Treatment
of Compound
David Seligson,
MD,
Stephen L. Henry,
Management of compound fractures remains a challenge to the surgeon. Methods to decrease patient morbidity include early fracture stabilization and sequential dgbridement. External fixation remains the standard; however, early internal fixation in low-grade injuries may be an acceptable option. Early soft tissue coverage is critical. The use of prophylactic parenteral antibiotics has decreased the incidence of acute infection and chronic osteomyelitis. Supplemental use of local antibiotic polymethyl methacrylate (PMMA) beads appears to further diminish the morbidity in high-grade open fractures.
he smallest puncture passing directly to the substance of a fractured bone adds difficulty to the method of T cure, and hazard to the event” [I]. The best definition is an old one: when a fracture communicates with the atmosphere, it is compound. This diagnosis covers a wide spectrum of mechanisms of injury resulting from a bone-smashing accident. Such comminution occurs when a car bumper strikes the subcutaneous cortex of the tibia or may result from a slow pirouetting fall where the glass-sharp tip of a spiral fracture of the femur lacerates the skin from within. Whatever the cause, this injury remains an important concern of the surgical profession. From the Department of Orthopedic Surgery, University of Louisville, Louisville, Kentucky. Requests for reprints should be addressed to David Seligson, MD, Deoartment of Orthooedics. Universitv of Louisville. Louisville. Kentucky40292. Manuscript submitted February 6, 1990, and accepted in revised form September 25.1990.
Fractures
MD, Louisville, Kentucky
For most of recorded history, open fractures have been considered potentially lethal. So much so that when amputation became safe and humane, it became the most appropriate therapy for contaminated compound fractures [2,3]. Percival Pott achieved considerable notoriety for insisting on careful transport, cleansing, and nonoperative treatment for his own compound ankle fracture [4]. Study of the bacterial environment and the utility of scientifically decontaminating compound fracture wounds by Dakin and Carrel in World War I paved the way in the Second World War for staged management of compound fractures with the realistic goal of saving functional limbs [ 51. Today, an impressive array of evolving technologies in microsurgery, antimicrobial therapy, and osteosynthesis is available for the treatment of compound fractures [a. A cautious approach is required for these patients since traumatic injury is the leading cause of loss of productivity before age 65 [ 71. Approximately one eighth of the hospital beds in the United States are occupied by patients as a result of musculoskeletal injuries [8]. Of these injuries, compound fractures frequently require long hospitalization, multiple surgical procedures, and expensive medications. The true extent of morbidity from this condition is unknown since compound fractures are not a reportable disease. The purpose of this review is to present the current state of the art and indicate new directions in the management of this seriously debilitating injury. DEFINITIONS Since compound fractures constitute a wide spectrum of bony injury, there has been an effort to classify them for an accurate comparison of the results from one series to another. The classification of Gustib and Anderson [9] is the most commonly used one in North America. The wound is graded as I, II, or III depending upon the degree of soft tissue damage [IO]. A grade I wound measures less than 1 cm, a grade II wound measures 1 to 10 cm, and grade III has either extensive soft tissue damage, a segmental fracture, marked contamination, or vascular injury. Recently, group III wounds were divided into IIIA, in which local soft tissue coverage is possible; BIB, in which soft tissue transfer for coverage is required; and IIIC, in which there is arterial injury requiring repair [ 1I-I 31. Gustilo [ 121 has modified his classification to recognize several risk factors: presence of significant contamination and the length of time between injury and debridement. The mechanistic approach of Allgower places fractures in equivalent groups: a grade I fracture is a puncture wound made by the bone (an “inside-out”); a grade II wound is the result of direct trauma from without (“outside-in”); and a grade III wound is extensive and involves the neurovascular bundle [14,15]. The classifications of
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additive [20]. Difficult compound fractures share a high incidence of delayed healing, chronic infection, and limb amputation and frequently require resource-intensive therapy [I9,21-231.
Flgure 1. are evident. The skin laceration Wasless than 0 cm, resulting in the classlflcation of this complex fracture as a grad8 II open fracture.
GOALS The goal of treatment of a compound fracture is to restore the limb to the pre-injury condition. For practical purposes, this should be defined as a functional limb with an uninfected fracture union. The principal goals are prevention of infection, soft tissue coverage, and fracture union. There are, however, a long list of local and systemic conditions that can occur as a result of the injury that must be evaluated in considering the overall quality of the result. These include joint stiffness and post-traumatic arthritis, causalgia and other alterations of sensation, chronic venous and lymphatic stasis, and abnormalities of limb length and alignment. Post-fracture morbidity must be evaluated in terms of the patient’s age, job, socioeconomic status, and the site and complexity of the injury. There is too little emphasis on length, morbidity, and cost of treatment and poor documentation of the accurate long-term incapacity this injury causes [23-251. The patient with an extremity fracture is likely to have a coexisting behavioral disorder ranging from alcohol or substance abuse to overt psychosis [26]. If treatment aggravates a co-morbidity to produce a dysfunctional individual, then treatment has not succeeded. Goal setting with the patient and family must include the question of the limb as well as a comprehensive discussion of all phases of rehabilitation including return-to-work [22], Tsai et al [24] have thoughtfully reported that the complete treatment regimen for complicated compound fractures should be accomplished in 1 year. This is a reasonable goal. The alternative to limb salvage is amputation [3,23,27]. When considering this procedure, the physician should be aware that the psychologic cost of an amputation to the individual is considerable. Esterhai et al compared patients with limb salvage to those with amputations and documented marked negative attitudes and residual bitterness due to the loss of the limb (unpublished data) [28]. As will be developed, restoration of a noninfected, functional limb after an open fracture is an age-old goal that has progressively become the expectation during our lifetimes.
Cauchoix et al [ I6j and Oestern and Tscheme [171 categorize compound fractures in a manner similar to that of burns. In a grade I or II wound, there is partial-thickness soft tissue damage, while a grade III injury has loss of soft tissue coverage. The most comprehensive report on this topic was by Edwards [ 181, who characterized compound fractures not only by their location and amount of contamination but also by the extent of damage to each of the constituents of the limb-skin, fascia, muscle, neurovascular bundle, periosteum, and bone. The deficiency of the Gustilo system is that certain high-energy injuries with degloving of soft tissue and marked periosteal stripping are associated with limited wounds (Figure 1). Complexity in classification may be the enemy of progress. In reality, there are two large groups of compound fractures-simple and complex. Simple compound fractures can be irrigated, dbbrided, and then treated as a closed fracture with the expectation that the fracture will heal in the usual time. Complex fractures have special characteristics-loss of bone or soft tissue, periosteal stripping, marked contamination, or arterial injury [13]. Each of these difficulties requires individualized therapeutic management: tissue grafting, compartment release, arterial repair [29]. These morbidities are
INITIAL TREATMENT Dhbridement: Compound fractures are medical emergencies. The standard of practice requires d&bridement of the wound and stabilization of the bone. Failure to act risks osteomyelitis and loss of limb. There are, however, other emergent conditions in the complete management of a severely injured patient and here the organization of initial treatment requires experience, skill, and thought. The need to operatively attend to a compound fracture can be delayed no longer than 6 to 8 hours without compromising the injured limb [II]. DBbridement and stabilization are the goals of initial fracture care [29,30]. Dhbridement originally meant unbridling, removing restraints, fasciotomy [31]. The mod-
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ern usage of dkbridement appears in the writing of Trueta [32]. Today, it is defined as a surgical excision of contaminated and nonviable tissue from an open fracture wound. For major long bones, this operative management is best performed in an operating room. Bone, muscle, fascia, subcutaneous tissue, and skin require different attention. It has been two decades since the Vietnam War, in which current methods and guidelines for safe wound management were developed [33,34]. The basic recommended procedure is to resect all devitalized tissue and thoroughly irrigate the wound. In general, a narrow margin of normal tissue is removed. This resection is minimal for skin but generous in subcutaneous tissue. Muscle is cut to brisk, bleeding, and contractile tissue. Fascial envelopes are incised; a good mechanical cleansing of bone is performed. In diaphyseal fractures, the ends of the bone are grasped, delivered into the field, and visually inspected for foreign debris. The skin overlying the fracture is extended as needed to accomplish the irrigation. The wound is copiously irrigated and dressed open. No transportation of tissue is performed at an initial dhbridement: “of the edge of the skin take a piece very thin The tighter the fascia the more you should slasher of muscle much more till you see fresh gore And bundles contract at the least impact leave intact the bone except bits quite alone [33].”
Figure 2. Grade IllB tibia1shaft frame managed acutely with antibioticbeads and stabilizedwith external fixation.
Several details deserve comment: With clean lacerations and timely dbbridement, there is no need to remove ment of compound fractures is preferable [21,30,38, the skin margin. In areas in which coverage is critical, 391. However, impressive evidence has accumulated that such as the anterior surface of the leg, too much di5bridement is not advised and may complicate closure. Skin under carefully controlled conditions the acute closure of that is contused can frequently be left and its viability compound fractures is safe, reduces morbidity, and has assessed at subsequent stages. The subcutaneous tissue an acceptable infection rate [40-441. Closure consists of and particularly subcutaneous veins should be generously nonabsorbable sutures to repair important tendons; fasexcised. Venous thrombosis tends to propagate and com- cial envelopes are left open; and the skin is closed loosely without tension over suction drains. promise potentially viable tissue. If certain wound conditions can be met, debridement, Muscle should also be dtbrided generously, but it is not necessary to develop the planes between muscle bel- rigid fracture stabilization, and wound closure can be lies. Scully and co-workers’ [35] four C’s-color, capaci- performed as the initial treatment for a compound fracty to bleed, contractibility, and consistency-are useful ture. These conditions are as follows: 1. Treatment is undertaken within 6 to 8 hours of guides. The surface of muscle is made smooth and contoured. Viability cannot be determined either by the pres- injury [45,46]. ence of bleeding or muscle contraction when cut, since 2. D6bridement results in a surgically clean wound. 3. Closure can be performed simply and without tenlocal vasospastic phenomena may occur. Only sequential sion. dhbridement will establish the vitality of muscle. 4. Follow-up of the wound will be under the superviIt is no longer acceptable to sterilize and reinsert pieces of cortical bone that are found at an accident site: loose sion of the surgeon who did the initial treatment [47]. Stabilization (fracture fixation) : The major addetached fragments should be removed even if they are important for stability [29,36,37]. Initial fracture immo- vance in this area during the past 20 years has been the bilization through the Vietnam era was plaster splinting, widespread introduction of external skeletal fixation for casting, or skeletal traction [33,34]. Immediate wound the initial management of open fractures [36,48-531. closure was prohibited. A body of opinion continues to External fixateurs are systems that include pins, clamps, hold that the completely open method of wound treat- and connectors that achieve skeletal stability (F’Igure 2). THE AMERICAN
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DEFINITIVE
Figure 3. Complex soft tissue loss with severe fracture commiw tion is best managed wfth extemal fixation and early soft tissue Coverage.
