Open fracture
The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture.
Most open fractures have extensive damage to soft tissues near and around the bone such as nerves, tendons, muscles, and blood vessels.
[1] Open fractures can occur due to direct impacts such as high-energy physical forces (trauma), motor vehicular accidents, firearms, and falls from height.
[8] These mechanisms are usually associated with substantial degloving of the soft-tissues, but can also have a subtler appearance with a small poke hole and accumulation of clotted blood in the tissues.
[11] There are various fracture types, including closed, open, stress, simple, comminuted, greenstick, displaced, transverse, oblique.
[5] Urgent interventions, including therapeutic irrigation and wound debridement, are often necessary to clean the area of injury and minimize the risk of infection.
[16] Other risks of delayed intervention include long-term complications, such as deep infection, vascular compromise and complete limb loss.
[5] Another important clinical decision during acute management of open fractures involves the effort to avoid preventable amputations, where functional salvage of the limb is clearly desirable.
Adding penicillin to cover for gas gangrene caused by anaerobic bacteria Clostridium perfringens is a controversial practice.
[5] The use of absorbable carriers with implant coatings at the time of surgical fixation is also an effective means of delivering local antibiotics.
Studies found out that there is no difference in infection rates by using normal saline or other various forms of water (distilled, boiled, or tap).
[5] The purpose of wound debridement is to remove all contaminated and non-viable tissues including skin, subcutaneous fat, muscles and bones.
The optimal timing of performing wound debridement and closure is debated and dependent on the severity of the injury, resources and antibiotics available, and individual needs.
[5][21] NICE guidelines suggest that the surgical debridement should be done immediately for open fracture that are highly contaminated or where there is a lot of bleeding (vascular compromise).
[22] Early fracture immobilisation and fixation helps to prevent further soft tissue injury and promotes wound and bone healing.
[23] Unreamed intramedullary nailing is advantageous because it has a lower incidence of superficial infection and malunion compared to external fixation.
[24] However, unreamed intramedullary nailing can result in high rates of hardware failure if a person's weight bearing after surgery is not closely controlled.
[24] Compared to external fixation, unreamed intramedullary nailing has similar rates of deep infection, delayed union and nonunion following surgery.
[5] Amputation is a last resort intervention, and is determined by factors such as tissue viability and coverage, infection, and the extent of damage to the vascular system.
Open fractures of long bones may cause subsequent damage to surrounding tissue resulting in compartment syndrome.
[7][30] Lastly, open fractures commonly occur in the setting of traumatic experiences, and the co-occurrence of these events may lead to chronic pain and mental health disorders.
[33] The infection rate of open fractures depend on characteristics of the injury, type and timing of treatment, and patient factors.
Treatment consisted of manual reduction, where the broken bone is made to be straight again with physical maneuvers, and then application of splints and topical ointments.
A topical ointment consisting of honey, grease, and lint made from vegetable fiber were then applied daily to the open fracture.
It has been reported that the pioneering Russian surgeon who introduced the novel technique had been inspired by watching sculptors creating works of art.
It was not until the latter half of the 19th century, when Joseph Lister adopted the aseptic technique in surgeries, that the rate of death from open fractures reduced from 50% to 9%.
