ad-
vocated rigid stabilisation of open fractures on the basis that such
stabilisation will help prevent the development of sepsis (Müller
et al, 1979; Chapman, 1982; Allgower and Border, 1983). For
example, Worlock et al (1994) conducted a study investigating
tibial fractures created in rabbits, which were stabilised using ei-
ther a dynamic compression plate (stable group) or a loose-fitting
intramedullary rod (unstable group). The fracture site was then
inoculated with Staphylococcus aureus. In the stable group, 35%
of rabbits developed osteomyelitis, while in the unstable group
71% of rabbits developed osteomyelitis. The difference in infec-
tion rates was statistically significant.
Several factors have been proposed to contribute to this re-
duction in infection rates associated with increased stability. Sta-
bility is clearly beneficial to revascularisation; both Rhinelander
et al (1967) and Ganz et al (1970) have confirmed that blood ves-
sels can be seen crossing an experimental osteotomy within a few
days of operation, provided that rigid internal fixation has been
maintained. Stable fixation of a fracture also leads to increased
tissue microperfusion in the adjacent area (Chapman, 1982).
This brings cellular and humoral defences into tissues contami-
nated with bacteria (Worlock et al, 1994). Anatomical reduction
and stabilisation of a fracture will also reduce tissue dead space
and decrease the chance of haematoma formation (Worlock et al,
1994). Conversely, instability at a fracture site may provide con-
ditions favouring bacterial proliferation, namely local necrosis of
surrounding soft tissues, and exudate formation (Kahn and Pritz-
ker, 1973; Chapman, 1982). Essentially, these studies have dem-
onstrated that metal does not stimulate or promote wound sepsis
and that the benefits of fracture stability override any potential
harmful effects of implants (Gristina et al, 1976; Gustilo et al,
1990; Martin, 1990). In addition to this, in the multiply injured
patient, fracture fixation also reduces the risk of acute respira-
tory distress syndrome and multiple organ failure, presumably by
calming the systemic inflammatory response (Pallister and Emp-
son, 2005). So, we know that stability is optimal, but what should
we use to achieve this stability?
It is a common misconception that an open fracture in a vet-
erinary patient precludes the use of internal fixation and neces-
sitates the use of external skeletal fixation. The severity of the
soft-tissue injury rather than the choice of implant appears to be
the main factor influencing infection and bone-healing (Henley
et al, 1998). In humans, intramedullary nailing is used widely for
© 2016 MA Healthcare Ltd
stabilisation of open diaphyseal fractures of the lower extremity
(Brumback et al, 1989; Tornetta et al, 1994; Henley et al, 1998).
The author has used interlocking nails for treatment of grade 1
and 2 open fractures in cats and dogs with very satisfactory re-
sults (Figure 3), and the use of an interlocking nail for treatment
Companion animal | April 2016, Volume 21 No 4
 orthopaedics

of an open (gun-shot) antebrachial fracture in a dog has been

reported previously in the peer-reviewed veterinary literature
(Gatineau and Plante, 2010). Prospective, randomised studies
have been performed comparing intramedullary nailing and ex-
ternal fixation for open tibial diaphyseal fractures in people, and
there were no differences in fracture-site infection or bone heal-
ing rates between the two methods (Tornetta et al, 1994; Henley
et al, 1998). A meta-analysis of the management of open tibial
fractures in people also demonstrated that intramedullary nail-
ing reduced the risks of reoperation, malunion and superficial in-
fection compared with the risks associated with external fixators
(Bhandari et al, 2001). Having said this, external fixators remain
particularly useful for patients with vascular injury or extensive
soft-tissue damage and contamination (Zalavras et al, 2007).
Plate fixation is said to be indicated for open periarticular
fractures and for diaphyseal fractures of the upper extremity in
people (Zalavras et al, 2007), and remains an option for open
fractures in our veterinary patients also (Figure 4). Bone plates
have been used to treat type  1 through  3 open fractures with Figure 3. An example of a case of grade 1 open fracture of the femur in a
satisfactory final results reported for veterinary patients (Nuna- domestic short-haired cat which was stabilised using a BioMedtrix size 4 I-Loc®
maker and Berg, 1985; Walter et al, 1986; Clark, 1987; Martin, interlocking nail.