Originally, external fixation was used in a short field trial by the Allies at the start of World War II. The results were so poor that their use was soon abandoned. Fixateurs were popularized by Vidal’s group [48] in Montpellier for the management of devastating open skeletal trauma and have achieved wide acceptance, particularly in patients with multiple trauma [22,36,49,53551. Frame design has evolved from double frames utilizing transfixing pins [56,57] to uniaxial designs utilizing bicortical half-pins [58]. Antibiotics, irrigation, and tetanus prophylaxis complete the standard regimen for initial care of compound fractures. In the operating room, the wound is sequentially ddbrided and irrigated with saline or antibiotic-containing irrigant (bacitracin, cefamandole, neomycinpolymyxin, etc.) [ 151. Evidence based on the retrieval of particulate matter from wounds suggests that focused pressurized irrigation either with a syringe or pulsatile irrigator reduces the bacterial burden of the wound [59]. Copious quantities of fluid have often been recommended, e.g., greater than 10 L. These practices have not been shown to be of significant benefit in comparison with bulb syringe irrigation. Air embolism has been reported after pulsed lavage of a pelvic fracture [60]. Systemic antibiotics should be administered from the time of dbbridement until a stable closed wound has been achieved [9,42,43,46,61-641.’ The regimen for severe compound fractures includes penicillin, a cephalosporin, and an aminoglycoside [62] (example: penicillin G 2 million units every 6 hours, cefazolin 1 g every 6 hours, and amikacin 500 mg every 8 hours. There is no evidence that antibiotic therapy prior to dbbridement is helpful except in situations of known contamination-creek-river injuries, barnyard accidents, and/or animal bites. Long courses of parenteral antibiotics in patients with stable wounds are probably not necessary [42,64,65]. In complex grade III wounds, repeat ddbridements at intervals of 2 to 3 days are often necessary to secure a clean wound that can be closed [36,43,45,64. 696
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The definitive management of a compound fracture requires stabilization of the bone and provision of soft tissue coverage. For most compound fractures, fracture stabilization is accomplished at the time of the initial treatment [45]. Once an intramedullary nail has been inserted to stabilize a diaphyseal fracture or a muscle flap has been mobilized to cover an area of soft tissue loss, an irreversible step has been taken with the hope that the clinical problem will be solved. In several retrospective reviews, the immediate and definitive stabilization of compound fractures of both the upper and lower limbs resulted in better outcomes than when stabilization was delayed [40,41,44,67]. Similarly, immediate free-flaps for the coverage of soft tissue defects has been reported to have a better success rate than delayed flap coverage [45,68,69]. Definitive management of the bone can be nonoperative by manipulation, reduction, and placement of an external orthosis, or operative by reduction and internal fmation with intramedullary nails, external fmateurs, or plates and screws [21,46,70,71]. Although immediate plate fmation [15,67,72] and formal intramedullary nailing [73-751 have been performed in all grades of compound fractures, these methods are not generally acceptable because the consequence of failure is too great [30]. Simply inserting a bone screw in an experimentally contaminated wound increases the incidence of infection [ 74. External fixation is the current method of choice for the initial treatment of most complicated compound fractures [13,51,52] (Figure 3). Insertion of multiple intramedullary pins (flexible or Ender nailing) has been re ported from several centers [77,78]. Advocates of these methods emphasize short operating times with little damage to the medullary blood supply [63]. An alternative point of view holds that the blood supply to bone is damaged by the injury and that flexible fixation has a high complication rate and provides inadequate stability. It has been generally shown that following d&bridement, straightforward (grade I or II) compound fractures can be treated in the same manner as closed fractures with similar infection and healing rates [75,78]. It is in the difficult or complicated compound fractures that invasive fracture surgery with intramedullary nails or plates and screws can lead to serious late complications [22,79]. A method with high biologic costs, such as intramedullary nailing, is acceptable in a bone with extraordinarily good vascularity such as the femur even if there has been compounding: the excellent mechanical condition provided by the nail will eventually lead to fracture healing since the blood supply is supra-abundant [63,75,80]. Converse ly, plate fixation in areas of vascular insufficiency, i.e., the tibia, can lead to infection, nonunion with plate failure, and deformity unless a plan for coverage produces substantial improvement in local wound condition. Fracture stabilization and the provision of adequate soft tissue coverage must be achieved after the general medical condition of the patient has been addressed. Increasing evidence suggests that early fracture stabilization will improve the general condition of the patient and
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result in a decreased incidence of complications [ 12,15,41,81-83]. Since there are many methods to gain control of an unstable fracture, an assessment of multiple organ function is required to determine if the patient can successfully withstand the procedure that is proposed for the definitive treatment of the injured extremity. The high-grade compound fracture with extensive soft tissue maceration can present a significant added stress to a patient’s physiologic reserve [3,20]. In the event that a patient has limited biologic resources in combination with a complex constellation of injuries, amputation of an extremity may be the only means to save a life. This requires bold and mature surgical judgement [23,27]. The definitive treatment of both the fracture and the soft tissues is a team problem [45,74]. On the one hand, the skeleton is dependent on motion and load for its maintenance. Soft tissues, on the other hand, require moderate elevation and immobilization, particularly in the early phases of wound healing. Weight-bearing ambulation might be desirable to impact fracture ends after a stable tibia nailing, while the same forces would compromise healing a split-thickness skin graft that had been placed to cover a muscle flap. The postoperative rehabilitation program needs careful planning. It is almost always true that it is easier and more successful to perform the transfer of soft tissues in the presence of skeletal stability. One of the contributions of the Montpellier group has been to organize flow diagrams for the rational reconstruction of severe compound fractures [84]. REHABILITATION Evidence is accumulating that the combined management of difficult compound fractures by specialists in orthopedics, vascular surgery, and plastic surgery can improve functional results [29,66]. A review of the literature, however, reveals articles that focus on specific specialty issues such as management of soft tissue coverage [24,69&j], prevention of infectious complications [43,86-891, methods of fracture fixation [55,58], and techniques to secure bone union. Parenthetically, the evidence points not only to the advances that can be made in improving the results of treatment of compound fractures but also the tremendous morbidity of this injury. Gustilo and Anderson [9] compared results in two series from 1955 to 1968 and from 1969 to 1973 and reported a marked decrease in late complications in the second series with a protocol management of decreased use of internal fixation, open treatment of grade III injuries, and use of antibiotics. The infection rate for grade III injuries declined from 44% to 10%. Weise et al [53] reported that 85% of 159 second- and third-degree fractures healed at an average of 5.4 months with an 18.7% infection rate. They believed that protection of the wound, expeditious operative debridement, and use of artificial wound dressings improved results. Despite provision of good soft tissue coverage, many compound fractures initially treated with external skeletal fixation fail to show signs of fracture healing. In a consecutive series of 5 1 compound tibia fractures treated with external fmation, half (26) of the fractures had delay THE AMERICAN
in healing past 14 weeks. These 26 tibias then took from 14 to 139 weeks (mean: 60 weeks) to heal [90]. Solutions to this problem include early cancellous bone grafting [91], sometimes in combination with a change to another fracture treatment strategy. In a series of 56 compound tibia fractures, 23 cases of delayed union were treated with lixateur removal, bone plate fixation, and cancellous grafting 13.2 weeks after the fracture. Solid union was obtained in 18 of these cases [50]. In a critical review of results of treatment of compound tibia fractures, Rommens et al [92] found 6% of grade I compound fractures, 29% of grade II fractures, and 60% of grade III fractures required two or more proceduresmost commonly cancellous bone grafting. End results were poor in 24% of the grade III fractures. Gustilo and co-workers [131 reported comparable complication rates of infection (13.7%), amputation (l&7%), and nonunion (18.5%) in grade III compound fractures. Similarly, Green et al [87] found bone plating and cancellous grafting much more successful than fibular osteotomy or bone plating alone in treating problem tibia1 nonunions mostly following compound fracture. Other methods (nailing, external fmation) yielded intermediate results. Edwards er al [36] followed 17 1 consecutive grade III tibia shaft fractures treated with primary external fixation and serial wound dtbridement. Ninety-three percent of the fractures united with a medium time to union of 9 months. There was a 15% rate of infection and a 7% incidence of late amputation. Bone loss and infection were associated with prolonged healing. The authors emphasized that cancellous bone graft was important and should be repeated if necessary. Early wound coverage has been reported to enhance healing and reduce complications [68,69,88,93]. Cierny ef al [94] studied 36 type III tibia fractures in which wound coverage was achieved within 30 days of injury. In 24 fractures in which the wound was closed by the seventh day, the mean time to union was 4 months and the incidence of problem wound healing was 20.8%. Those wounds that closed between 8 and 30 days had a mean time to union of 6.4 months and a 83.3% incidence of wound complications [94]. Associated vascular injury suggests a particularly poor prognosis especially below the level of the knee [ 13,951. Amputation rates have been reported to be 50% [96]. Long ischemia times and internal but not external fixation increase the risk of amputation [19,97,98]. The role of microvascular free tissue transfer [24,93] in improving limb salvage is better established in the upper than the lower limb [85]. There are two principal trends in the late-phase management of fractures initially stabilized with an external fmateur [99]. On the one hand, a new generation of mechanically versatile fixateurs has been introduced. These appliances allow for modifications of frame stiffness and encourage callus formation by axial loading. When the soft tissue envelope is stable (4 to 6 weeks), the connecting rods of the fixateur are released by removing a set screw. This permits limited pistoning at the fracture with loading (walking). In a further variation of this JOURNAL
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Figure 4.Top left, malepatient who sustained grade NIB tibia1 and IIIA mid-foot compound fractures. Top right, this severely contaminated mower injuy was tibrlded, stabilized wlth external fixation, and managed with antibiotic impregnated beads and OpSlte coverage. Bottom left, the antibiotic bead pouch permits collectlon of hematoma wlth extremely high levels of antibiotic released by the beads. Bottom right, on day 6 following two d6brldements, a primary ankle fusion and skin closure over beads was performed. The wound healed uneventfully and at 30 months there was no evidence of Infection.
