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PubMed1983

Guidelines for treatment of open fractures and infected pseudarthroses by external fixation.

There are three phases in the treatment of open fractures and infected pseudarthroses by the Hoffmann external fixator. During the initial phase a careful surgical debridement is performed in the bony tissues, and the external fixator is applied in a manner appropriate to the type and level of the lesion site (double- or triple-frame mounting; additional anchorages; neutralization, compression, or distraction; ligamentotaxis). During the intermediate phase both the nursing of the patient and care of the apparatus are critical for the avoidance of complications; it is during this period that granulation tissue must develop and bone infections must be controlled. In the final phase the loss of osseous substance must be treated by various means (regular tightening of the external fixator; Papineau's technique; intertibiofibular graft; free microvascular bone transplantation technique.

Arm Injuries↗
PubMed1990

Open fractures of the tibia in children.

Forty-one children who had forty-two open fractures of the tibial metaphysis or diaphysis were studied retrospectively. Twelve fractures were Type I; eighteen, Type II; six, Type IIIA; four, Type IIIB; and two, Type IIIC, according to the classification of Gustilo et al. All fractures were irrigated and debrided, and antibiotics were given for a minimum of forty-eight hours after the injury. Twenty fractures were initially treated with external fixation and twenty-two, with immobilization in a plaster cast. Three patients had an early infection of the wound, one of which was associated with osteomyelitis; all were successfully treated. The average time to healing of the fracture was five months (range, two to twenty-one months). The time to union was related to the severity of the soft-tissue injury, the pattern of the fracture, the amount of segmental bone loss, the occurrence of infection, and the use of external fixation. There were six delayed unions. Four patients had an angular malunion of more than 10 degrees, which spontaneously corrected in three. One patient who had a proximal metaphyseal-diaphyseal segmental fracture had a progressive valgus deformity. Four patients who had a severe fracture that was treated with external fixation had more than one centimeter of tibial over-growth. There were no amputations. The incidences of compartment syndrome, vascular injury, infection, and delayed union were similar to those reported for open tibial fractures in adults.

Anterior Compartment Syndrome↗
PubMed1992

[Open fractures. The problem of their classification and solution using the IMT-NV de l'AO (Osteosynthesis Study Group) system].

The IMT-NV system proposed by the AO-ASIF for classifying soft tissue injuries associated with long bone fractures allows to avoid the troubles of the historical discussion between two different opinions: which is the most important feature of an open fracture? The extent of the skin lesion or the deeper muscular and neurovascular damage? This classification as it is proposed in the new AO-manual will bring more precision and more possibilities in comparing different surgical approaches to this hard challenge called open fracture.

Fractures, Open↗
PubMed1975

150 open fractures of the tibial shaft--the relation between necrosis of the skin and delayed union.

In 150 open fractures of the tibial shaft a close relationship between the presence of skin necrosis and delayed union was found. The incidence of skin necrosis rose with the severity of trauma. It was high (22 per cent) among the fractures that were treated conservatively, but even higher (41 per cent) among those treated with primary osteosynthesis. Neither conventional conservative treatment nor osteosynthesis seems to be satisfactory as a primary treatment of the most severe cases. It is instead suggested that external fixation by the Hoffmann-Vidal technique should be combined with transposition of viable muscle tissue across denuded fractured bone areas according to the method of Ger.

Adolescent↗
PubMed1996

Surgical treatment of patients with open tibial fractures.

Open tibial fractures are true surgical emergencies because of the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is osteomyelitis, which usually can be prevented by prompt surgical intervention within six to eight hours after injuries occur. Open tibial fractures often are the result of trauma from motor vehicle collisions, farm accidents, falls from heights, or gunshot wounds. Initial management of patients with multiple trauma injuries focuses on their life-threatening injuries before or during orthopedic surgical intervention for open tibial fractures. Orthopedic surgeons often work in collaboration with general, vascular, and plastic surgeons and perform multiple surgical procedures (eg, fasciotomy procedures for compartment syndromes, irrigation and debridement of wounds, application of external fixation devices, placement of intramedullary nails, possible limb amputations). The type and extent of open tibial fractures and soft tissue injuries determine the best treatment options for patients. Perioperative nurses should help patients focus on treatment choices for their open tibial fractures that ensure optimal surgical outcomes and maintain their quality of life.

Accidents↗
PubMed1998

[Management of patients with pyogenic complications of long bones open fractures].