1990; Dudley et al, 1997). As mentioned previously, the view that
the stability provided by internal fixation outweighs the disad- control) (Roberts et al, 2005). Sisk (1983) summarised the ad-
vantages of the implantation of foreign material is supported by vantages and disadvantages of external fixation; in addition to
the results of many studies (Rüedi et al, 1976; Christensen et al, those advantages already mentioned above, he noted the ability
1982; Oertli et al, 1984; Clifford et al, 1988). External fixation to provide rigid fixation without additional soft tissue stripping,
at a distance from the open fracture has been a popular choice and the adaptability of the technique to suit nearly all types of
previously, but external fixators are cumbersome and have several fracture. An additional advantage not mentioned in this report is
disadvantages: they limit access to the wound, pin track sepsis is that implant removal is relatively easily accomplished (Martin,
common, and the incidence of angular deformity in humans is 1990). The general disadvantages associated with ESF use in any
high (Edge and Denham, 1981; Benum and Svenningsen, 1982; situation also apply to their use in open fractures, including the
Clifford et al, 1987). necessity for experience with fixator systems; the risk of fracture
While internal fixation may be preferable in some circum- through a pin-tract; risk of tampering with the frame by non-
stances, external fixation remains an option for open fracture compliant patients; and risk of damage to neurovascular struc-
management and is preferentially indicated for fractures as- tures during pin insertion (Sisk, 1983). External fixation has also
sociated with extensive contamination and soft-tissue damage been documented to pose practical difficulties for reconstruction
(Figure  5), particularly where this soft tissue damage prevents of large soft-tissue defects in humans (Gopal et al, 2000).
a tension-free closure being obtained over the internal implant. It has been postulated that consideration should be given to
External fixation may also be preferable when there is a need the type of organism contaminating the wound when decisions
for rapid fracture stabilisation or minimal interference with the are being made regarding internal fixation. In an experimental
patient’s physiologic response to the injury (so-called damage study by Merritt and Dowd (1987), internal fixation reduced the
© 2016 MA Healthcare Ltd

Figure 4. An example of a grade 1 open fracture of the humerus (same cat as in Figure 1) which was stabilised using a 2.4 mm locking plate and
screws showing both pre-operative (left) and postoperative (right) radiographic views and photographs.

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 orthopaedics

a b c d e

Figure 5. An example of a case where external fixation was considered the best option for stabilisation due to extensive contamination and soft-tissue
damage in a region where soft tissue coverage is notoriously poor (same cat as in Figure 1). The images show from left to right: a) the appearance of
the wound upon presentation following clipping; b) appearance of the wound following external skeletal fixation placement and 3 days of wet-to-dry
dressing management; c) the patient comfortable with the fixation 3 days postoperatively; d) the appearance of the wound after 3 days of wet-to-dry
dressings and 2 days of management using hydrocolloid gels and polyurethane foam dressings; e) the appearance of the wound on the same day as
(d) but following partial closure of the proximal portion of the wound.

infection rate in hamsters when Staphylococcus aureus was the
infecting organism, but increased the rate of infection when a
Gram-negative organism, Proteus sp., was the infecting organ-
ism. Proteus spp. organisms have endotoxin as part of the cell
wall, which may increase bone destruction, and the mucoid cell
wall and capsular structure may lead to increased adherence to
implants. The ability of organisms to adhere to biomaterials is
associated with the infection rate at the site of these materials,
and may be an important factor in infection rates in fractures
Box 1: Possible adjunctive therapies
zzBone grafting: autogenous cancellous bone is the gold standard. This is
generally performed at the time of wound closure and fracture fixation,
other than in type 3 fractures where it may be delayed. Bone grafting
has been shown to lead to a shorter time to bone union (Blick et al,
1989; Trabulsy et al, 1994). Problems with bone grafting include the
limited quantity of autogenous cancellous bone available and donor site
morbidity (Zalavras et al, 2007).