concept, the telescoping element is cycled by a machine that the patient can plug in [lOO,lOl]. An alternative point of view holds that after initial stabilization, the fixateur is an encumbrance to fracture management. In this concept, early (usually 6 to 8 weeks) removal of the fmateur and change to a nonoperative (casting or bracing [22]) or operative strategy (nailing [55] or plating [SO]) is advocated. These approaches work best when bone and soft tissue vitality is good: the operative strategies have an appreciable risk of infection [102]. When healing is delayed, the problem is most likely the biology at the fracture site rather than the device [68,92]. The underlying principle is outlined in Halloran’s [80,203] callous formula. According to this concept, fracture healing or callous formation is dependent upon micro-motion between the fracture fragments and the vascularity at the fracture site. This concept explains why fractures of well-vascularized areas, such as the humerus and femur, heal more efficiently than fractures in bones with less muscular and soft tissue coverage such as the tibia and ulna. Logically, operations, i.e., plate fixation, 698
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that further devascularize the fracture site can be expected to have high complication rates. Improving the conditions for functional fracture healing and securing adequate soft tissue coverage are thus complimentary goals that have a unique solution for each compound fracture [21,68,74,84]. THE FUTURE There are several promising areas in improving the results of treatment of compound fractures. New ap proaches for improving fracture healing include introduction of bioelectric stimulators, which often use the external fixateur pins as electrodes, and new synthetic materials as autogenous bone graft substitutes, i.e., Collagraft. These include substances that serve as matrix for bone ingrowth (osteoconductors) and substances that stimulate bone growth (osteoinductors). New materials have been introduced for wound management. These include the implantation of antibioticimpregnated bone cement beads at initial dhbridement and use of porous plastic skin substitutes [38,66,89,104] (Figure4). These approaches have been shown to reduce
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the rate of infection and accelerate wound granulation. At our institution, grade III compound fractures prophylactically treated with tobramycin polymethyl methacrylate (PMMA) beads had 5m fewer wound infections and osteomyelitis than those treated with systemic antibiotics alone. Prospective trials are currently focusing on the biology of the wound environment, the value of local versus systemic antibiotic therapy, and possible approaches to immune system enhancement to prevent infection [ IO51 and accelerate wound healing [ 106,107]. In particularly severe injuries, there is continued interest in microsurgical methods to restore vitality by transplanting skin, soft tissue [45], and bone into an area of deficit. Fracture healing is markedly enhanced by improving local vascularity in the compromised extremity. Radical debridement and acute free tissue transfer are being attempted in an effort to reduce the morbidity of severe devitalizing injuries. The treatment of osteomyelitis may provide a model for dead space management with PMMA antibiotic-laden chains and immediate free flap coverage [1081. Although free flaps have an appreciable failure rate, they have a lower infection rate than local muscle flaps [ 291. Expansion of soft tissue and bone by gradual mechanical stimulation will receive a major trial in the near future [ 1091. This method has been developed by Professor Ilizarov of Churgin, Siberia, over the past 20 years. It calls for rigid stabilization of the extremity in a fine wire circular external fixateur and gradual elongation of the limb to fill bone and soft tissue defects [1lo]. It remains to be seen whether this method will work reliably when used by many surgeons under varying clinical circumstances. The greatest progress will be made in the next decade by an increased understanding of the morbidity from compound fractures. The initial treatment of injury is an area of surgical decision making that has been relatively free from regulation by government and third-party payers. The accurate categorization of compound fractures, assessment of the risks and benefits of treatment, and evaluation of end results will increasingly shape decisionmaking in future years. Currently, the patient’s desire to save a limb at all costs governs the increasing expenditure of resources [I 1I]. In a particularly provocative recent essay, Professor Sigvard T. Hansen, Jr., [27] pointed to the need to have the courage to amputate severely damaged limbs. What is clearly needed is research to identify both local and systemic markers to assist in decisionmaking [6,19,20,23,95]. The trail of morbidity, loss of productivity, and high cost of therapy will be categorized and regulated by providers unless traumatologists are able to reach an improved standard of care and better consensus about appropriate and medically necessary therapeutic adventures in the care of these devastating injuries. The study of progress in the care of compound fractures is the study of the history of surgery itself [2], for these injuries have been survivable since the prehistory of medicine. They continue to provide a challenge to surgeons everywhere to preserve vitality, restore function, and offer humane treatment.
REFERENCES 1. Bell B. A system of surgery. 2nd American edition, Vol. III. Troy, New York: 0. Penniman and Co., 1804: 371. 2. Aldea PA, Shaw WW. The evolution of the surgical management of severe lower extremity trauma. Clin Plast Surg 1986; 13: 549-69. 3. Kirk NT. The classic: amputations. Clin Orthop 1989; 243: 316. 4. Rang M. Anthology of Orthopaedics. Edinburgh: E. & S. Livingstone Ltd., 1968: 7-8, 99-102. 5. Carrel A, Dehelly G. The treatment of infected wounds. New York: Paul B. Hoeber, 1917. 6. Burri C, Stober R. Indikation zur sofortigen oder verspateten Amputation bei schweren Weichteil-und Skeletverletzungen am distalen Unterschenkel. Lange&e&s Arch Chir 1986; 369: 621-3. 7. Committee on Trauma Research. Injury in America: a continuing public health problem. Washington, DC: National Academy Press, 1985. 8. American Academy of Orthopaedic Surgeons. Musculoskeletal system research: current and future research needs. Chicago: American Academy of Orthopaedic Surgeons, 1981: 148. 9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1,025 open fractures of long bones: retrospective and prospective analysis. J Bone Joint Surg [Am] 1976; 58: 453-8. 10. Gustilo RB, Merkow RL, Templeman D. Current concepts review: the management of open fractures. J Bone Joint Surg [Am] 1990; 72: 299-304. 11. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24: 742-6. 12. Gustilo RB. Current concepts in the management of open fractures. In: Griffin PP, ed. American Academy of Orthopaedic Surgeons Instructional Course Lectures 1987; 36: 359-66. 13. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 1987; 10: 1781-8. 14. Allgower M. Weichteilprobleme und Infektionsrisiko der Osteosynthese. Lange&&s Arch Chir 1971; 329: 1127-36. 15. La Duca JN, Bone LL, Seibel RW, Border JR. Primary open reduction and internal fixation of open fractures. J Trauma 1980; 20: 580-6. 16. Cauchoix J, Duparc J, Boulez P. Traitement des fractures ouvertes de jambe. Med Acta Chir 1975; 83: 811. 17. Oestern HJ, Tscherne H. Pathophysiology and classification of soft-tissue injuries associated with fractures. In: Tscherne H, Gotzen L, eds. Fractures with soft-tissue injuries. New York: SpringerVerlag, 1984: l-9. 18. Edwards P. Fracture of the shaft of the tibia: 492 consecutive cases in adults. Acta Orthop Stand 1965; 76: (39 Suppl): l82. 19. Lange RH, Bach AW, Hansen ST, Jr, Johansen KH. Open tibia1 fractures with associated vascular injuries: prognosis for limb salvage. J Trauma 1985; 25: 203-8. 20. Gregory RT, Gould RJ, Peclet M, et al. The mangled extremity syndrome (M.E.S.): a severity grading system for multi-system injury of the extremity. J Trauma 1985; 25: 1147-50. 21. Clancey GJ, Hansen ST Jr. Open fractures of the tibia. J Bone Joint Surg [Am] 1978; 60: 118-22. 22. Augeneder M, Boszotta H, Sauer G. Zur Behandlung der offenen Unterschenkelfraktur mit dem Fixateur externe. Unfallchirurgie 1989; 92: 531-6. 23. Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop 1989; 243: 92-9. 24. Tsai T-M, Werntz JR, Kirkpatrick DK, Harkess JW. Freetissue transfer in type III open lower extremity fractures. Surgical Rounds for Orthopaedics, May 1988: 17-23. 25. Purry NA, Hannon MA. How successful is below-knee amputation for injury? Injury 1989; 20: 32-6.
