Management of open fractures: A narrative review

Abstract

Open fractures are an emergency where the principal aim of the treatment is to maximise the restoration of limb function while preventing the dreaded consequences of infection and non-union. The decision-making process for open injuries is influenced by a variety of criteria, such as patient age, injury features, systemic response, activity level, comorbidities, and functional requirements. A collaborative orthoplastic approach to treating these injuries is essential for minimizing complications and need to be considered as a single specialty in early and long-term management. It has been shown that early prophylactic systemic antibiotics, wound irrigation, aggressive debridement of contaminated and devitalized tissue, and appropriate fracture fixation decreases the complications in all grades of open fractures. The advantages of Gram-negative antibiotics, the use of local antibiotics, intraoperative wound cultures, the "fix and flap" approach, and Negative Pressure Wound Therapy are few of the treatment options that are still controversial. The aim of this review is to provide a comprehensive review and practice guidelines regarding the management of open fractures.

1. Introduction

An open fracture is an injury where the fractured bone and/or hematoma are exposed to the external environment through a traumatic violation of the soft tissue and skin¹. The spectrum of open fractures can vary from cases that achieve primary closure after debridement to more complex patterns requiring advanced reconstructive techniques. The main objectives of the treatment are to maximise limb function restoration while preventing the dreaded consequences of infection and non-union. which can pose significant challenges to both patients and healthcare systems. In the article, we aim to provide a comprehensive review and practice guidelines regarding the management of open fractures.

2. Initial evaluation

Open injuries are often due to high-velocity impact and present a dramatic picture that may draw one's attention away from life-threatening injuries. Therefore, it is pertinent to assess the patient in accordance with the Advanced Trauma Life Support (ATLS) protocol to find any potentially fatal injuries. The primary survey of the patient takes priority should be evaluated first, and any necessary resuscitation techniques should be carried out.¹ Early and adequate resuscitation is now considered a crucial factor to reduce mortality, future chances of infection, and delayed wound healing.

After patient stabilizes, open fractures need to be assessed and treated emergently. Plain radiographs are usually adequate to assess the extent of the fracture. CT scan may be done if the patient is hemodymically stable, when necessary. In the absence of pulses, a CT angiogram can be used to identify vascular injury. It is essential to photograph the wound and document neurovascular injuries as a routine in these injuries.² Several factors, including patient age, injury characteristics, systemic response, activity level, comorbidities, and functional demands play a role in the decision-making of open injuries.

3. Occlusive dressings in the emergency department

Although the National Institute for Health and Care Excellence (NICE) advises against using wound irrigation in the emergency department(ED),³ delegates at the International Consensus Meeting (ICM) on Musculoskeletal Infection supported wound irrigation in the emergency setting to remove all visible contaminants before applying dressings⁴(Grade D recommendation). Adequate wound washing and dressing can reduce contamination and provide time for a quality debridement.⁵

4. Classification systems

Despite the existence of various classification systems, there is currently no single system that is sensitivite and classify open fractures based on their outcomes and accurately reflects their prognosis.

Gustilo-Anderson classification: It is the most widely used classification which is based on wound severity, size, periosteal stripping, contamination, and vascularity, but it has high inter-observer variability and lacks sensitivity.⁶ .It has undergone many modifications since its original description to allow a more accurate prognosis for more severe injuries (i.e., Type III injuries).⁷ It is widely accepted for research, communication, training purposes, and remains useful as a good, basic approach for managing open fractures. Additionally, its implementation has played a significant role in improving surgical protocols, modifying antibiotic guidelines, and determining the optimal timing for interventions such as debridement, internal fixation, and soft tissue coverage. Despite being often used in practice, it lacks sensitivity and has a number of drawbacks. The wound descriptors used in the classification system are highly subjective and have high inter-observer variability.⁸ Also, the descriptors are not always mutually exclusive. For example, a 3 cm wound with periosteal stripping has features of both type 2 and type 3 and cannot be classified accurately. Additionally, the spectrum of injuries that are grouped under type 3 is vast, ranging from manageable to barely salvageable. The subtypes are completely varied in terms of management and outcomes, which makes it difficult to predict the prognosis.