122 patients with purulent complications of open diaphyseal fractures of long bones were treated. Comparative analysis of different surgical methods for treatment of pyogenic complications has shown that the most effective method is one of active sanation of the area of inflammation with the use of combined drainage ensured successful and steady decrease of pyogenic process (follow-up up to 4 years, 89.7% of patients). The drainage provides stable fixation of bones fragments by dipped fixators until consolidation of the fracture. It also promotes repain of residual diaphyseal defects without application of complicated plastic methods.

Drainage↗
PubMed2005

Nutritional status and wound healing in open fractures of the lower limb.

Forty-three patients averaging 28.2 (range 16--74) years with open fractures of the lower limbs were studied prospectively for 40 weeks using anthropometrical, biochemical and haematological parameters to ascertain their relationship to wound healing following injury. Nearly half (21/43) of the patients were malnourished at admission and the number increased to 22 a week after injury. Dietary advice and better food intake improved nutritional status with only 13 patients remaining malnourished at the 40th week. Wound healing was earlier when creatinine-height index was normal throughout the course of treatment and was delayed when serum albumin level was low.

Adolescent↗
PubMed1978

Open fractures of the tibia: a review of one hundred and two cases.

One hundred and two consecutive open fractures of the tibial shaft were treated from 1970 to 1976. Four required primary amputation. The remainder received standardized wound care, consisting of surgical débridement and delayed primary wound closure. Soft-tissue injuries were classified according to severity, because the initial injury was the most important prognostic factor. All patients received a seventy-two-hour course of parenteral antibiotics. Fifty-six fractures were managed with cast immobilization, thirty-five with rigid internal fixation, and seven with rigid external pin fixation. The over-all rates of infection (15 per cent) and delayed union (13 per cent) are not directly comparable to other series because one must consider the severity of each injury when analyzing results. Management of the fracture itself should be individualized. The risk of primary wound closure does not appear to be warranted.

Adolescent↗
PubMedDate not supplied

Open fractures of the tibia in children.

We treated 38 patients from 4 to 15 years old and with open growth plates for open fractures of the tibia. The average follow-up was 33 months (range, 9-122). All patients had repeated operative debridement, parenteral antibiotics, and immobilization by cast or fixation. Outcomes were analyzed with respect to age at the time of injury, grade of injury, and type of immobilization. The time to union was prolonged and averaged 21 weeks (range, 6-82). No patients younger than 11 years required bone grafting for union. The deep infection and nonunion rate was 8%, with all of these occurring in patients older than 11 years. Clinically significant leg-length discrepancy or functional limitation was encountered only in patients with an ipsilateral femur fracture or with deep infection requiring osseous debridement. Our data suggest that open tibia fractures in children older than 11 years have nonunion and infection rates that parallel those of adult patients, but that younger children have a more benign course. With aggressive wound care and adequate stabilization, few complications or sequelae should occur in open tibial shaft fractures in younger patients.

Adolescent↗
PubMed1998

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.

OBJECTIVE: To compare unreamed intramedullary nailing (IMN) with external fixation (EF) in patients with Type II, IIIA, and IIIB open fractures of the tibial shaft. DESIGN: An inception cohort of consecutive patients with Type II, IIIA, and IIIB tibial fractures incurred between January 1988 and March 1993 were systematically allocated into one of two treatment groups. Patients were treated and followed with a prospectively designed protocol. PATIENTS AND SETTING: All patients were skeletally mature and had incurred a fracture of the tibial diaphysis within twenty-four hours of presentation to the tertiary care hospital, a Level I Trauma Center. One hundred seventy-four fractures in 168 patients were stabilized with either IMN (104) or half-pin EF (70). There were 132 men and thirty-six women, with an average age of thirty-three years (range, 14 to 77 years). INTERVENTION: Except for the selection of the fixation device, open fracture care was similar in the two treatment groups. All patients underwent emergent irrigation and debridement with concomitant skeletal stabilization. Cephalosporin antibiotics were administered perioperatively for twenty-four to forty-eight hours. No wounds were closed primarily. Delayed primary closure, skin grafting, and/or myoplasty were performed between three and ten days after injury. MAIN OUTCOME MEASURES: The main outcome measures were final fracture alignment, presence of infection or inflammation, hardware failure, time to union, and the number of operative procedures. RESULTS: The IMN group had significantly fewer incidences of malalignment than did the EF group [8 vs. 31 percent; p = 0.00005; confidence interval (CI) = 0.18, 0.76] and had significantly fewer subsequent procedures (mean of 1.7 vs. mean of 2.7 per fracture; p = 0.001; CI = 0.45, 1.59). IMN resulted in fewer infections/ inflammatory problems than did EF at the injury site (13 vs. 21 percent; p = 0.73; CI = -0.63, 0.45) and significantly fewer at surgical interfaces (i.e., pin sites, nail and interlocking screw insertion sites; 2 vs. 50 percent; p = 0.000; CI = 0.39, 0.60). No significant difference was found in the healing rates for the two implant groups. The more severe Gustilo injury types had longer healing times regardless of the type of fixation. CONCLUSIONS: Results suggest that unreamed interlocking intramedullary nails are more efficacious than half-pin external fixators, in particular with regard to maintenance of limb alignment. However, the severity of soft tissue injury rather than the choice of implant appears to be the predominant factor influencing rapidity of bone healing and rate of injury site infection.