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26. Kuhn WF, Bell RA, Netscher RE, Seligson D, Kuhn SJ. Psychiatric assessment of leg fracture patients: a pilot study. Int J Psychiatry Med 1989; 19: 145-54. 27. Hansen ST Jr. The typeIIIC tibia1 fracture. Salvage or amputation [editorial]? J Bone Joint Surg [Am] 1987; 69: 799-800. 28. Esterhai JL, Lerner RK, Polomano RC, Heppenstall BR, Brighton CT, Cheatle MD. Psychosocial sequelae of treatment of osteomyelitis: non-union and amputation (unpublished data). 29. Yaremchuk MJ. Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity. Clin Plast Surg 1986; 13: 621-9. 30. Welz V. Ergebnisse der Behandlung offener Femurschaftbriiche. Erwachsenen Beite Orthop Traumatol 1987; 34: 605-13. 31. Andral G, &gin L, Blandin P, et al. Dictionnaire de m&lecine et de chirurgie practique. Paris: MQtigron-Marvis, J.-B. Baillibre, 1831. 32. Trueta J. Treatment of war wounds and fractures. New York: Paul B. Hoeber, Inc., 1940. 33. CINCPAC Third Conference on War Surgery. Camp H.M. Smith, Hawaii, January 20-23, 1969: 53. 34. CINCPAC Fourth Conference on War Surgery. Tokyo, Japan, February 16-19, 1970: 11. 35. Scully RE, Artz CP, Sako Y. An evaluation of the surgeon’s criteria for determining viability of muscle during debridement. Arch Surg 1956; 73: 1031-5. 36. Edwards CC, Simmons SC, Browner BD, Weigd MC. Severe open tibia1 fractures. Clin Orthop 1988; 230: 98-l 15. 37. Swiontkowski MF. Criteria for bone dbbridement in massive lower limb trauma. Clin Orthop 1989; 243: 41-7. 38. Knapp A, Weller S. Care of soft-tissues in open fractures. Aktuel Traumatol 1978; 8: 319-27. 39. Russell GG, Henderson R, Amett G. Primary or delayed closure for open tibia1 fractures. J Bone Joint Surg [Br] 1990; 72: 125-8. 40. Davis AG. Primary closure of compound fracture wounds, with immediate internal fixation, immediate skin graft, and compression dressings. J Bone Joint Surg [Am] 1948; 30: 405-15. 41. Chapman MW, Mahoney M. The role of early internal fmation in the management of open fractures. Clin Orthop 1979; 138: 12031. 42. Antrum RM, Solomkin JS. A review of antibiotic prophylaxis for open fractures. Orthop Rev 1987; 16: 246-54. 43. Patzakis MJ. Management of open fracture wounds. In: Griffin PP, ed. American Academy of Orthopaedic Surgeons Instructional Course. Lectures, 1987; 36: 367-9. 44. Rittmann WW, Schibli M, Matter P, Allgower M. Open fractures: long-term results in 200 consecutive cases. Clin Orthop 1979; 138: 132-40. 45. Byrd HS, Cierny G III, Tebbetts JB. The management of open tibia1 fractures with associated soft-tissue loss: external pin fuation with early flap coverage. J Plast Reconstr Surg 1981; 68: 73-9. 46. Scott WO, Grantham SA. The open fracture. Orthop Rev 1985; 14: 49-56. 47. Seligson D, Bailey R. Traumatic amputations: a Vietnam experience. Clin Orthop 1976; 114: 304-6. 48. Vidal J, Buscayret CH, Cannes H, Paran M, Allieu Y. Traitement des fractures ouvertes de jambe par le tixateur exteme en double cadre. Rev Chir Orthop 1976; 62: 433-48. 49. Edwards CC, Jaworski MF, Solana J, Aronson BS. Management of compound tibia1 fractures using external fixation. Am J Surg 1979; 45: 190-203. 50. Etter C, Burri C, Claes L, Kinzl L, Raible M. Treatment by external fixation of open fractures associated with severe soft tissue damage of the leg. Clin Orthop 1983; 178: 80-8. 5 I. Karlstrom G, Olerud S. External fixation of severe open tibia1 fractures with the Hoffmann frame. Cim Orthop 1983; 180: 68-77. 52, Larsson K, Van der Linden W. Open tibia1shaft fractures. Clin Orthop 1983; 180: 63-7. 53. Weise K, Holz U, Sauer N. Zweit-bis drittgradig offene Frak-
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turen Langer Rbhrenknochen-therapeutisches. Management turd Behandlungsergebnisse Aktuel Traumatol 1983; 13: 24-9. 54. Seligson D, Dudey D. Historical introduction. In: Seligson D, Pope M, eds. Concepts in external fixation. New York: Grune and Stratton, 1982: 3-12. 55. Aho AJ, Nieminen SJ, Nylamo EJ. External fixation by Hoffmann-Vidal-Adrey osteotaxis for severe tibia1 fractures. Clin Orthop 1983; 181: 154-64. 56. Karlstrom J, Olerud S. Percutaneous pin fixation of open tibia1 fractures. Double frame anchorage using the Vidal-Adrey method. J Bone Joint Surg [Am] 1975; 57: 915-24. 57.Velazco A, Fleming LL. Open fractures of the tibia treated by the Hoffmann external fmateur. Clin Orthop 1983; 180: 125-32. 58. Behrens F, Comfort TH, Searls K, Denis F, Young JT. Unilateral external faation for severe open tibia1 fractures. Clin Orthop 1983; 178: 111-20. 59. Gross A, Cutright DE, Bhaskar SN. Effectiveness of pulsing water jet lavage in treatment of contaminated crushed wounds. Am J Surg 1972; 124: 373-7. 60. Brunicardi FC, Scalea TM, Bernstein MO, Sclafani SSJ, Phillips TF. Air embolism during pulsed saline irrigation of an open pelvic fracture: case report. J Trauma 1989; 29: 700-l. 61. Patzakis MJ, Harvey SP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg [Am] 1974; 56: 532-41. 62. Pat&is MJ, Wilkins J, Moore TM. Use of antibiotics in open tibia1 fractures. Clin Orthop 1983; 178: 31-5. 63. Chapman MW. The role of intramedullary fvration in open fractures. Clin Orthop 1986; 212: 26-34. 64. Braun R, Enzler MA, Rittmann WW. A double-blind clinical trial of prophylactic cloxacillin in open fractures. J Orthop Trauma 1987; 1: 12-7. 65. Dellinger EP, Caplan ES, Weaver LD, et al. Duration of preventive antibiotic administration for open extremity fractures. Ann Surg 1988; 123: 333-9. 66. Seligson D, Banis J, Matheny L. Tibia terrible. In: Coombs R, Green SA, Sarmiento A, eds. External fixation and functional bracing. London: Orthotext, 1989: 281-4. 67. Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg [Am] 1986; 68: 1008-17. 68. Byrd HS, Spicer TE, Cierney G III. Management of open tibia1 fractures. J Plast Reconstr Surg 1985; 76: 719-30. 69. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. J Plast Reconstr Surg 1986; 78: 285-92. 70. Dabezies EJ, D’Ambrosia R, Shoji H, Norris R, Murphy G. Fractures of the femoral shaft treated by external fnation with the Wagner device. J Bone Joint Surg [Am] 1984; 66: 360-4. 71. Wiss DA, Gilbert P, Merritt PO, Sarmiento A. Immediate internal furation of open ankle fractures. J Grthop Trauma 1988; 2: 265-71. 72. Von Langenberg R. Ergebnisse der operativen Therapie von offenen Tibiaschaftfrakturen. Zentralbl Chir 1987; 112: 1508-14. 73. Velazco A, Whitesides TE Jr, Fleming LL. Open fractures of the tibia treated with the Lottes nail. J Bone Joint Surg [Am] 1983; 65: 879-85. 74. Velazco A, Fleming LL, Nahai F. Soft-tissue reconstruction of the leg associated with the use of the Hoffmann external tixator. J Trauma 1983; 23: 1052-7. 75. Lhowe DW, Hansen ST. Immediate nailing of open fractures of the femoral shaft. J Bone Joint Surg [Am] 1988; 70: 812-20. 76. Grewe SR, Stephen BO, Perlino C, Riggins R. Influence of internal fixation on wound infections. J Trauma 1987; 27: 1051-4. 77. Browner BD, Burgess AR, Robertson RJ, Baugher WH, Freedman MT, Edwards CC. Immediate closed antegrade Ender nailing of femoral fractures in polytrauma patients. J Trauma 1984; 24: 921-7. 78. DeLong WG Jr, Born CT, Marcelli E, Shaikh KA, Iannccone WM, Schwab CW. Ender nail fixation in long bone fractures:
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experience in a level I trauma center. J Trauma 1989; 29: 571-6. 79. Bach AW, Hansen ST Jr. Plates versus external fixation in severe open tibia1 shaft fractures. Clin Orthop 1989; 241: 89-94. 80. Halloran WX. Motion. In: Combs R, Green S, Sarmiento A, eds. External fmation and functional bracing. London: Orthotext, 1989: 9-11. 8 1. Riska EB, Von Bonsdorff H, Hakkinen S, et al. Prevention of fat embolism by early internal fmation of fractures in patients with multiple injuries. Injury 1976; 8: 110-6. 82. Kivioja A. Factors affecting the prognosis of multiply injured patients: an analysis of 1169 consecutive cases. Injury 1989; 20: 7780. 83. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. J Bone Joint Surg [Am] 1989; 71: 336-40. 84. Cannes H. Hoffmann’s external anchorage: technique, indications and results. Paris: Gead, 1977. 85. Swartz WM, Mears DC. The role of free-tissue transfers in lower extremity reconstruction. J Plast Reconstr Surg 1985; 76: 364-73. 86. Anderson JT, Gustilo RB. Immediate internal fixation in open fractures. Orthop Clin North Am 1980; 11: 569-77. 87. Green SA, Moore TA, Spohn PJ. Nonunion of the tibia1 shaft. Grthopaedics 1988; 11: 1149-57. 88. Johnson KD, Bone LB, Scheinberg R. Severe open tibia1 fractures: a study protocol. J Orthop Trauma 1988; 2: 175-80. 89. Ostermann PAW, Henry SL, Seligson D. Behandlung von Zweit-und drittgradii komplizierten Tibiaschaftfrakturen mit der PMMA-Kettentaschen-Tech& Unfallchirurgie 1989; 92: 52330. 90. Korkala 0, Antti-Poika I, Karaharju EO. La fixation externe dans les fractures ouvertes de jambe. Rev Chir Orthop 1987; 73: 637-42. 9 1. Heiser TM, Jacobs RR. Complicated extremity fractures. Clin Orthop 1983; 178: 89-95. 92. Rommens P, Broos P, Gruwez JA. Operative results in 124 open fractures of the tibia1 shaft. Unfallchirurgie 1986; 89: 127-31. 93. May JW Jr, Gallico GG III, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity. N Engl J Med 1982; 306: 253-7. 94. Ciemy G III, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibia1 fractures. Clin Grthop 1983; 178: 54-63. 95. Howe HR Jr, Poole GV Jr, Hansen KJ Jr, et al. Salvage of lower extremities following combined orthopedic and vascular trau-
ma. A predictive salvage index. Am Surg 1987; 53: 205-8. 96. Gp den Winkel R, Wet-net E, Glaser F. Repair of vascular injuries associated with tibia1 shaft fractures: early and late results. Vasa 1987; 16: 354-7. 97. Rich NM, Metz CW, Hutton JE Jr, Baugh JH, Hughes CW. Internal versus external fixation of fractures with concomitant vascular injuries in Vietnam. J Trauma 1971; 11: 463-73. 98. Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Joint Surg [Br] 1990; 72: 116-20. 99. Seligson D, Stanwyck TS. The general technique of external fixation. In: Seligson D, Pope M. Concepts in external fixation. New York: Grune and Stratton, 1982: 79-107. 100. Goodship AE, Kenwright J. The influence of induced micrcmovement upon the healing of experimental tibia1 fractures. J Bone Joint Surg [Br] 1985; 67: 650-5. 101. Kenwright J, Go&hip AE. Controlled mechanical stimulation in the treatment of tibia1 fractures. Clin Orthop 1989; 241: 3647. 102. McGraw JM, Lim EVA. Treatment of open tibial-shaft fractures. J Bone Joint Surg [Am] 1988; 70: 900-l 1. 103. Halloran WX. Flexibility and the callus formula [letter]. Clin Orthop 1988; 234: 308-9. 104. Vaubel E, Gorkisch K, Linke K. Polyurethane skin substitute for temporary covering of wounds. Fortschr Med 1980; 35: 1351556. 105. Polk HC Jr. Non-specific host defense stimulation in the reduction of surgical infection in man [editorial]. Br J Surg 1987; 74: 969-70. 106. Brown GL, Curtsinder LJ, White M, et al. Acceleration of tensile strength of incisions treated with EGF and TFB-beta. Ann Surg 1988; 208: 788-94. 107. Brown GL, Nanney LB, Griffin J, et al. Enhancement of wound healing by topical treatment with epidermal growth factor. N Engl J Med 1989; 321: 76-9. 108. Schamagl E. Haut-Weichteilersatz am Unterschenkel-Therapie und Prophylaxe der Osteomyelitis. Handchir Mikrochir Plast Chir 1986; 18: 128-34. 109. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattanec R. Ilizarov treatment of tibia1 nonunions with bone loss. Clin Orthop 1989; 241: 146-65. 110. Aronson J, Johnson E, Harp JH. Local bone transportation for treatment of intercalary defects by the Ilizarov technique. Clin Grthop 1989; 243: 71-9. 111. Heatley FW. Severe open fractures of the tibia: the courage to amputate. BMJ 1988; 296: 229.