Orthopaedic Trauma Association (OTA) and the Open Fracture Study Group (OFSG) classification: In 2010, OTA/OFSG published a classification based on a review of the literature of 34 risk variables and a consensus from a panel.⁹ It depends on the condition of the skin, muscle, bone, and vascular system as well as the degree of contamination. With moderate to excellent interobserver reliability, this classification was shown to be better than the Gustilo-Anderson system.¹⁰ This classification also has subjective descriptors that limit its application.

4.1. Scoring systems

Type III open fractures are the most difficult injuries to classify and treat due to their diverse injury patterns, higher morbidity resulting from associated injuries, significant soft tissue damage, wound contamination, and fracture instability. The decision to amputate or salvage a severely injured limb can be very challenging to the trauma surgeon. However, the assessment of the injury's severity to the limb is often subjective rather than objective. A misjudgment can lead to either an unnecessary amputation of a limb that could have been salvaged or, on the other hand, a secondary amputation after attempted salvage has failed. To aid the treating surgeon in this difficult decision-making process, several scoring systems have been proposed such as Mangled Extremity Severity Score (MESS), Predictive Salvage Index (PSI), Limb Salvage Index (LSI), Nerve Injury, Ischemia, Soft tissue injury, Skeletal injury, Shock, and Age of patient (NISSSA) score, Hannover Fracture Scale-97 (HFS-97).

4.1.1. MESS score¹¹

The Mangled Extremity Severity Score (MESS) was initially designed as an objective tool to aid surgeons in making decisions between amputation and salvage in cases of complex lower extremity trauma involving vascular component. It considers four factors such as skeletal and soft tissue damage, limb ischemia time, shock presence, and patient age. A MESS score of 7 or higher is suggested as highly predictive of amputation. Several studies have validated its effectiveness in predicting the treatment of major limb trauma, particularly in identifying limbs suitable for salvage.12, 13, 14 However, it may not reliably predict the need for amputation, especially in type 3B fractures. Poor sensitivity results in higher rates of failed attempts at salvage and secondary amputations. These scoring systems, including MESS, were primarily designed for cases with combined vascular and orthopedic injuries, thus performing poorly in type IIIB injuries, even when the limb is severely injured and not salvageable. While the need of amputation is widely recognized in Grade IIIC injuries, the management of Grade IIIB injuries often presents challenges, leading to frequent errors in limb salvage due to the lack of specific guidelines.

Ganga Hospital Open Injury Severity Score (GHOISS)¹⁵: It is an extremely useful predictive tool rather than a true classification, which aids in decision-making between limb salvage v/s. amputation.¹⁶ This was proposed in 2006, specifically for IIIB open fracture of the tibia, as this subtype in the Gustilo-Anderson classification includes a varied spectrum of injuries. GHIOSS uses three components to score open injury severity (skin, bone, and musculotendinous unit) on a scale of 0–5 in increasing severity and seven co-morbid factors that influence treatment and outcome with two marks each. The overall score is used to prognosticate the outcomes and guide the timing and type of reconstruction.¹⁷ While global reconstruction of the bone and soft tissue injuries can be carried out when the score is < 9, a total of >9 necessitates staged reconstruction shown in Fig. 1. 15 and 16 constitute the grey zone where the decision of amputation or salvage has to be made on a case-to-case basis, taking into consideration the general condition of the patient, the cost involved, and the time to recovery.¹³ A score of >17 is predictive of an amputation. Furthermore, the individual component scores of GHIOSS can be used in decision-making regarding the type of bony and soft tissue reconstruction needed.¹⁸ Good specificity, sensitivity, and ease of use make it a very useful tool that can be used routinely in a clinical context.^19,20

Fig. 1.

(a)- Presenting Xrays clinical pictures with a puncture wound over distal third of the leg. (b): After debridement, it was classified as type IIIb with GHIOSS of 7. ‘Global reconstruction’ -Local transposition flap and nailing of tibia was done. (c): At 1 year follow-up, flap has healed well and fracture is united. (d): Patient achieved full range of movements.