Adolescent↗
PubMed1997

Reamed interlocking intramedullary nailing of open fractures of the tibia.

One hundred twelve open tibial fractures were treated by reamed interlocking nailing in 108 patients. There were 31 (28%) Grade I fractures, 38 (34%) Grade II, 23 Grade IIIA (21%), and 20 (18%) Grade IIIB fractures. Early amputation was performed in 2 (10%) Grade IIIB fractures for severe crushing injuries. Compartment syndrome complicated 8 (7%) fractures. Mean time to union was 29 weeks for Grade I fractures, 32 weeks for Grade II, 34 weeks for Grade IIIA, and 39 weeks for Grade IIIB. Nonunion complicated 9 (8%) fractures: 1 (3%) Grade I fracture, 2 (5%) Grade II fractures, 3 (13%) Grade IIIA fractures, and 3 (17%) Grade IIIB fractures. Deep infection complicated 4 Grade II fractures (10%) and 2 (11%) Grade IIIB fractures. Reamed locking intramedullary nailing is a safe and effective technique for management of open tibial fractures.

Adolescent↗
PubMed1988

The prevention of infection in open fractures. An experimental study of the effect of antibiotic therapy.

Using an experimental rabbit model of a contaminated open fracture of the tibia that was fixed with an intramedullary pin, we assessed the effect of a single dose of cephradine in preventing post-traumatic osteomyelitis in which the infecting organism was Staphylococcus aureus. We paid particular attention to the effect of a delay in giving the antibiotic. The frequency of osteomyelitis in the animals in a control group (no antibiotic) was 91 per cent. When a single injection of cephradine was given one hour before inoculation with the bacteria, the rate was 30 per cent, a statistically significant reduction (p less than 0.01). When cephradine was not administered until one to four hours after inoculation with the bacteria, the average rate of osteomyelitis was 51 per cent, a 40 per cent reduction compared with the rate for the control group. The effect of the antibiotic therefore persisted even when the initial dose was delayed for four hours after bacterial inoculation.

Animals↗
PubMed1990

[Prognostication of expert testimony-labor outcomes in the treatment of open fractures of the shin bones].

In the process of clinical and expert examinations of 202 patients with crus bone open fractures, treated by conservative methods, it has been determined that good and satisfactory results have been obtained with 82 (40.6%) victims. At primary examination 92 (45.5%) patients were given the 11 group of invalidism and 28 (13.9%) patients were given the III group of invalidism. In order to decrease the number of expert mistakes, exclude the cases of unsubstantiated groups of invalidism determination and reduce the duration of the doctor's certificate term for victims of the given category, the authors propose to use 3 variants of prognostication of the expert--labour terminations of these damages. The number of the expert mistakes at primary examination of the patients, owing to the proposed method, has come to only 1.4%.

Adolescent↗
PubMed1988

Risk of infection after open fracture of the arm or leg.

Two hundred forty consecutive patients admitted for operative treatment of an open fracture of the arm or leg were followed up prospectively for the development of fracture infection. The independent risk of fracture infection was increased in patients with grade IIIB or IIIC fractures, internal or external fixation, lower-leg fracture, any blood transfusion, or injuries resulting from motorcycle accidents or motor vehicle-pedestrian accidents. By stepwise multivariate logistic regression, the most significant risk factors were the grade of the fracture, internal or external fixation, and fractures of the lower leg. These risk factors all represent local wound characteristics, and we conclude that the most important actions by the surgeon to prevent infection involve local wound care. There was no relation between the timing of antibiotic administration or duration of antibiotic therapy and infection risk.