zzRecombinant human bone morphogenetic protein-2 (rhBMP-2) has been
shown to lead to faster fracture healing, a reduced risk of secondary
interventions (Govender et al, 2002) and reduced infection rates
(Swiontkowski et al, 2006). Problems which may be associated with it
however include the short biologic half-life, difficulties in retaining the
product at the fracture site, and the high cost associated with its use
(Zalavras et al, 2007).
zzElectrical stimulation of bone has been shown to play a role in
promoting bone healing (Sharrard, 1990; Scott and King, 1994;
Brighton et al, 1995), but this is not used routinely in veterinary practice.
Electrohydraulic shock wave therapy has been shown to accelerate bone
healing when used following proximal tibial osteotomies in veterinary
patients (Kieves et al, 2015) but this has not been evaluated in open
fracture management to date.
zzLow-intensity ultrasound has also been shown to reduce the time to
stabilised using internal fixation (Christensen et al, 1983; Sheth
et al, 1983; Gristina and Costerton, 1985; Gristina et al, 1985;
Merritt and Dowd, 1987). Organisms that have been document-
ed to adhere well to implants include Pseudomonas aeruginosa,
enterococci, Citrobacter spp., Corynebacterium spp., and various
strains of Staphylococcus spp. As many of these are associated
with implant-associated infections in veterinary species, this may
be an important point to consider. Further studies are warranted
in this regard. Currently, if infection with Proteus sp. or a similar
organism is suspected, it may be prudent to elect for external
fixation as a method of stabilisation.
In summary, type  1 open fractures can generally be treated
using the same method of fixation as would be used for a closed
fracture of similar configuration. Type 2 fractures that are prop-
erly managed often can be treated using the same method of
fixation as would be used for closed fractures, but appropriate,
experienced judgement is necessary (Martin, 1990; Houlton,
1996). Extensive soft tissue damage associated with type 3 open
fractures may preclude internal fixation (Etter et al, 1983).
Adjunctive therapies
Many methods have been reported to potentially improve fracture
healing and reduce the incidence of delayed union and nonunion
(Box  1). Since the potential for complications is greater when
dealing with open fractures, promoting neovascularisation and
bone healing may be of even greater importance here. While not
appropriate for every case, these options should be considered.
Complications and follow-up
Postoperatively, frequent and regular checks are necessary to as-
sess the wound and limb function. The frequency of dressing
changes required will be dictated by the wound management ini-
tially. If wet-to-dry dressings are being used, daily re-evaluation
will be necessary; if NPWT is being used with a portable unit,
© 2016 MA Healthcare Ltd

healing in management of open tibial fractures (Heckman et al, 1994;
Cook et al, 1997).
zzIn the future, gene transfer therapy may be used to deliver growth
factors to the fracture site (Baltzer et al, 2000; Betz et al, 2006).
evaluation would be appropriate every 3 days and if the wound has
been closed, rechecks may be scheduled less frequently. Clini-
cal and radiographic evaluation may be required more frequently
than for a closed fracture, to monitor for signs of a deep-seated
infection (Millard and Towle, 2012). Clinical signs of infection

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may include pain on palpation of the affected bones and soft tis-
sues, soft tissue swelling, pyrexia, anorexia and lethargy, with or
without discharging sinus tracts. The radiographic appearance is
dependent upon the stage of the disease. It may take 2 weeks or
more for radiographic changes to become apparent in the bone,
therefore in the acute stage soft tissue swelling is likely to be the
only radiographic abnormality. In the later stages, bone lysis (usu-
ally focal or adjacent to the implants), periosteal new bone, bone
sclerosis, cortical thinning, sequestrum or involucrum formation
or delayed fracture healing may become apparent.
Potential complications of open fractures include superficial
infection; deep-seated infection; delayed union or nonunion;
necrosis of soft tissue and breakdown of soft tissue repair tech-
niques; and temporary or permanent neurologic damage from the
initial injury (Millard and Towle, 2012). Delayed union and non-
union rates are reported as 0–5% in type 1 fractures, 1–14% in
type 2 fractures, and 2–37% in type 3 fractures (DeLong et al,
1999; Harley et al, 2002). Amputation may be necessary with
type  3 fractures, fractures with multiple complications, and
those associated with severe neurovascular injury (Millard and
Towle, 2012). Septicemia and death may result from infections
that are not treated appropriately (Egger, 1991).