5. Current treatment recommendations

5.1. Antibiotic prophylaxis: agent of choice

Antibiotics are an essential first-line therapy for open wounds, as gram-positive bacteria are present in 78% of open fractures, while gram-negative bacteria are present in 26% of cases.²¹ First-generation cephalosporins are recommended to cover gram-positive bacteria at initial presentation for all grades of open fracture (Grade A recommendation),²² and an additional high-dose penicillin for farmyard contamination(Grade A recommendation). Clindamycin is the preferred antibiotic in individuals allergic to penicillin, while vancomycin is preferable for penicillin-allergic patients with an increased prevalence of community-acquired MRSA infections.²³ Although there is limited evidence in literature regarding the use of third generation cephalosporins, a study by Johnson et al. showed that there was no statistical difference in the rate of infection with the use of a first-versus a third-generation cephalosporin24. However, they noted a decreased infection rate and severity with the use of a third-generation cephalosporin. Similarly Suzuki et al. showed no difference in the incidence of deep infection between first and third generation cephalosporins.²⁵

Given that gram-negative organisms are a common cause of infections in grade III fractures, it is recommended to add gram-negative coverage when treating them²² (Grade A recommendation). Aminoglycosides have traditionally been used extensively for prophylaxis against most aerobic gram-negative organisms in open fractures. However, a study by Bankhead-Kendall et al. found no difference in surgical site infection rates between patients treated with a first-generation cephalosporin with or without an additional aminoglycoside, although those receiving aminoglycoside treatment had a statistically significant increase in renal dysfunction.²⁶ Further analysis by Tessier et al. suggested that patients with higher ISS (Injury Severity Score) and low blood pressure on presentation are at an increased risk of renal dysfunction.²⁷ The adverse effects of aminoglycosides are dose-dependent, and a once-daily dose of 5 mg/kg of gentamicin had a lower infection rate compared to equivalent three divided doses although it was not statistically significant.²⁸ Hence, a once daily dose of an aminoglycoside is recommended for an extended gram negative coverage(Grade B recommendation).²²

5.2. Timing of administration

One cannot overstate the importance of administering antibiotics as soon as possible as an infection prevention measure, as contamination is present in all open fractures to some extent.²⁹ The BOAST (British Orthopedic Association for Trauma and Orthopaedics) guidelines recommend administering antibiotics ideally within 1 h from the time of injury (Grade C recommendation).³⁰ In type III open tibia fractures, when cephazolin was administered within 66 min of the injury, there were no deep infections seen for 90 days as opposed to 17% if it was given later.³¹

5.3. Duration of antibiotics

Studies have shown non-inferiority of 24 h of antibiotic treatment with a second-generation cephalosporin when compared to 5 days in all grades of open fractures.³² According to a review of the literature on antimicrobial therapy for open fractures by Metsemakers et al., antibiotics should be given for at least 24 h after wound closure but not more than 72 h after injury (Grade A recommendation).³³

5.4. Systemic versus local therapy

The use of topical antibiotics is evolving, and while there is currently no evidence to support the use of topical antibiotics alone without adjunct systemic antibiotics, preliminary results of topical vancomycin are promising.³⁴ Compared to intravenous delivery, the concentration of antibiotics at the fracture site is substantially higher for 48 h, making it effective in preventing surgical site infection. In a meta-analysis, Morgenstern et al. found a significant risk reduction (11.9%) with local antibiotics.³⁵ However, much research is needed to clearly define the indications and dosing.

5.5. The “orthoplastic approach”

The importance of teamwork cannot be overemphasized, as open injuries require the combined efforts of orthopedic and plastic surgeons to collaboratively decide on the treatment plan and surgical interventions, ensuring the most appropriate and effective care for the patient. To achieve the comprehensive care by both the specialities, a new type of emergency trauma organization was establishedinitiated by Marko Godina in 1976 in Ljubljana, bringing together orthopedic and plastic surgery services to collaborate on combined treatments 24 h a day, seven days a week.³⁶ This "Ljubljana" orthoplastic approach emphasizes the management of acute trauma cases from the very first visit in the emergency department to the patient's full weight-bearing stage.³⁷ Hospitals that have implemented orthoplastic services have shown significant reductions in deep infection rates, fewer revision surgeries, shorter hospital stays, reduced overall costs, and improved outcomes with lower rates of non-union and amputation.