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David Seligson,
MD,
Stephen L. Henry,
Management of compound fractures remains a challenge to the surgeon. Methods to decrease patient morbidity include early fracture stabilization and sequential dgbridement. External fixation remains the standard; however, early internal fixation in low-grade injuries may be an acceptable option. Early soft tissue coverage is critical. The use of prophylactic parenteral antibiotics has decreased the incidence of acute infection and chronic osteomyelitis. Supplemental use of local antibiotic polymethyl methacrylate (PMMA) beads appears to further diminish the morbidity in high-grade open fractures.
he smallest puncture passing directly to the substance of a fractured bone adds difficulty to the method of T cure, and hazard to the event” [I]. The best definition is an old one: when a fracture communicates with the atmosphere, it is compound. This diagnosis covers a wide spectrum of mechanisms of injury resulting from a bone-smashing accident. Such comminution occurs when a car bumper strikes the subcutaneous cortex of the tibia or may result from a slow pirouetting fall where the glass-sharp tip of a spiral fracture of the femur lacerates the skin from within. Whatever the cause, this injury remains an important concern of the surgical profession. From the Department of Orthopedic Surgery, University of Louisville, Louisville, Kentucky. Requests for reprints should be addressed to David Seligson, MD, Deoartment of Orthooedics. Universitv of Louisville. Louisville. Kentucky40292. Manuscript submitted February 6, 1990, and accepted in revised form September 25.1990.
Fractures
MD, Louisville, Kentucky
For most of recorded history, open fractures have been considered potentially lethal. So much so that when amputation became safe and humane, it became the most appropriate therapy for contaminated compound fractures [2,3]. Percival Pott achieved considerable notoriety for insisting on careful transport, cleansing, and nonoperative treatment for his own compound ankle fracture [4]. Study of the bacterial environment and the utility of scientifically decontaminating compound fracture wounds by Dakin and Carrel in World War I paved the way in the Second World War for staged management of compound fractures with the realistic goal of saving functional limbs [ 51. Today, an impressive array of evolving technologies in microsurgery, antimicrobial therapy, and osteosynthesis is available for the treatment of compound fractures [a. A cautious approach is required for these patients since traumatic injury is the leading cause of loss of productivity before age 65 [ 71. Approximately one eighth of the hospital beds in the United States are occupied by patients as a result of musculoskeletal injuries [8]. Of these injuries, compound fractures frequently require long hospitalization, multiple surgical procedures, and expensive medications. The true extent of morbidity from this condition is unknown since compound fractures are not a reportable disease. The purpose of this review is to present the current state of the art and indicate new directions in the management of this seriously debilitating injury. DEFINITIONS Since compound fractures constitute a wide spectrum of bony injury, there has been an effort to classify them for an accurate comparison of the results from one series to another. The classification of Gustib and Anderson [9] is the most commonly used one in North America. The wound is graded as I, II, or III depending upon the degree of soft tissue damage [IO]. A grade I wound measures less than 1 cm, a grade II wound measures 1 to 10 cm, and grade III has either extensive soft tissue damage, a segmental fracture, marked contamination, or vascular injury. Recently, group III wounds were divided into IIIA, in which local soft tissue coverage is possible; BIB, in which soft tissue transfer for coverage is required; and IIIC, in which there is arterial injury requiring repair [ 1I-I 31. Gustilo [ 121 has modified his classification to recognize several risk factors: presence of significant contamination and the length of time between injury and debridement. The mechanistic approach of Allgower places fractures in equivalent groups: a grade I fracture is a puncture wound made by the bone (an “inside-out”); a grade II wound is the result of direct trauma from without (“outside-in”); and a grade III wound is extensive and involves the neurovascular bundle [14,15]. The classifications of
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additive [20]. Difficult compound fractures share a high incidence of delayed healing, chronic infection, and limb amputation and frequently require resource-intensive therapy [I9,21-231.
Flgure 1. are evident. The skin laceration Wasless than 0 cm, resulting in the classlflcation of this complex fracture as a grad8 II open fracture.
GOALS The goal of treatment of a compound fracture is to restore the limb to the pre-injury condition. For practical purposes, this should be defined as a functional limb with an uninfected fracture union. The principal goals are prevention of infection, soft tissue coverage, and fracture union. There are, however, a long list of local and systemic conditions that can occur as a result of the injury that must be evaluated in considering the overall quality of the result. These include joint stiffness and post-traumatic arthritis, causalgia and other alterations of sensation, chronic venous and lymphatic stasis, and abnormalities of limb length and alignment. Post-fracture morbidity must be evaluated in terms of the patient’s age, job, socioeconomic status, and the site and complexity of the injury. There is too little emphasis on length, morbidity, and cost of treatment and poor documentation of the accurate long-term incapacity this injury causes [23-251. The patient with an extremity fracture is likely to have a coexisting behavioral disorder ranging from alcohol or substance abuse to overt psychosis [26]. If treatment aggravates a co-morbidity to produce a dysfunctional individual, then treatment has not succeeded. Goal setting with the patient and family must include the question of the limb as well as a comprehensive discussion of all phases of rehabilitation including return-to-work [22], Tsai et al [24] have thoughtfully reported that the complete treatment regimen for complicated compound fractures should be accomplished in 1 year. This is a reasonable goal. The alternative to limb salvage is amputation [3,23,27]. When considering this procedure, the physician should be aware that the psychologic cost of an amputation to the individual is considerable. Esterhai et al compared patients with limb salvage to those with amputations and documented marked negative attitudes and residual bitterness due to the loss of the limb (unpublished data) [28]. As will be developed, restoration of a noninfected, functional limb after an open fracture is an age-old goal that has progressively become the expectation during our lifetimes.
Cauchoix et al [ I6j and Oestern and Tscheme [171 categorize compound fractures in a manner similar to that of burns. In a grade I or II wound, there is partial-thickness soft tissue damage, while a grade III injury has loss of soft tissue coverage. The most comprehensive report on this topic was by Edwards [ 181, who characterized compound fractures not only by their location and amount of contamination but also by the extent of damage to each of the constituents of the limb-skin, fascia, muscle, neurovascular bundle, periosteum, and bone. The deficiency of the Gustilo system is that certain high-energy injuries with degloving of soft tissue and marked periosteal stripping are associated with limited wounds (Figure 1). Complexity in classification may be the enemy of progress. In reality, there are two large groups of compound fractures-simple and complex. Simple compound fractures can be irrigated, dbbrided, and then treated as a closed fracture with the expectation that the fracture will heal in the usual time. Complex fractures have special characteristics-loss of bone or soft tissue, periosteal stripping, marked contamination, or arterial injury [13]. Each of these difficulties requires individualized therapeutic management: tissue grafting, compartment release, arterial repair [29]. These morbidities are
INITIAL TREATMENT Dhbridement: Compound fractures are medical emergencies. The standard of practice requires d&bridement of the wound and stabilization of the bone. Failure to act risks osteomyelitis and loss of limb. There are, however, other emergent conditions in the complete management of a severely injured patient and here the organization of initial treatment requires experience, skill, and thought. The need to operatively attend to a compound fracture can be delayed no longer than 6 to 8 hours without compromising the injured limb [II]. DBbridement and stabilization are the goals of initial fracture care [29,30]. Dhbridement originally meant unbridling, removing restraints, fasciotomy [31]. The mod-
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ern usage of dkbridement appears in the writing of Trueta [32]. Today, it is defined as a surgical excision of contaminated and nonviable tissue from an open fracture wound. For major long bones, this operative management is best performed in an operating room. Bone, muscle, fascia, subcutaneous tissue, and skin require different attention. It has been two decades since the Vietnam War, in which current methods and guidelines for safe wound management were developed [33,34]. The basic recommended procedure is to resect all devitalized tissue and thoroughly irrigate the wound. In general, a narrow margin of normal tissue is removed. This resection is minimal for skin but generous in subcutaneous tissue. Muscle is cut to brisk, bleeding, and contractile tissue. Fascial envelopes are incised; a good mechanical cleansing of bone is performed. In diaphyseal fractures, the ends of the bone are grasped, delivered into the field, and visually inspected for foreign debris. The skin overlying the fracture is extended as needed to accomplish the irrigation. The wound is copiously irrigated and dressed open. No transportation of tissue is performed at an initial dhbridement: “of the edge of the skin take a piece very thin The tighter the fascia the more you should slasher of muscle much more till you see fresh gore And bundles contract at the least impact leave intact the bone except bits quite alone [33].”
Figure 2. Grade IllB tibia1shaft frame managed acutely with antibioticbeads and stabilizedwith external fixation.
Several details deserve comment: With clean lacerations and timely dbbridement, there is no need to remove ment of compound fractures is preferable [21,30,38, the skin margin. In areas in which coverage is critical, 391. However, impressive evidence has accumulated that such as the anterior surface of the leg, too much di5bridement is not advised and may complicate closure. Skin under carefully controlled conditions the acute closure of that is contused can frequently be left and its viability compound fractures is safe, reduces morbidity, and has assessed at subsequent stages. The subcutaneous tissue an acceptable infection rate [40-441. Closure consists of and particularly subcutaneous veins should be generously nonabsorbable sutures to repair important tendons; fasexcised. Venous thrombosis tends to propagate and com- cial envelopes are left open; and the skin is closed loosely without tension over suction drains. promise potentially viable tissue. If certain wound conditions can be met, debridement, Muscle should also be dtbrided generously, but it is not necessary to develop the planes between muscle bel- rigid fracture stabilization, and wound closure can be lies. Scully and co-workers’ [35] four C’s-color, capaci- performed as the initial treatment for a compound fracty to bleed, contractibility, and consistency-are useful ture. These conditions are as follows: 1. Treatment is undertaken within 6 to 8 hours of guides. The surface of muscle is made smooth and contoured. Viability cannot be determined either by the pres- injury [45,46]. ence of bleeding or muscle contraction when cut, since 2. D6bridement results in a surgically clean wound. 3. Closure can be performed simply and without tenlocal vasospastic phenomena may occur. Only sequential sion. dhbridement will establish the vitality of muscle. 4. Follow-up of the wound will be under the superviIt is no longer acceptable to sterilize and reinsert pieces of cortical bone that are found at an accident site: loose sion of the surgeon who did the initial treatment [47]. Stabilization (fracture fixation) : The major addetached fragments should be removed even if they are important for stability [29,36,37]. Initial fracture immo- vance in this area during the past 20 years has been the bilization through the Vietnam era was plaster splinting, widespread introduction of external skeletal fixation for casting, or skeletal traction [33,34]. Immediate wound the initial management of open fractures [36,48-531. closure was prohibited. A body of opinion continues to External fixateurs are systems that include pins, clamps, hold that the completely open method of wound treat- and connectors that achieve skeletal stability (F’Igure 2). THE AMERICAN
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DEFINITIVE
Figure 3. Complex soft tissue loss with severe fracture commiw tion is best managed wfth extemal fixation and early soft tissue Coverage.
