Principles of Open Fracture Management

Open fractures are contaminated wounds that contain gram-positive and gram-negative organisms; therefore, wide-spectrum antibiotic therapy should be incorporated into the treatment plan. Antibiotics should be initiated as soon after injury as possible, preferably within 3 hours of injury, after which time the rate of infection has been reported to increase. Time to surgical débridement within 12 hours of injury has not been reported to affect the rate of infection, given that a patient is being treated with antibiotics. An antibiotic bead pouch and vacuum-assisted wound closure may help reduce the risk for secondary and nosocomial contamination and subsequent infection. Open fractures are always associated with a soft-tissue injury; therefore, they can be considered a soft-tissue injury that involves a fracture. The management of the bone and the soft tissues in a patient with an open fracture is the major determinant of fracture healing and functional restoration of the injured extremity. The formulation of a soft-tissue treatment plan must occur during the initial wound assessment and the initial fixation of an open fracture and should not be considered a secondary or consecutive process. A soft-tissue surgeon should be consulted the night of the injury. Selection of fracture fixation depends on the fractured bone, the location of the fracture (intra-articular, metaphyseal, or diaphyseal), the extent of soft-tissue injury and contamination, and the physiologic status of the patient. More than one fixation method may be applicable for the management of a specific injury; therefore, a surgeon's expertise and the availability of implants also should be considered. Surgeons must understand bone healing biology to achieve successful outcomes in the management of open fractures. The cornerstones of these bone healing treatments include optimization of host biology, recognition of a patient's nutritional status, appropriate use of medications, and eradication of infection. Surgeons should consider bone grafting and/or the use of biologics to achieve bony union in patients with an acute open fracture and in the management of delayed union or nonunion.