5.6. Debridement

Debridement is an important step in the management of open fractures. The primary goal of debridement is to remove all non-viable tissues and decontaminate the wound to prevent infection and further complications. The soft tissues must be handled with the utmost care, and the debridement should be performed by an expert to remove all the devitalized tissue. A coordinated orthoplastic approach helps in minimizing complications.³⁸ Using a tourniquet gives a bloodless field which provides better visualization of structures. However, it must be released at the end of the debridement to assess the viability of the tissues retained.

5.6.1. Timing of debridement

The classic “6-h rule” for initial debridement is no longer followed.³⁹ The adequacy of debridement is given much importance compared to the timing. Delaying the debridement of less infected open fractures by up to 24 h has not been found to increase the risk of infection, although having a good debridement has been shown to be advantageous (Grade D recommendation). The new BOAST guidelines state that in cases of severe contamination, suspected compartment syndrome, or vascular injury, urgent debridement should be performed.³⁰ It is preferable to debride high-energy solitary injuries within 12 h and low-energy injuries within 24 h^20,30 (Grade C recommendation).

5.6.2. Guidelines for debridement

Wounds should be extended longitudinally, regardless of the direction of the open wound. For wounds near joints, a longer incision may be necessary for a thorough examination. Non-viable tissue including avascular fascia, muscles, and soft tissue impregnated with fine contaminants, paint, or organic materials must be removed. The viability of the muscles is determined by the 4 ‘Cs’: Color, Consistency, Contractility and, Capacity to bleed. It is important to note that even after the removal of 30% of the mass, muscle function is not affected. Hence, there shouldn't be any hesitation in removal of the contaminated and devitalized muscles.

Open injuries create a vacuum effect that draws contaminants and debris deep into the medullary canal and muscle plane. So, any protruded fragments must be delivered through the wound, ends nibbled, and the intramedullary canal must be thoroughly curetted and washed. All the loose bony fragments should be removed as they can act as a source of infection and can displace causing significant soft tissue and neurovascular injury. The "tug test" can determine the removal of fragments with less than 50% soft tissue attachment.⁴⁰ Large diaphyseal fragments can be temporarily used to achieve reduction and discarded at the end of the debridement. However, the key articular fragments must be retained to reconstruct the joint surface. If grossly contaminated, the fragment must be thoroughly washed, and cancellous bone nibbled to remove the contaminants while preserving the cartilage.

It is important to identify the hypovascular zone of injury, particularly in high-velocity injuries with significant periosteal stripping and soft tissue damage.⁴¹ High velocity injuries result in a zone of necrosis under the wound that received the direct impact. The surrounding area, including the uninvolved and normal-looking tissue, constitutes the zone of injury, characterized by a precarious vascular supply due to the impact.⁴² The size of this zone is determined by the force of impact, and over time, the tissues in this zone undergo necrosis.

Caution must be exercised, especially in small wounds with comminuted fractures, as the appearance of the soft tissue may be misleading. Due to their precarious blood supply, the soft tissues in the zone of injury may gradually undergo necrosis. Therefore, a second 'relook' debridement may be necessary after the development of the line of demarcation. Also, a delayed wound cover in these situations would be a prudent approach.

At the end of the debridement, it is recommended to evaluate the loss of tissues and document it with a photograph for future reference and planning. It is essential to create a definitive plan for both soft tissue coverage and skeletal stabilization. Financial considerations related to the treatment and the possibility of secondary amputation must be discussed with the patient's family at this stage.