Originally, external fixation was used in a short field trial by the Allies at the start of World War II. The results were so poor that their use was soon abandoned. Fixateurs were popularized by Vidal’s group [48] in Montpellier for the management of devastating open skeletal trauma and have achieved wide acceptance, particularly in patients with multiple trauma [22,36,49,53551. Frame design has evolved from double frames utilizing transfixing pins [56,57] to uniaxial designs utilizing bicortical half-pins [58]. Antibiotics, irrigation, and tetanus prophylaxis complete the standard regimen for initial care of compound fractures. In the operating room, the wound is sequentially ddbrided and irrigated with saline or antibiotic-containing irrigant (bacitracin, cefamandole, neomycinpolymyxin, etc.) [ 151. Evidence based on the retrieval of particulate matter from wounds suggests that focused pressurized irrigation either with a syringe or pulsatile irrigator reduces the bacterial burden of the wound [59]. Copious quantities of fluid have often been recommended, e.g., greater than 10 L. These practices have not been shown to be of significant benefit in comparison with bulb syringe irrigation. Air embolism has been reported after pulsed lavage of a pelvic fracture [60]. Systemic antibiotics should be administered from the time of dbbridement until a stable closed wound has been achieved [9,42,43,46,61-641.’ The regimen for severe compound fractures includes penicillin, a cephalosporin, and an aminoglycoside [62] (example: penicillin G 2 million units every 6 hours, cefazolin 1 g every 6 hours, and amikacin 500 mg every 8 hours. There is no evidence that antibiotic therapy prior to dbbridement is helpful except in situations of known contamination-creek-river injuries, barnyard accidents, and/or animal bites. Long courses of parenteral antibiotics in patients with stable wounds are probably not necessary [42,64,65]. In complex grade III wounds, repeat ddbridements at intervals of 2 to 3 days are often necessary to secure a clean wound that can be closed [36,43,45,64. 696
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The definitive management of a compound fracture requires stabilization of the bone and provision of soft tissue coverage. For most compound fractures, fracture stabilization is accomplished at the time of the initial treatment [45]. Once an intramedullary nail has been inserted to stabilize a diaphyseal fracture or a muscle flap has been mobilized to cover an area of soft tissue loss, an irreversible step has been taken with the hope that the clinical problem will be solved. In several retrospective reviews, the immediate and definitive stabilization of compound fractures of both the upper and lower limbs resulted in better outcomes than when stabilization was delayed [40,41,44,67]. Similarly, immediate free-flaps for the coverage of soft tissue defects has been reported to have a better success rate than delayed flap coverage [45,68,69]. Definitive management of the bone can be nonoperative by manipulation, reduction, and placement of an external orthosis, or operative by reduction and internal fmation with intramedullary nails, external fmateurs, or plates and screws [21,46,70,71]. Although immediate plate fmation [15,67,72] and formal intramedullary nailing [73-751 have been performed in all grades of compound fractures, these methods are not generally acceptable because the consequence of failure is too great [30]. Simply inserting a bone screw in an experimentally contaminated wound increases the incidence of infection [ 74. External fixation is the current method of choice for the initial treatment of most complicated compound fractures [13,51,52] (Figure 3). Insertion of multiple intramedullary pins (flexible or Ender nailing) has been re ported from several centers [77,78]. Advocates of these methods emphasize short operating times with little damage to the medullary blood supply [63]. An alternative point of view holds that the blood supply to bone is damaged by the injury and that flexible fixation has a high complication rate and provides inadequate stability. It has been generally shown that following d&bridement, straightforward (grade I or II) compound fractures can be treated in the same manner as closed fractures with similar infection and healing rates [75,78]. It is in the difficult or complicated compound fractures that invasive fracture surgery with intramedullary nails or plates and screws can lead to serious late complications [22,79]. A method with high biologic costs, such as intramedullary nailing, is acceptable in a bone with extraordinarily good vascularity such as the femur even if there has been compounding: the excellent mechanical condition provided by the nail will eventually lead to fracture healing since the blood supply is supra-abundant [63,75,80]. Converse ly, plate fixation in areas of vascular insufficiency, i.e., the tibia, can lead to infection, nonunion with plate failure, and deformity unless a plan for coverage produces substantial improvement in local wound condition. Fracture stabilization and the provision of adequate soft tissue coverage must be achieved after the general medical condition of the patient has been addressed. Increasing evidence suggests that early fracture stabilization will improve the general condition of the patient and
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result in a decreased incidence of complications [ 12,15,41,81-83]. Since there are many methods to gain control of an unstable fracture, an assessment of multiple organ function is required to determine if the patient can successfully withstand the procedure that is proposed for the definitive treatment of the injured extremity. The high-grade compound fracture with extensive soft tissue maceration can present a significant added stress to a patient’s physiologic reserve [3,20]. In the event that a patient has limited biologic resources in combination with a complex constellation of injuries, amputation of an extremity may be the only means to save a life. This requires bold and mature surgical judgement [23,27]. The definitive treatment of both the fracture and the soft tissues is a team problem [45,74]. On the one hand, the skeleton is dependent on motion and load for its maintenance. Soft tissues, on the other hand, require moderate elevation and immobilization, particularly in the early phases of wound healing. Weight-bearing ambulation might be desirable to impact fracture ends after a stable tibia nailing, while the same forces would compromise healing a split-thickness skin graft that had been placed to cover a muscle flap. The postoperative rehabilitation program needs careful planning. It is almost always true that it is easier and more successful to perform the transfer of soft tissues in the presence of skeletal stability. One of the contributions of the Montpellier group has been to organize flow diagrams for the rational reconstruction of severe compound fractures [84]. REHABILITATION Evidence is accumulating that the combined management of difficult compound fractures by specialists in orthopedics, vascular surgery, and plastic surgery can improve functional results [29,66]. A review of the literature, however, reveals articles that focus on specific specialty issues such as management of soft tissue coverage [24,69&j], prevention of infectious complications [43,86-891, methods of fracture fixation [55,58], and techniques to secure bone union. Parenthetically, the evidence points not only to the advances that can be made in improving the results of treatment of compound fractures but also the tremendous morbidity of this injury. Gustilo and Anderson [9] compared results in two series from 1955 to 1968 and from 1969 to 1973 and reported a marked decrease in late complications in the second series with a protocol management of decreased use of internal fixation, open treatment of grade III injuries, and use of antibiotics. The infection rate for grade III injuries declined from 44% to 10%. Weise et al [53] reported that 85% of 159 second- and third-degree fractures healed at an average of 5.4 months with an 18.7% infection rate. They believed that protection of the wound, expeditious operative debridement, and use of artificial wound dressings improved results. Despite provision of good soft tissue coverage, many compound fractures initially treated with external skeletal fixation fail to show signs of fracture healing. In a consecutive series of 5 1 compound tibia fractures treated with external fmation, half (26) of the fractures had delay THE AMERICAN
in healing past 14 weeks. These 26 tibias then took from 14 to 139 weeks (mean: 60 weeks) to heal [90]. Solutions to this problem include early cancellous bone grafting [91], sometimes in combination with a change to another fracture treatment strategy. In a series of 56 compound tibia fractures, 23 cases of delayed union were treated with lixateur removal, bone plate fixation, and cancellous grafting 13.2 weeks after the fracture. Solid union was obtained in 18 of these cases [50]. In a critical review of results of treatment of compound tibia fractures, Rommens et al [92] found 6% of grade I compound fractures, 29% of grade II fractures, and 60% of grade III fractures required two or more proceduresmost commonly cancellous bone grafting. End results were poor in 24% of the grade III fractures. Gustilo and co-workers [131 reported comparable complication rates of infection (13.7%), amputation (l&7%), and nonunion (18.5%) in grade III compound fractures. Similarly, Green et al [87] found bone plating and cancellous grafting much more successful than fibular osteotomy or bone plating alone in treating problem tibia1 nonunions mostly following compound fracture. Other methods (nailing, external fmation) yielded intermediate results. Edwards er al [36] followed 17 1 consecutive grade III tibia shaft fractures treated with primary external fixation and serial wound dtbridement. Ninety-three percent of the fractures united with a medium time to union of 9 months. There was a 15% rate of infection and a 7% incidence of late amputation. Bone loss and infection were associated with prolonged healing. The authors emphasized that cancellous bone graft was important and should be repeated if necessary. Early wound coverage has been reported to enhance healing and reduce complications [68,69,88,93]. Cierny ef al [94] studied 36 type III tibia fractures in which wound coverage was achieved within 30 days of injury. In 24 fractures in which the wound was closed by the seventh day, the mean time to union was 4 months and the incidence of problem wound healing was 20.8%. Those wounds that closed between 8 and 30 days had a mean time to union of 6.4 months and a 83.3% incidence of wound complications [94]. Associated vascular injury suggests a particularly poor prognosis especially below the level of the knee [ 13,951. Amputation rates have been reported to be 50% [96]. Long ischemia times and internal but not external fixation increase the risk of amputation [19,97,98]. The role of microvascular free tissue transfer [24,93] in improving limb salvage is better established in the upper than the lower limb [85]. There are two principal trends in the late-phase management of fractures initially stabilized with an external fmateur [99]. On the one hand, a new generation of mechanically versatile fixateurs has been introduced. These appliances allow for modifications of frame stiffness and encourage callus formation by axial loading. When the soft tissue envelope is stable (4 to 6 weeks), the connecting rods of the fixateur are released by removing a set screw. This permits limited pistoning at the fracture with loading (walking). In a further variation of this JOURNAL
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Figure 4.Top left, malepatient who sustained grade NIB tibia1 and IIIA mid-foot compound fractures. Top right, this severely contaminated mower injuy was tibrlded, stabilized wlth external fixation, and managed with antibiotic impregnated beads and OpSlte coverage. Bottom left, the antibiotic bead pouch permits collectlon of hematoma wlth extremely high levels of antibiotic released by the beads. Bottom right, on day 6 following two d6brldements, a primary ankle fusion and skin closure over beads was performed. The wound healed uneventfully and at 30 months there was no evidence of Infection.