Arm Injuries↗
PubMed1989

Comparison of isotonic saline, distilled water and boiled water in irrigation of open fractures.

A prospective randomised study was carried out on 86 patients with first, second and third degree open fractures in order to compare the effect of isotonic saline, distilled water and boiled water as irrigating fluids. The standard management consisted of emergency surgical toilet, use of broad spectrum antibiotics and fracture immobilization. The results show that the outcome was not affected by the type of irrigating fluid used.

Amputation, Surgical↗
PubMed1983

Morphologic aspects of bone healing after third-degree open fractures. An experimental study.

The morphologic aspects of undisturbed and disturbed bone healing following third-degree open fractures is demonstrated by means of experimental investigations using animals. As an experimental model we used a canine thigh fractured by a shot. The data was obtained as part of bioballistic investigations of the effect of highvelocity bullets in living tubular bones. The shot fracture was immobilized by external fixation. Progressive radiological controls, as well as microangiographic, microradiographic and histological findings are used to show bone healing. Bone healing following shot fractures follows the basic pattern of secondary bone healing, which is manifested in an X-ray by the formation of periosteal callus. The periosteal callus tissue has its own vascular system and receives blood from the extraosseous vessels of the adjacent soft tissue surrounding it. It not only fulfills the function of the biological stabilizer of the fragments, but also contributes decisively to their revascularization through transcortical anastomosis. The morphologic appearance and the causes for the disruption of bone healing are demonstrated using individual examples. Predominant are insufficient stability and above all circulatory disturbances. In the case of fractures with considerable soft-tissue damage, not only is the intramedullary vascular system destroyed, but the blood supply to the periosteal vessels is also disrupted. The resulting delay to or absence of callus formation leads on the one hand to insufficient biological stabilization, and on the other hand to an impairment of fragment revascularization. The morphologic appearance is dominated by the fragment necroses and related complications, such as pseudarthrosis induced by bone necrosis and infected pseudarthrosis.

Animals↗
PubMed2002

The effect of time to definitive treatment on the rate of nonunion and infection in open fractures.

OBJECTIVES: To determine the association between time to definitive surgical management and the rates of nonunion and infection in open fractures resulting from blunt trauma. To determine the association of other clinical determinants with these same adverse events. DESIGN: Retrospective review of a consecutive series of open long bone fractures. SETTING: Referral trauma center with transport times often extending beyond eight hours from the time of injury. PATIENTS: A total of 227 skeletally mature patients with 241 open long bone fractures were treated between January 1996 and December 1998; 215 fractures were available for review at a minimum of twelve months postinjury. INTERVENTION: Medical charts of all patients were reviewed using a standardized data collection form. All available records and radiograph reports were inspected. All cases were followed to clinical and radiographic union of the fracture or until a definitive procedure for nonunion or deep infection was carried out. MAIN OUTCOME MEASURES: Occurrence of deep infections or nonunions after fracture treatment. RESULTS: The mean time to definitive treatment was eight hours and twenty-five minutes (range 1 hour 35 minutes to 30 hours 40 minutes). Forty patients went on to nonunion, and twenty developed a deep infection. In the final multivariate regression model, time was not a significant factor in predicting either nonunion or infection (p > 0.05). The strongest determinants for nonunion were found to be presence of infection and grade of injury (p < 0.05). The strongest predictors for the development of a deep infection were fracture grade and a lower extremity fracture (p < 0.05). CONCLUSIONS: The risk of developing an adverse outcome was not increased by aggressive debridement/lavage and definitive fixation up to thirteen hours from the time of injury when early prophylactic antibiotic administration and open fracture first aid were instituted.

Adult↗
PubMed1976

Salvage of complicated open fractures by transfixation.

The use of a commercially available Reduction-Retention apparatus for transfixation of nine cases of open fractures with severe soft-tissue damage is reported. Seven patients are walking, two with drop foot braces. Two required amputations, one because of infection and the other because he had suffered severe vascular injury. These two are walking on protheses and are able to work. Of the other seven, five have returned to their previous occupations; one is receiving a disability pension and the other is awaiting further surgery. The problems and advantages of this method of treatment are discussed.

Accidents, Traffic↗