6. Intraoperative wound cultures

A study by Bosse et al. found that only 26.9% of infections were caused by the organisms identified in the initial wound cultures.⁴³ However, individuals who had positive cultures for any organism during the first debridement were at a higher risk to acquire an infection (Odds ratio of 1.92).³⁴ Therefore, there is no need to perform cultures initially since there is no clinical correlation between the original organism and the one causing the surgical site infection (Grade C recommendation).

7. Irrigation

Wound irrigation is an effective method to reduce contamination and bacterial load, with minimal damage to the surrounding soft tissues and bone. The risk of infection directly correlates with the number of bacteria in a wound, which further emphasizes the importance of thorough irrigation and debridement. Nonetheless, there are still controversies surrounding their use.

8. Irrigating agent

Several irrigating fluids have been studied for their efficacy and effects on soft tissue, especially in the “zone of injury”. This transition zone at the margin of the wound, which is viable but vulnerable to a secondary insult, is susceptible to necrosis from chemicals. Normal saline has stood the test of time and remains the fluid of choice for irrigation for open fractures (Grade A recommendation). The FLOW trial showed that normal saline had decreased rates of infection and reoperation when compared to the castile soap solution (11.6% vs. 14.85%).⁴⁴ The antibacterial action of surfactants and antiseptics helps to reduce the infection burden of the wound, but they are caustic to the tissue, affecting the host cell viability. Hence, they are not routinely recommended in the management of open wounds. Also, antimicrobials such as bacitracin had higher wound-healing complications compared to the castile soap group (9.5% vs. 4%).⁴⁵

9. Volume

The principle of “the solution to pollution is dilution” remains the strategy, as the volume of the irrigation directly correlates to the reduction in the amount of contamination and bacterial load.³⁴ Although there are no specific recommendations regarding the volume of fluid to be used, the quantity depends upon the extent of soft tissue damage and the amount of contamination. Conventionally, 3, 6, and 9 L are used for the type I, type II and type III Gustilo-Anderson fracture types⁴⁶ (Grade C recommendation).

10. Delivery pressure and pulsatile lavage

High-pressure pulsatile lavage (HPPL) systems were previously considered more effective in removing bacteria and debris, but recent studies have shown that they can damage adjacent soft tissues and impair bone healing. Additionally, high-pressure systems may push contaminants into deep tissues, leading to higher infection rates.⁴⁷ While both the low-pressure and high-pressure systems equally reduce contamination at 3 h of bacterial incubation time, the HPPL was effective for longer hours. This implies that high-pressure lavage, which exceeds the adhesion force of the bacteria, may be helpful in delayed presentations. The FLOW trial found no differences between irrigation at very low, low, and high pressure pulsatile irrigation in terms of non-union, wound complications, or reoperation rates.⁴⁴ Therefore, non-pulsatile flow irrigation with copious normal saline is the safest form of wound irrigation for open fractures (Grade A recommendation).

11. Irrigation timing

With the "6-h" rule for debridement no longer being followed, timely wound irrigation is crucial since bacterial adhesion starts within 3 h and biofilm maturation within ten hours⁴⁸ Wound irrigation at three, six, and 12 h resulted in bacteria removal of 70%, 52%, and 37%, respectively.⁴⁹ Hence, an wound irrigation at the earliest possible opportunity is advisable.

12. Skeletal stabilization

The decision for fracture fixation in open injuries depends on the patient's condition and the severity of the wound. We routinely make our treatment decisions based on the GHOISS.

13. Temporary fixation

External fixators are the workhorse of damage control orthopaedics and are routinely used in the staged management of open fractures when GHOISS is > 9.²⁰ External fixators is less invasive, minimize the further soft tissue damage and provide a stable skeletal stabilization. It is essential to carefully position the pins to allow for soft tissue reconstruction, which can be evaluated during the debridement process. External fixator pins must be placed appropriately through intact skin, not through the wound, to allow soft tissue reconstruction. They should also not be placed along the lines of future surgical incisions as this can interfere with definitive fixation if pin tracts become infected. It is advisable to reduce the fracture if the patient's hemodynamic condition permit. If the wound is located at a distance from the fracture site, skin incisions to reduce the fracture can be made in coordination with a plastic surgeon to avoid interference with soft tissue reconstruction. Otherwise, temporary external fixation can be applied with the limb in traction to maintain its length, and later this can be converted to internal fixation. Open wounds with articular fractures present an excellent opportunity for articular reconstruction on day 1. The articular congruity will be maintained even if the definitive fixation is delayed. External fixators can be used as a definitive fixation modality in stable fracture patterns (Fig. 2). However, if there is a secondary loss of reduction, internal fixation is advisable.