Conclusions
While many components of open fracture management remain
contentious, complications can be limited by adhering to some
basic principles. In addition to appropriate initial patient man-
agement, as detailed in the first article in this series, adequate
debridement should be performed on an urgent basis; however
there is limited evidence to suggest that the previously advised
‘6-hour window’ should influence management. Soft tissue re-
construction should be performed as soon as possible where ap-
propriate. If this is not possible, wound coverage via alternative
techniques should be pursued in order to reduce the incidence of
nosocomial infection. Rigid fixation of the open fracture should
be achieved as soon as the relevant expertise is available, using
either internal or external fixation depending on the degree of
soft tissue injury and contamination. CA
Conflict of interest: The author declares no conflict of interest
related to this report.
References
Allgöwer M, Border JR (1983) Management of fractures in the multiple trauma patient.
World J Surg 7: 88–95
Argenta LC, Morykwas MJ (1997) Vacuum-assisted closure: a new method for wound
control and treatment: clinical experience. Ann Plast Surg 38: 563–76
Aron DN (1988) Management of open musculoskeletal injuries. Semin Vet Med Surg
(Small Anim) 3: 290–301
Ashford RU, Mehta JA, Cripps R (2004) Delayed presentation is no barrier to satisfac-
tory outcome in the management of open tibial fractures. Injury 35: 411–16
Baltzer AW, Lattermann C, Whalen JD et al (2000) Genetic enhancement of fracture
repair: healing of an experimental segmental defect by adenoviral transfer of the
BMP-2 gene. Gene Ther 7: 734–9
Bednar DA, Parikh J (1993) Effect of time delay from injury to primary management on
© 2016 MA Healthcare Ltd
the incidence of deep infection after open fractures of the lower extremities caused
by blunt trauma in adults. J Orthop Trauma 7: 532–5
Benum P, Svenningsen S (1982) Tibial fractures treated with Hoffman’s external
fixation: a comparative analysis of Hoffmann bilateral frames and the Vidal-Adrey
double frame modification. Acta Orthop Scand 53: 471–6
Betz OB, Betz VM, Nazarian A et al (2006) Direct percutaneous gene delivery to
enhance healing of segmental bone defects. J Bone Joint Surg Am 88: 355–65
Companion animal | April 2016, Volume 21 No 4
Companion Animal. Downloaded from magonlinelibrary.com by 144.082.108.120 on June 10, 2016. For personal use only. No other uses without permission. . All rights reserved.
orthopaedics
KEY POINTS
zzDebridement should be performed on an urgent, but not emergent basis;
adequacy of debridement and timeliness of soft tissue closure coverage
are likely more important than time from injury to debridement.
zzIf thorough debridement of the open fracture wound can be achieved,
early closure of the wound may reduce complication rates and improve
outcomes.
zzWhere doubt persists regarding adequacy of debridement, the wound
should not be closed but appropriate measures should be taken to cover
the wound and limit risks of nosocomial infection.
zzExternal coaptation is not recommended as the definitive method of
fixation for any open fracture.
zzGenerally, type 1 and 2 open fractures can be stabilised using the same
method of fixation as would be used for a closed fracture of similar
configuration, while the extensive soft tissue damage associated with
type 3 fractures may preclude internal fixation.
Bhandari M, Adili A, Schemitsch EH (2001) The efficacy of low-pressure lavage with
different irrigating solutions to remove adherent bacteria from bone.
J Bone Joint Surg Am 83: 412–19
Blick SS, Brumback RJ, Lakatos R (1989) Early prophylactic bone grafting of high-
energy tibial fractures. Clin Orthop Relat Res 240: 21–41
Brighton CT, Shaman P, Heppenstall RB, Esterhai JL Jr, Pollack SR, Friedenberg ZB
(1995) Tibial nonunion treated with direct current, capacitive coupling or bone graft.