concept, the telescoping element is cycled by a machine that the patient can plug in [lOO,lOl]. An alternative point of view holds that after initial stabilization, the fixateur is an encumbrance to fracture management. In this concept, early (usually 6 to 8 weeks) removal of the fmateur and change to a nonoperative (casting or bracing [22]) or operative strategy (nailing [55] or plating [SO]) is advocated. These approaches work best when bone and soft tissue vitality is good: the operative strategies have an appreciable risk of infection [102]. When healing is delayed, the problem is most likely the biology at the fracture site rather than the device [68,92]. The underlying principle is outlined in Halloran’s [80,203] callous formula. According to this concept, fracture healing or callous formation is dependent upon micro-motion between the fracture fragments and the vascularity at the fracture site. This concept explains why fractures of well-vascularized areas, such as the humerus and femur, heal more efficiently than fractures in bones with less muscular and soft tissue coverage such as the tibia and ulna. Logically, operations, i.e., plate fixation, 698
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that further devascularize the fracture site can be expected to have high complication rates. Improving the conditions for functional fracture healing and securing adequate soft tissue coverage are thus complimentary goals that have a unique solution for each compound fracture [21,68,74,84]. THE FUTURE There are several promising areas in improving the results of treatment of compound fractures. New ap proaches for improving fracture healing include introduction of bioelectric stimulators, which often use the external fixateur pins as electrodes, and new synthetic materials as autogenous bone graft substitutes, i.e., Collagraft. These include substances that serve as matrix for bone ingrowth (osteoconductors) and substances that stimulate bone growth (osteoinductors). New materials have been introduced for wound management. These include the implantation of antibioticimpregnated bone cement beads at initial dhbridement and use of porous plastic skin substitutes [38,66,89,104] (Figure4). These approaches have been shown to reduce
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the rate of infection and accelerate wound granulation. At our institution, grade III compound fractures prophylactically treated with tobramycin polymethyl methacrylate (PMMA) beads had 5m fewer wound infections and osteomyelitis than those treated with systemic antibiotics alone. Prospective trials are currently focusing on the biology of the wound environment, the value of local versus systemic antibiotic therapy, and possible approaches to immune system enhancement to prevent infection [ IO51 and accelerate wound healing [ 106,107]. In particularly severe injuries, there is continued interest in microsurgical methods to restore vitality by transplanting skin, soft tissue [45], and bone into an area of deficit. Fracture healing is markedly enhanced by improving local vascularity in the compromised extremity. Radical debridement and acute free tissue transfer are being attempted in an effort to reduce the morbidity of severe devitalizing injuries. The treatment of osteomyelitis may provide a model for dead space management with PMMA antibiotic-laden chains and immediate free flap coverage [1081. Although free flaps have an appreciable failure rate, they have a lower infection rate than local muscle flaps [ 291. Expansion of soft tissue and bone by gradual mechanical stimulation will receive a major trial in the near future [ 1091. This method has been developed by Professor Ilizarov of Churgin, Siberia, over the past 20 years. It calls for rigid stabilization of the extremity in a fine wire circular external fixateur and gradual elongation of the limb to fill bone and soft tissue defects [1lo]. It remains to be seen whether this method will work reliably when used by many surgeons under varying clinical circumstances. The greatest progress will be made in the next decade by an increased understanding of the morbidity from compound fractures. The initial treatment of injury is an area of surgical decision making that has been relatively free from regulation by government and third-party payers. The accurate categorization of compound fractures, assessment of the risks and benefits of treatment, and evaluation of end results will increasingly shape decisionmaking in future years. Currently, the patient’s desire to save a limb at all costs governs the increasing expenditure of resources [I 1I]. In a particularly provocative recent essay, Professor Sigvard T. Hansen, Jr., [27] pointed to the need to have the courage to amputate severely damaged limbs. What is clearly needed is research to identify both local and systemic markers to assist in decisionmaking [6,19,20,23,95]. The trail of morbidity, loss of productivity, and high cost of therapy will be categorized and regulated by providers unless traumatologists are able to reach an improved standard of care and better consensus about appropriate and medically necessary therapeutic adventures in the care of these devastating injuries. The study of progress in the care of compound fractures is the study of the history of surgery itself [2], for these injuries have been survivable since the prehistory of medicine. They continue to provide a challenge to surgeons everywhere to preserve vitality, restore function, and offer humane treatment.
REFERENCES 1. Bell B. A system of surgery. 2nd American edition, Vol. III. Troy, New York: 0. Penniman and Co., 1804: 371. 2. Aldea PA, Shaw WW. The evolution of the surgical management of severe lower extremity trauma. Clin Plast Surg 1986; 13: 549-69. 3. Kirk NT. The classic: amputations. Clin Orthop 1989; 243: 316. 4. Rang M. Anthology of Orthopaedics. Edinburgh: E. & S. Livingstone Ltd., 1968: 7-8, 99-102. 5. Carrel A, Dehelly G. The treatment of infected wounds. New York: Paul B. Hoeber, 1917. 6. Burri C, Stober R. Indikation zur sofortigen oder verspateten Amputation bei schweren Weichteil-und Skeletverletzungen am distalen Unterschenkel. Lange&e&s Arch Chir 1986; 369: 621-3. 7. Committee on Trauma Research. Injury in America: a continuing public health problem. Washington, DC: National Academy Press, 1985. 8. American Academy of Orthopaedic Surgeons. Musculoskeletal system research: current and future research needs. Chicago: American Academy of Orthopaedic Surgeons, 1981: 148. 9. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1,025 open fractures of long bones: retrospective and prospective analysis. J Bone Joint Surg [Am] 1976; 58: 453-8. 10. Gustilo RB, Merkow RL, Templeman D. Current concepts review: the management of open fractures. J Bone Joint Surg [Am] 1990; 72: 299-304. 11. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984; 24: 742-6. 12. Gustilo RB. Current concepts in the management of open fractures. In: Griffin PP, ed. American Academy of Orthopaedic Surgeons Instructional Course Lectures 1987; 36: 359-66. 13. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 1987; 10: 1781-8. 14. Allgower M. Weichteilprobleme und Infektionsrisiko der Osteosynthese. Lange&&s Arch Chir 1971; 329: 1127-36. 15. La Duca JN, Bone LL, Seibel RW, Border JR. Primary open reduction and internal fixation of open fractures. J Trauma 1980; 20: 580-6. 16. Cauchoix J, Duparc J, Boulez P. Traitement des fractures ouvertes de jambe. Med Acta Chir 1975; 83: 811. 17. Oestern HJ, Tscherne H. Pathophysiology and classification of soft-tissue injuries associated with fractures. In: Tscherne H, Gotzen L, eds. Fractures with soft-tissue injuries. New York: SpringerVerlag, 1984: l-9. 18. Edwards P. Fracture of the shaft of the tibia: 492 consecutive cases in adults. Acta Orthop Stand 1965; 76: (39 Suppl): l82. 19. Lange RH, Bach AW, Hansen ST, Jr, Johansen KH. Open tibia1 fractures with associated vascular injuries: prognosis for limb salvage. J Trauma 1985; 25: 203-8. 20. Gregory RT, Gould RJ, Peclet M, et al. The mangled extremity syndrome (M.E.S.): a severity grading system for multi-system injury of the extremity. J Trauma 1985; 25: 1147-50. 21. Clancey GJ, Hansen ST Jr. Open fractures of the tibia. J Bone Joint Surg [Am] 1978; 60: 118-22. 22. Augeneder M, Boszotta H, Sauer G. Zur Behandlung der offenen Unterschenkelfraktur mit dem Fixateur externe. Unfallchirurgie 1989; 92: 531-6. 23. Lange RH. Limb reconstruction versus amputation decision making in massive lower extremity trauma. Clin Orthop 1989; 243: 92-9. 24. Tsai T-M, Werntz JR, Kirkpatrick DK, Harkess JW. Freetissue transfer in type III open lower extremity fractures. Surgical Rounds for Orthopaedics, May 1988: 17-23. 25. Purry NA, Hannon MA. How successful is below-knee amputation for injury? Injury 1989; 20: 32-6.