Fig. 2.

(a)- Presenting Xrays clinical pictures of a IIIb open fracture of tibia and fibula. (b)- After debridement, definitive external fixator was applied and split thickness skin grafting was done. (c): At 4 months follow-up, the fracture was in good alignment. External fixator was removed and full weight bearing started. (d): Good functional outcome at 6 months.

14. Primary internal fixation

In the past, internal fixation was often avoided due to concerns about infection risk, biofilm formation, and potential damage to blood supply.⁵⁰ However, with improved debridement techniques that ensure a clean environment, internal fixation is becoming more popular and widely accepted. Properly applied internal fixation can promote better healing and functional recovery in such situations.

Primary internal fixation can be carried out for open fractures with a GHIOSS score less than 9, with no gross contamination and excessive soft tissue involvement, and if the patient is stable. A good debridement with gentle handling of the fragments to not devascularize the bony fragments is the key. Definitive fixation of upper limb fractures can be carried out except in cases of heavy organic contamination⁵¹(Grade C recommendation). An example is shown in Fig. 3.

Fig. 3.

(a)- Open IIIb fracture of both bones forearm with comminution and protruding bony fragments. (b)- The wound was included in the incision at the time of debridement. Primary shortening and plating was done. (c): At 4 months, wounds have healed well and fracture is united. (d): Clinical pictures showing good range of movements and functional outcome.

In the nailing of the lower limb fractures, although reaming of the canal was a controversy in the past, many studies, including the SPRINT trial, have concluded that the reamed nails are better in terms of union with no difference in the rate of complications.⁵² In patients with bone loss, the primary use of the Limb Reconstruction System (LRS) is a very good alternative. The technique of “temporary spacer-rod and plate” helps in achieving perfect docking in IIIb open injuries(Fig. 4).⁵³ (see Fig. 5)

Fig. 4.

(a): A 22 year old presented 1 week after the injury with external fixator in place. Note the unhealthy wound and dry, dessicated bone. (b)- Removal of the dead bone resulted in a bone gap of 8 cm. Hence, it was decided to apply primary LRS using the “spacer-rod” technique. (c)- X-rays after application of LRS frame showing good alignment of the fracture ends. (d)- Clinical image at the time of the soft tissue cover and Xrays showing corticotomy. (e)- 15 months follow up after removal of LRS and plating showing consolidation of the regenerate. (f)- Clinical pictures showing good functional outcomes.

Fig. 5.

(a): Open IIIb fracture of the distal fourth tibia with degloving of the skin. It was decided to follow “fix and flap” approach with primary soft tissue cover and fracture fixation. (b): Wound image at the end of plating and intra-operative images showing anterolateral plating of tibia and rush nail fixation fibula. (c): Post-operative clinical image showing split thickness grafting and definitive fracture fixation. (d): At two years follow up, fracture has united and flap has healed well.

15. Primary closure

Rajasekaran et al. reported excellent outcomes with only a 3% deep infection rate after immediate primary skin closure in Type III injuries with strict inclusion and exclusion criteria.⁵⁴ Primary closure in type IIIb fractures can be done when the GHOISS skin score is 1 or 2 i.e., no skin loss after debridement, and the total score is less than 10, with no sewage or organic contamination and farmyard injuries. The closure has to be tension free and be carried out after the skeletal fixation.