Clin Orthop Relat Res 321: 223–34
Brumback RJ, Ellison PS Jr, Poka A, Lakatos R, Bathon GH, Burgess AR (1989)
Intramedullary nailing of open fractures of the femoral shaft. J Bone Joint Surg Am
71: 1324–31
Byrd HS, Cierny G 3rd, Tebbetts JB (1981) The management of open tibial fractures
with associated soft-tissue loss: external pin fixation with early flap coverage. Plast
Reconstr Surg 68: 73–82
Byrd HS, Spicer TE, Cierny G 3rd (1985) Management of open tibial fractures. Plast
Reconstr Surg 76: 719–30
Caudle RJ, Stern PJ (1987) Severe open fractures of the tibia. J Bone Joint Surg Am 69:
801–7
Chapman MW (1982) Role of bone stability in open fractures. Instr Course Lect 31:
75–87
Charalambous CP, Siddique I, Zenois M et al (2005) Early versus delayed surgical
treatment of open tibial fractures: effect on the rates of infection and need of sec-
ondary surgical procedures to promote bone union. Injury 36: 656–61
Christensen J, Greiff J, Rosendahl S (1982) Fractures of the shaft of the tibia treated
with AO-compression osteosynthesis. Injury 13: 307–14
Christensen GD, Simpson WA, Bisno AL, Beachley EH (1983) Experimental foreign
body infections in mice challenged with slime-producing Staphylococcus epidermidis.
Infect Immun 40: 407–10
Cierny G 3rd, Byrd HS, Jones RE (1983) Primary versus delayed soft tissue coverage
for severe open tibial fractures. A comparison of results. Clin Orthop Relat Res 178:
54–63
Clark D (1987) Treatment of open comminuted intraarticular fractures of the proximal
ulna in dogs. J Am Anim Hosp Assoc 23: 331–6
Clifford RP, Lyons TJ, Webb JK (1987) Complications of external fixation of open
fractures of the tibia. Injury 18: 174–6
Clifford RP, Beuchamp CG, Kellam JF, Webb JK, Tile M (1988) Plate fixation of open
fractures of the tibia. J Bone Joint Surg 70B: 644–8
Cook SD, Ryaby JP, McCabe J, Frey JJ, Heckman JD, Kristiansen TK (1997) Accelera-
tion of tibia and distal radius fracture healing in patients who smoke. Clin Orthop
Relat Res 337: 198–207
DeFranzo AJ, Argenta LC, Marks MW et al (2001) The use of vacuum-assisted closure
therapy for the treatment of lower extremity wounds with exposed bone. Plast
Reconstr Surg 108: 1184–91
DeLong WG, Born CT, Wei SY, Petrik ME, Ponzio R, Schwab CW (1999) Aggressive
treatment of 119 open fracture wounds. J Trauma 46: 1049–54
Dudley M, Johnson AL, Olmstead M, Smith CW, Schaeffer DJ, Abbuehl U (1997)
Open reduction and bone plate stabilization, compared with closed reduction and
external fixation, for treatment of comminuted tibial fractures: 47 cases (1980–
1995) in dogs. J Am Vet Med Assoc 211: 1008–12
Edge AJ, Denham RA (1981) External fixation for complicated tibial fractures.
J Bone Joint Surg (Br) 63B: 92–7
Egger EL (1991) Complications of external fixation: a problem-oriented approach. Vet
Clin North Am Small Anim Pract 21: 705–33
Egger EL, Rigg DL, Blass CE, Berg RJ, Runyon CL, Wykes PM (1985) Type I biplanar
configuration of external skeletal fixation: application technique in nine dogs and
one cat. J Am Vet Med Assoc 187: 262–7
203
 orthopaedics
Epps CH, Adams JP (1961) Wound management in open fractures. Am Surg 27:
766–9
Esterhai JL (1990) Management of soft-tissue wounds associated with open fractures.
