The Current Concepts in the Management of Open Fractures

Ki-Chul Park; Young-Sik Song

doi:10.4055/jkoa.2018.53.1.9

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Park and Song: The Current Concepts in the Management of Open Fractures

Symposium

Difficult Fractures & Problems

Journal of the Korean Orthopaedic Association 2018; 53(1): 9-18.

Published online: 28 February 2018

DOI: https://doi.org/10.4055/jkoa.2018.53.1.9

The Current Concepts in the Management of Open Fractures

Ki-Chul Park, M.D., Ph.D., Young-Sik Song, M.D.

Department of Orthopedic Surgery, Hanyang University Guri Hospital, Guri, Korea.

Correspondence to: Ki-Chul Park, M.D., Ph.D. Department of Orthopedic Surgery, Hanyang University Guri Hospital, 153 Gyeongchun-ro, Guri 11923, Korea. TEL: +82-31-560-2187, FAX: +82-31-557-8781, kcpark722@gmail.com

Received 27 June 2017 Revised 7 August 2017 Accepted 19 August 2017

The Korean Orthopaedic Association

(open-access):

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Open fractures require infection prevention, injured soft tissue management, and fracture fixation. Moreover, it should be treated according to the emergency surgery. The main goals of treatment are life preservation, limb preservation, infection prevention, and functional restoration. Treatment procedure is carried out in the following order. Early diagnosis and management in the emergency room, appropriate antibiotic treatment, adequate irrigation and thorough debridement, fracture fixation and wound restoration (temporary stabilization of the fracture and covering of the wound, definite fixation of the fracture and soft tissue coverage). Herein, we discuss the current trends in each treatment phase to be helpful to other clinicians regarding the applicability of these steps in clinical practice.

Keywords: open fractures, debridement, external fixators, internal fixators

Figures and Tables

Figure 1

Low-pressure wound irrigation using intravenous line with normal saline.

Figure 2

(A, B) A 61-year-old male with a right shaft fracture of the tibia and (C) open wound (Gustillo-Anderson classification type II). (D–F) Planning of pin placement is essential to avoid a compromise of definitive internal fixation. (G) External fixator was used as a reduction tool.

Figure 3

(A) A 42-year-old male with a right shaft fracture of the tibia and open wound (Gustillo-Anderson classification type 3B). (B) External fixator and vacuum-assisted closure was applied. (C) After 5 days of injury, large bone defect was observed when definitive plate fixation was performed. (D) Polymethylmethacrylate was filled in bone defect. (E) Soft tissue defect was reconstructed by gastrocnemius flap. (F) The fibula fracture was fixated at the same time to increase stability. (G) After 6 weeks, the wound was healed without complications. (H, I) Autogenous bone graft was performed using the Masquelet technique. (J) After 7 months, the fracture was united without complications.

Figure 4

(A) A 53-year-old male with a right shaft fracture of the tibia and (B) open wound (Gustillo-Anderson classification type 3B). (C) The fracture was fixated using the minimally invasive plate osteosynthesis technique. (D) At the same time, soft tissue defect was reconstructed by gastrocnemius flap. (E, F) After 1 year, the fracture united and (G) the wound healed without complications. (H) Function of the right limb was normal (images courtesy of CW Oh, M.D.).

Figure 5

(A) A 10-year-old male with a shaft fracture of the right tibia and fibula. (B) The open wound (Gustillo-Anderson classification type 3B) was approximated using a surgi loop. (C) Using surgical gel to prevent skin maceration. (D) The sponge was applied using the OPSITE® (Smith & Nephew). (E) After 6 days, the open wound became smaller. (F) The wound was sutured. (G) The fractures were fixated using a plate at the same time. (H) After 2 weeks, the wound healed without complications.

Figure 6

(A) A 48-year-old male with a right shaft fracture of the tibia and fibula and (B) open wound (Gustillo-Anderson classification type 3B). (C) External fixator was applied and fibula fracture was fixated with a plate. (D) The sponge was applied. (E) After 5 days, the fracture was fixated with intramedullary nail. (F) After 2 months, bone defect was observed. (G) Autogenous iliac bone graft was performed. (H) After 18 months, the fracture was united.

Figure 7

(A) The same patient in Figure 6 with a combined right shaft segmental fracture of the femur and (B) open wound (Gustillo-Anderson classification type 3A). (C) The fracture was fixated with intramedullary nail. (D) After 2 months, the fracture was in union. (E) After 6 months, the fracture was in union. (F) After 18 months, the fracture was united.

Table 1

Gustillo-Anderson Classification of Open Fracture1)

Notes

^{CONFLICTS OF INTEREST} The authors have nothing to disclose.

^{감사의 글} We would like to express our thanks to CW Oh, M.D. from Kyung-pook National University for preparing the figure

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