16. Interim dressing the open wounds

Negative Pressure Wound Therapy (NPWT) can be used in those wounds that cannot undergo immediate soft tissue cover, particularly those with the zone of injury. In the UK WOLLF Collaboration trial, deep infection rates and quality of life were comparable between NPWT and occlusive dressings.⁵⁵ However, a meta-analysis showed that wounds treated with NPWT had lower rates of infection, non-union, and flap complications.⁵⁶

17. Definitive fixation

Conversion to internal fixation is recommended in several scenarios during staged reconstruction. This includes where there is non-anatomic reduction, secondary malalignment, or delayed union. After acute management, there exists a dilemma about the timing of conversion to definitive fixation. It can be either ex-fix removal and internal fixation in a single surgery, or staged with a "window period" in a cast after ex-fix removal to allow granulation of the pin sites followed by internal fixation(Grade B recommendation). The choice of staging is frequently made based on the presence of pin tract infections, and soft tissue condition. When converting to internal fixation, it is crucial to ensure there are no signs of pin tract infection or irritation, such as oozing or granulation tissue around the pin sites. Radiographic evaluation should also reveal no signs of pin loosening or rarefaction around the pin tract sites. Additionally, biochemical markers like ESR (erythrocyte sedimentation rate) and CRP (C-reactive protein) should be within normal limits to indicate a reduced risk of infection. Fram et al. found that one-stage conversion had comparable or even lower infection rates than two-stage conversion.⁵⁷ They also found no difference in rates of deep infection when conversion to intramedullary nailing was done in a single-stage even in the presence of pin site infection.

Another dilemma exists about the timing of internal fixation with respect to the soft tissue cover. Definitive internal fixation is ideally performed before the stage of definitive soft tissue cover.^17,54 After soft tissue cover, definitive internal fixation has to be postponed until the flap settles, which may take around 6 weeks.

Bone loss: Removal of bone fragments or loss at the site of injury may result in bone loss. The treatment strategy for bone loss depends on the location and degree of the defect, contamination, and soft tissue coverage. The treatment plan should be tailored based on the patient's condition and the experience and expertise of the treating surgeon. While defects of <4 cm maybe managed with bone grafting or primary shortening, larger defects are preferably treated with structural allografts or Masquelet technique or bone transport(Fig. 4).

17.1. Definitive soft tissue cover

The outcome of open fractures after debridement and skeletal stabilization depends on the timing of wound cover. Prolonged delays increase the chances of soft tissue necrosis and hospital acquired infection. Therefore, it is crucial to plan soft tissue cover at the earliest opportunity to avoid complications. In a study by Godina, the infection rate was lower (1.5%) when soft tissue reconstruction was done within 72 h compared to those done between 72 h and 3 months (17.5%).⁵⁸ Several studies have also found that earlier wound cover results in better outcomes, including lower rates of deep infection, earlier mobilisation, reduced need for further unplanned surgery, shorter hospital stay, and less flap complications. Based on these findings, it has been a common practice to achieve soft tissue cover within 7 days⁵⁹(Grade B recommendation). The Ganga Hospital Open Injury Score (GHOIS) offers guidelines for determining the appropriate soft tissue cover in open injuries.

17.2. Fix and closure

Injuries with a skin score of 1 or 2 do not have skin loss at the time of injury or during debridement. When contamination is less, tension free primary suturing can be done after adequate debridement. The total score must be < 9, indicating low-energy trauma, wherein skeletal stabilization can be carried out as well. However, injuries with a skin score of 1 or 2 but with either a total score above 9 or moderate to severe contamination should not be treated with primary closure. A total score exceeding 9 suggests high-energy trauma, and reassessment after 48 or 72 h becomes necessary. A delayed suturing is done if wound characteristics allow for closure during a second-look debridement.

17.3. Fix and skin grafting

A skin score of 3 indicates the presence of skin loss either at the time of injury or during debridement. However, the wound does not expose the fracture site, or there is sufficient soft tissue cover such as in femur fractures. In such cases, split skin grafting after skeletal stablisation is.