Instr Course Lect 39: 483–6
Etter C, Burri C, Claes L, Kinzl L, Raible M (1983) Treatment by external fixation of
open fractures associated with severe soft tissue damage of the leg: biomechanical
principles and clinical experience. Clin Orthop Relat Res 178: 80–8
Fischer MD, Gustilo RB, Varecka TF (1991) The timing of flap coverage, bone grafting,
and intramedullary nailing in patients who have a fracture of the tibial shaft with
extensive soft tissue injury. J Bone Joint Surg Am 73: 1316–22
Foland MA, Egger EL (1991) Application of type III external fixators: a review of 23
clinical fractures in 20 dogs and two cats. J Am Anim Hosp Assoc 27: 193–202
Friedrich PL (1898) Die aseptische Versorgung frischer Wundern. Arch Klin Chir 57:
288–310
Ganz R, Brennwald J, Hunter W, Perren SM (1970) The recovery of medullary circula-
tion after osteotomy and internal fixation. Eur Surg Res 2: 106
Gatineau M, Planté J (2010) Ulnar interlocking intramedullary nail stabilization of a
proximal radio-ulnar fracture in a dog. Vet Surg 39: 1025–9. doi: 10.1111/j.1532-
950X.2010.00731.x
Godina M (1986) Early microsurgical reconstruction of complex trauma of the extremi-
ties. Plast Reconstr Surg 78: 285–92
Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM (2000) Fix and
flap: the radical orthopaedic and plastic treatment of severe open fractures of the
tibia. J Bone Joint Surg Br 82: 959–66
Govender S, Csimma C, Genant HK et al (2002) Recombinant human bone morpho-
genetic protein-2 for treatment of open tibial fractures: a prospective, controlled,
randomized study of four hundred and fifty patients. J Bone Joint Surg Am 84:
2123–34
Gristina AG, Costerton JW (1985) Bacterial adherence to biomaterials and tissue. J
Bone Joint Surg Am 67: 264–73
Gristina AG, Rovere GD, Shoji H, Nicastro JF (1976) An in vitro study of bacterial
response to inert and reactive metals and to methyl methacrylate. J Biomed Mater
Res 10: 273–81
Gristina AG, Oga M, Webb LX, Hobgood CD (1985) Adherent bacterial colonization
in the pathogenesis of osteomyelitis. Science 228: 990–3
Gustilo RB, Anderson JT (1976) Prevention of infection in the treatment of one
thousand and twenty-five open fractures of long bones: retrospective and prospective
analyses. J Bone Joint Surg Am 58: 453–8
Gustilo RB, Merkow RL, Templeman D (1990) The management of open fractures. J
Bone Joint Surg Am 72: 299–304
Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW (2002) The effect of time
to definitive treatment on the rate of nonunion and infection in open fractures. J
Orthop Trauma 16: 484–90
Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF (1994) Acceleration of tibial
fracture healing by non-invasive low-intensity pulsed ultrasound. J Bone Joint Surg
Am 76: 26–34
Henley MB, Chapman JR, Agel J, Harvey EJ, Whorton AM, Swiontkowski MF (1998)
Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective
comparison of unreamed interlocking intramedullary nails and half-pin external
fixators. J Orthop Trauma 12: 1–7
Herscovici D Jr, Sanders RW, Scaduto JM, Infante A, DiPasquale T (2003) Vacuum-
assisted wound closure (VAC therapy) for the management of patients with high-
energy soft tissue injuries. J Orthop Trauma 17: 683–8
Hertel R, Lambert SM, Müller S, Ballmer FT, Ganz R (1999) On the timing of soft-
tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg
119: 7–12
Houlton J (1996) The management of open fractures. Veterinary Annual 36: 173–86
Johnson AL, Kneller SK, Weigel RM (1989) Radial and tibial fracture repair with
external skeletal fixation: effects of fracture type, reduction, and complications on
healing. Vet Surg 18: 367–72
Johnson AL, Seitz SE, Smith CW, Johnson JM, Schaeffer DJ (1996) Closed reduction
and type-II external fixation of comminuted fractures of the radius and tibia in dogs:
23 cases (1990–1994). J Am Vet Med Assoc 209: 1445–8
Kahn DE, Pritzker KPH (1973) The pathophysiology of bone infection. Clin Orthop
Relat Res 96: 12–19
Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH (2003) Outcomes
in open tibial fractures: relationship between delay in treatment and infection. J
Trauma 55: 949–54
Kieves NR, MacKay CS, Adducci K et al (2015) High energy focused shock wave
therapy accelerates bone healing: A blinded, prospective, randomized canine clinical
trial. Vet Comp Orthop Traumatol 28: 425–32
Kindsfater K, Jonassen EA (1995) Osteomyelitis in grade II and III open tibia fractures
with late debridement. J Orthop Trauma 9: 121–7
Kreder HJ, Armstrong P (1995) A review of open tibia fractures in children.
J Pediatr Orthop 15: 482–8
Labler L, Keel M, Trentz O (2004) Vacuum-assisted closure (V.A.C.) for temporary
coverage of soft-tissue injury in type III open fracture of the lower extremities. Eur J
Trauma 30: 305–12
Levin LS (2006) New developments in flap techniques. J Am Acad Orthop Surg 14(10
Suppl): S90–3
Martin R (1990) Open fractures. In: Bojrab MJ, ed. Current Techniques in Small
Animal Surgery. 3rd edn. Lea & Febiger, Philadelphia, PA: 901
McLaughlin HL (1956) Internal fixation of fractures. Surgery 39: 892–9
204
Companion Animal. Downloaded from magonlinelibrary.com by 144.082.108.120 on June 10, 2016. For personal use only. No other uses without permission. . All rights reserved.
Merritt K, Dowd JD (1987) Role of internal fixation in infection of open fractures:
Studies with Staphylococcus aureus and Proteus mirabilis. J Orthop Res 5: 23–8
Millard RP, Towle HA (2012) Open fractures. In Tobias KM, Johnston SA, eds. Veteri-
nary Surgery Small Animal. Elsevier Saunders, St Louis, MO: 572–5
Morykwas MJ, Argenta LC, Shelton-Brown EI McGuirt W (1997) Vacuum-assisted
closure: a new method for wound control and treatment: animal studies and basic
foundation. Ann Plast Surg 38: 553–62
Mooney JF 3rd, Argenta LC, Marks MW, Morykwas MJ, DeFranzo AJ (2000) Treat-
ment of soft tissue defects in pediatric patients using the V.A.C. system. Clin Orthop
Relat Res 376: 26–31
Moucharafieh RS, Saghieh SS, Nassar H, Hamdan AM, Hashim HA, Atiyeh BS
(1996) Microvascular soft-tissue coverage and distraction osteosynthesis for lower-
extremity salvage. Microsurgery 17: 666–73
Müller ME, Allgower M, Schneider R, Willenegger H, eds. (1979) Manual of Internal
Fixation. 2nd edn. Springer-Verlag, Berlin
Nunamaker DM, Berg P (1985) Open fractures and gunshot injuries. In: Newton
CD, Nunamaker DM, eds. Textbook of Small Animal Orthopaedics. Lippincott,
Philadelphia, PA: 481–97
Oertli D, Matter P, Scharplatz D, Zehnder R (1984) Evaluation of surgically treated
shaft fractures: analysis of the Swiss AO/ASIF documentation 1967-1980. Bulletin:
Official publication of the Swiss Association for the study of internal fixation: 60–3
Okike K, Bhattacharyya T (2006) Trends in the management of open fractures.