Fix and flap: A skin score of 4 indicates the presence of skin loss either at the time of injury or during debridement. If the wound exposes bone, articular cartilage, tendons, or a vascular anastomosis site, flap becomes necessary. Some centers have adopted a more radical approach called "fix and flap," which involves performing definitive bony stabilization and soft tissue cover at the same time to prevent colonization of "naked" implants and subsequent deep infection.⁶⁰ Patients with a single procedure were less likely to require amputation or further unplanned surgery when compared to staged management. An early flap is considered if the total score is less than 9, whereas delayed flap cover is done when the score exceeds 10 depending on the condition of the wound and the soft tissue swelling. A skin score of >5 needs staged reconstruction.

18. Types of soft tissue cover

Type III injuries present with wounds of varying size and complexity. Traditionally, a reconstructive ladder for managing soft tissue defects has been described, starting with simple split skin grafts and advancing to more complex options such as fascio-cutaneous flaps, rotational muscle flaps, and free muscle flaps. The choice of treatment depends on factors such as wound location, exposure of bone and implants, and the presence of a healthy muscle bed. For wounds not directly over the bone and with a healthy muscle bed, split skin grafts are typically sufficient. Small defects over bone and exposed implants can be effectively covered with rotational fascio-cutaneous flaps, given that there is no extensive zone of injury or degloving. Larger defects that expose bone and tendons require coverage with vascularized tissue, such as a muscle flap covered with a split skin graft. In cases where a pedicle flap is not suitable or the wound is too large for a pedicle flap, free microvascular tissue transfer becomes necessary.

Recently, a "revised reconstructive ladder" has been advocated, incorporating newer developments such as vacuum-assisted closure (VAC) therapy, acute bone shortening, bone transport, and other advanced techniques.⁶¹ These innovations have significantly impacted clinical practice, leading to increased use of delayed primary closures and reduced reliance on traditional skin flaps for wound management.

Alternatively, in the “reconstructive elevator” model, the surgeon chooses the reconstructive procedure that best suits the patient's needs and the overall clinical context, rather than solely opting for the simplest technique that achieves wound closure.⁶² The goal is to achieve the most optimal reconstruction with minimal morbidity for the patient. This approach encourages flexibility and the freedom to select the most appropriate procedure, similar to taking an elevator to the desired level, rather than following a rigid step-by-step ladder approach.

19. Future trends

While modern treatment modalities are effective, there is ongoing research to further improve outcomes for open injuries. Identification of infection using bacterial DNA sequencing and protein biomarker detection are promising. The development of hardware coating techniques to prevent biofilm formation and stimulate the local immune response is ongoing.

20. Algorithm for the management of open injuries

While adhering to a strict algorithm in managing such complex injury patterns may not always be feasible, the provided flowcharts offer a comprehensive overview of open fracture management. Fig. 6, Fig. 7 give a concise outlines for the management of open injuries based on Ganga Hospital Open Injury Score.⁶³

Fig. 6.

Stepwise initial assessment and management of open fractures.

Fig. 7.

Flowchart for the management of type IIIb fractures, considering various factors that may influence treatment decisions.

21. Conclusion

Despite the challenges posed by open injuries, following the principles of adequate resuscitation, infection prevention, and a combined "orthoplastic" approach during initial and definitive management can yield good results. The use of the Ganga hospital score for assessment can help with salvage and prognostication. Early stable fracture stabilization facilitates quick soft tissue reconstruction, while an appropriate secondary intervention with bone grafting ensures union and early joint mobilization.

Level of clinical care

Level I Tertiary trauma centre.

Ethics approval

Approval was obtained from the Institutional ethics committee.

Funding

No funding was received for conducting this study.

Conflicts of interests

The authors have no competing interests to declare that are relevant to the content of this article.

Credit author statement

Jayaramaraju Dheenadhayalan: Conceptualization, Methodology, Project supervision, Writing - review & editing; Vasudeva Nagashree: Data curation, Methodology, Writing - original draft; Agraharam Devendra: Project administration, Supervision, Writing - review & editing; Purnaganapathi Sundaram Velmurugesan: Data curation, Project administration, Supervision, Writing - review & editing; Shanmuganathan Rajasekaran: Project administration, Supervision, Writing - review & editing.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.