J Bone Joint Surg 88A: 2739–48
Pallister I, Empson K (2005) The effects of surgical fracture fixation on the systemic
inflammatory response to major trauma. J Am Acad Orthop Surg 13: 93–100
Patzakis MJ, Wilkins J (1989) Factors influencing infection rate in open fracture
wounds. Clin Orthop Relat Res 243: 36–40
Perry KL (2016) Management of open fractures: part 1. Companion Animal 21:
165–70
Piras A (2007) Management of open fractures. Proceedings of the North American
Veterinary Conference, 13–17 January 2007, Orlando, FL: 919
Pollack AN, Castillo RC, Jones AL et al (2003) Time to definitive treatment signifi-
cantly influences incidence of infection after open, high-energy lower-extremity
trauma. Read at the Annual Meeting of the Orthopaedic Trauma Association; Oct
9-11, Salt Lake City, UT
Rhinelander FW, Gracilla RV, Phillips RS, Steele WM (1967) Microangiography in
bone healing III. Osteotomies with internal fixation. J Bone Joint Surg Am 49A:
1006–7
Roberts CS, Pape HC, Jones AL et al (2005) Damage control orthopaedics: evolving
concepts in the treatment of patients who have sustained orthopaedic trauma. Instr
Course Lect 54: 447–62
Robson MC, Duke WF, Krizek TJ (1973) Rapid bacterial screening in the treatment of
civilian wounds. J Surg Res 14: 426–30
Rüedi T, Webb JK, Allgower M (1976) Experience with the dynamic compression plate
(DCP) in 418 recent fractures of the tibial shaft. Injury 7: 252–7
Scott G, King JB (1994) A prospective, double-blind trial of electrical capacitive cou-
pling in the treatment of non-union of long bones. J Bone Joint Surg Am 76: 820–6
Sharrard WJ (1990) A double-blind trial of pulsed electromagnetic fields for delayed
union of tibial fractures. J Bone Joint Surg Br 72: 347–55
Sheth NK, Franson TR, Rose HD, Buckmire FL, Cooper JA, Sohnle PG (1983)
Colonization of bacteria on polyvinyl chloride and Teflon intravascular catheters in
hospitalized patients. J Clin Microbiol 18: 1061–3
Sinclair JS, McNally MA, Small JO, Yeates HA (1997) Primary free-flap cover of open
tibial fractures. Injury 28: 581–7
Sisk TD (1983) External fixation. Historic review, advantages, disadvantages, complica-
tions and indications. Clin Orthop 180: 15–22
Skaggs DL, Friend L, Alman B et al (2005) The effect of surgical delay on acute infec-
tion following 554 open fractures in children. J Bone Joint Surg Am 87: 8–12
Spencer J, Smith A, Woods D (2004) The effect of time delay on infection in open
long-bone fractures: a 5-year prospective audit from a district general hospital. Ann
R Coll Surg Engl 86: 108–12
Swiontkowski MF, Aro HT, Donell S et al (2006) Recombinant human bone morpho-
genetic protein-2 in open tibial fractures. A subgroup analysis of data combined from
two prospective randomized studies. J Bone Joint Surg Am 88: 1258–65
Tornetta P 3rd, Bergman M, Watnik N, Berkowitz G, Steuer J (1994) Treatment of
grade IIIb open tibial fractures. A prospective randomized comparison of external
fixation and non-reamed locked nailing. J Bone Joint Surg Br 76: 13–19
Trabulsy PP, Kerley SM, Hoffman WY (1994) A prospective study of early soft tissue
coverage of grade IIIB tibial fractures. J Trauma 36: 661–8
Tsur I, Christie BA (1999) Third degree open fracture of the humerus of a dog: suc-
cessful treatment with a less than optimum repair modality. Aust Vet Pract 29: 31–35
Tukiainen E, Asko-Seljavaara S (1993) Use of the Ilizarov technique after a free micro-
vascular muscle flap transplantation in massive trauma of the lower leg. Clin Orthop
Relat Res 297: 129–34
Walter MC, Lenehan TM, Smith GK, Matthiesen DT, Newton CD (1986) Treatment
© 2016 MA Healthcare Ltd
of severely comminuted diaphyseal fractures in the dog, using standard bone plates
and autogenous cancellous bone graft to span fracture gaps: 11 cases (1979–1983) J
Am Vet Med Assoc 189: 457–62
Worlock P, Slack R, Harvey L, Mawhinney R (1994) The prevention of infection in
open fractures: an experimental study of the effect of fracture stability. Injury 25:
31–8
Zalavras CG, Marcus RE, Levin S, Patzakis MJ (2007) Management of open fractures
and subsequent complications. J Bone Joint Surg 89: 884–95
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