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26. Kuhn WF, Bell RA, Netscher RE, Seligson D, Kuhn SJ. Psychiatric assessment of leg fracture patients: a pilot study. Int J Psychiatry Med 1989; 19: 145-54. 27. Hansen ST Jr. The typeIIIC tibia1 fracture. Salvage or amputation [editorial]? J Bone Joint Surg [Am] 1987; 69: 799-800. 28. Esterhai JL, Lerner RK, Polomano RC, Heppenstall BR, Brighton CT, Cheatle MD. Psychosocial sequelae of treatment of osteomyelitis: non-union and amputation (unpublished data). 29. Yaremchuk MJ. Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity. Clin Plast Surg 1986; 13: 621-9. 30. Welz V. Ergebnisse der Behandlung offener Femurschaftbriiche. Erwachsenen Beite Orthop Traumatol 1987; 34: 605-13. 31. Andral G, &gin L, Blandin P, et al. Dictionnaire de m&lecine et de chirurgie practique. Paris: MQtigron-Marvis, J.-B. Baillibre, 1831. 32. Trueta J. Treatment of war wounds and fractures. New York: Paul B. Hoeber, Inc., 1940. 33. CINCPAC Third Conference on War Surgery. Camp H.M. Smith, Hawaii, January 20-23, 1969: 53. 34. CINCPAC Fourth Conference on War Surgery. Tokyo, Japan, February 16-19, 1970: 11. 35. Scully RE, Artz CP, Sako Y. An evaluation of the surgeon’s criteria for determining viability of muscle during debridement. Arch Surg 1956; 73: 1031-5. 36. Edwards CC, Simmons SC, Browner BD, Weigd MC. Severe open tibia1 fractures. Clin Orthop 1988; 230: 98-l 15. 37. Swiontkowski MF. Criteria for bone dbbridement in massive lower limb trauma. Clin Orthop 1989; 243: 41-7. 38. Knapp A, Weller S. Care of soft-tissues in open fractures. Aktuel Traumatol 1978; 8: 319-27. 39. Russell GG, Henderson R, Amett G. Primary or delayed closure for open tibia1 fractures. J Bone Joint Surg [Br] 1990; 72: 125-8. 40. Davis AG. Primary closure of compound fracture wounds, with immediate internal fixation, immediate skin graft, and compression dressings. J Bone Joint Surg [Am] 1948; 30: 405-15. 41. Chapman MW, Mahoney M. The role of early internal fmation in the management of open fractures. Clin Orthop 1979; 138: 12031. 42. Antrum RM, Solomkin JS. A review of antibiotic prophylaxis for open fractures. Orthop Rev 1987; 16: 246-54. 43. Patzakis MJ. Management of open fracture wounds. In: Griffin PP, ed. American Academy of Orthopaedic Surgeons Instructional Course. Lectures, 1987; 36: 367-9. 44. Rittmann WW, Schibli M, Matter P, Allgower M. Open fractures: long-term results in 200 consecutive cases. Clin Orthop 1979; 138: 132-40. 45. Byrd HS, Cierny G III, Tebbetts JB. The management of open tibia1 fractures with associated soft-tissue loss: external pin fuation with early flap coverage. J Plast Reconstr Surg 1981; 68: 73-9. 46. Scott WO, Grantham SA. The open fracture. Orthop Rev 1985; 14: 49-56. 47. Seligson D, Bailey R. Traumatic amputations: a Vietnam experience. Clin Orthop 1976; 114: 304-6. 48. Vidal J, Buscayret CH, Cannes H, Paran M, Allieu Y. Traitement des fractures ouvertes de jambe par le tixateur exteme en double cadre. Rev Chir Orthop 1976; 62: 433-48. 49. Edwards CC, Jaworski MF, Solana J, Aronson BS. Management of compound tibia1 fractures using external fixation. Am J Surg 1979; 45: 190-203. 50. Etter C, Burri C, Claes L, Kinzl L, Raible M. Treatment by external fixation of open fractures associated with severe soft tissue damage of the leg. Clin Orthop 1983; 178: 80-8. 5 I. Karlstrom G, Olerud S. External fixation of severe open tibia1 fractures with the Hoffmann frame. Cim Orthop 1983; 180: 68-77. 52, Larsson K, Van der Linden W. Open tibia1shaft fractures. Clin Orthop 1983; 180: 63-7. 53. Weise K, Holz U, Sauer N. Zweit-bis drittgradig offene Frak-
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turen Langer Rbhrenknochen-therapeutisches. Management turd Behandlungsergebnisse Aktuel Traumatol 1983; 13: 24-9. 54. Seligson D, Dudey D. Historical introduction. In: Seligson D, Pope M, eds. Concepts in external fixation. New York: Grune and Stratton, 1982: 3-12. 55. Aho AJ, Nieminen SJ, Nylamo EJ. External fixation by Hoffmann-Vidal-Adrey osteotaxis for severe tibia1 fractures. Clin Orthop 1983; 181: 154-64. 56. Karlstrom J, Olerud S. Percutaneous pin fixation of open tibia1 fractures. Double frame anchorage using the Vidal-Adrey method. J Bone Joint Surg [Am] 1975; 57: 915-24. 57.Velazco A, Fleming LL. Open fractures of the tibia treated by the Hoffmann external fmateur. Clin Orthop 1983; 180: 125-32. 58. Behrens F, Comfort TH, Searls K, Denis F, Young JT. Unilateral external faation for severe open tibia1 fractures. Clin Orthop 1983; 178: 111-20. 59. Gross A, Cutright DE, Bhaskar SN. Effectiveness of pulsing water jet lavage in treatment of contaminated crushed wounds. Am J Surg 1972; 124: 373-7. 60. Brunicardi FC, Scalea TM, Bernstein MO, Sclafani SSJ, Phillips TF. Air embolism during pulsed saline irrigation of an open pelvic fracture: case report. J Trauma 1989; 29: 700-l. 61. Patzakis MJ, Harvey SP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg [Am] 1974; 56: 532-41. 62. Pat&is MJ, Wilkins J, Moore TM. Use of antibiotics in open tibia1 fractures. Clin Orthop 1983; 178: 31-5. 63. Chapman MW. The role of intramedullary fvration in open fractures. Clin Orthop 1986; 212: 26-34. 64. Braun R, Enzler MA, Rittmann WW. A double-blind clinical trial of prophylactic cloxacillin in open fractures. J Orthop Trauma 1987; 1: 12-7. 65. Dellinger EP, Caplan ES, Weaver LD, et al. Duration of preventive antibiotic administration for open extremity fractures. Ann Surg 1988; 123: 333-9. 66. Seligson D, Banis J, Matheny L. Tibia terrible. In: Coombs R, Green SA, Sarmiento A, eds. External fixation and functional bracing. London: Orthotext, 1989: 281-4. 67. Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg [Am] 1986; 68: 1008-17. 68. Byrd HS, Spicer TE, Cierney G III. Management of open tibia1 fractures. J Plast Reconstr Surg 1985; 76: 719-30. 69. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. J Plast Reconstr Surg 1986; 78: 285-92. 70. Dabezies EJ, D’Ambrosia R, Shoji H, Norris R, Murphy G. Fractures of the femoral shaft treated by external fnation with the Wagner device. J Bone Joint Surg [Am] 1984; 66: 360-4. 71. Wiss DA, Gilbert P, Merritt PO, Sarmiento A. Immediate internal furation of open ankle fractures. J Grthop Trauma 1988; 2: 265-71. 72. Von Langenberg R. Ergebnisse der operativen Therapie von offenen Tibiaschaftfrakturen. Zentralbl Chir 1987; 112: 1508-14. 73. Velazco A, Whitesides TE Jr, Fleming LL. Open fractures of the tibia treated with the Lottes nail. J Bone Joint Surg [Am] 1983; 65: 879-85. 74. Velazco A, Fleming LL, Nahai F. Soft-tissue reconstruction of the leg associated with the use of the Hoffmann external tixator. J Trauma 1983; 23: 1052-7. 75. Lhowe DW, Hansen ST. Immediate nailing of open fractures of the femoral shaft. J Bone Joint Surg [Am] 1988; 70: 812-20. 76. Grewe SR, Stephen BO, Perlino C, Riggins R. Influence of internal fixation on wound infections. J Trauma 1987; 27: 1051-4. 77. Browner BD, Burgess AR, Robertson RJ, Baugher WH, Freedman MT, Edwards CC. Immediate closed antegrade Ender nailing of femoral fractures in polytrauma patients. J Trauma 1984; 24: 921-7. 78. DeLong WG Jr, Born CT, Marcelli E, Shaikh KA, Iannccone WM, Schwab CW. Ender nail fixation in long bone fractures:
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experience in a level I trauma center. J Trauma 1989; 29: 571-6. 79. Bach AW, Hansen ST Jr. Plates versus external fixation in severe open tibia1 shaft fractures. Clin Orthop 1989; 241: 89-94. 80. Halloran WX. Motion. In: Combs R, Green S, Sarmiento A, eds. External fmation and functional bracing. London: Orthotext, 1989: 9-11. 8 1. Riska EB, Von Bonsdorff H, Hakkinen S, et al. Prevention of fat embolism by early internal fmation of fractures in patients with multiple injuries. Injury 1976; 8: 110-6. 82. Kivioja A. Factors affecting the prognosis of multiply injured patients: an analysis of 1169 consecutive cases. Injury 1989; 20: 7780. 83. Bone LB, Johnson KD, Weigelt J, Scheinberg R. Early versus delayed stabilization of femoral fractures. J Bone Joint Surg [Am] 1989; 71: 336-40. 84. Cannes H. Hoffmann’s external anchorage: technique, indications and results. Paris: Gead, 1977. 85. Swartz WM, Mears DC. The role of free-tissue transfers in lower extremity reconstruction. J Plast Reconstr Surg 1985; 76: 364-73. 86. Anderson JT, Gustilo RB. Immediate internal fixation in open fractures. Orthop Clin North Am 1980; 11: 569-77. 87. Green SA, Moore TA, Spohn PJ. Nonunion of the tibia1 shaft. Grthopaedics 1988; 11: 1149-57. 88. Johnson KD, Bone LB, Scheinberg R. Severe open tibia1 fractures: a study protocol. J Orthop Trauma 1988; 2: 175-80. 89. Ostermann PAW, Henry SL, Seligson D. Behandlung von Zweit-und drittgradii komplizierten Tibiaschaftfrakturen mit der PMMA-Kettentaschen-Tech& Unfallchirurgie 1989; 92: 52330. 90. Korkala 0, Antti-Poika I, Karaharju EO. La fixation externe dans les fractures ouvertes de jambe. Rev Chir Orthop 1987; 73: 637-42. 9 1. Heiser TM, Jacobs RR. Complicated extremity fractures. Clin Orthop 1983; 178: 89-95. 92. Rommens P, Broos P, Gruwez JA. Operative results in 124 open fractures of the tibia1 shaft. Unfallchirurgie 1986; 89: 127-31. 93. May JW Jr, Gallico GG III, Lukash FN. Microvascular transfer of free tissue for closure of bone wounds of the distal lower extremity. N Engl J Med 1982; 306: 253-7. 94. Ciemy G III, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibia1 fractures. Clin Grthop 1983; 178: 54-63. 95. Howe HR Jr, Poole GV Jr, Hansen KJ Jr, et al. Salvage of lower extremities following combined orthopedic and vascular trau-
ma. A predictive salvage index. Am Surg 1987; 53: 205-8. 96. Gp den Winkel R, Wet-net E, Glaser F. Repair of vascular injuries associated with tibia1 shaft fractures: early and late results. Vasa 1987; 16: 354-7. 97. Rich NM, Metz CW, Hutton JE Jr, Baugh JH, Hughes CW. Internal versus external fixation of fractures with concomitant vascular injuries in Vietnam. J Trauma 1971; 11: 463-73. 98. Howard PW, Makin GS. Lower limb fractures with associated vascular injury. J Bone Joint Surg [Br] 1990; 72: 116-20. 99. Seligson D, Stanwyck TS. The general technique of external fixation. In: Seligson D, Pope M. Concepts in external fixation. New York: Grune and Stratton, 1982: 79-107. 100. Goodship AE, Kenwright J. The influence of induced micrcmovement upon the healing of experimental tibia1 fractures. J Bone Joint Surg [Br] 1985; 67: 650-5. 101. Kenwright J, Go&hip AE. Controlled mechanical stimulation in the treatment of tibia1 fractures. Clin Orthop 1989; 241: 3647. 102. McGraw JM, Lim EVA. Treatment of open tibial-shaft fractures. J Bone Joint Surg [Am] 1988; 70: 900-l 1. 103. Halloran WX. Flexibility and the callus formula [letter]. Clin Orthop 1988; 234: 308-9. 104. Vaubel E, Gorkisch K, Linke K. Polyurethane skin substitute for temporary covering of wounds. Fortschr Med 1980; 35: 1351556. 105. Polk HC Jr. Non-specific host defense stimulation in the reduction of surgical infection in man [editorial]. Br J Surg 1987; 74: 969-70. 106. Brown GL, Curtsinder LJ, White M, et al. Acceleration of tensile strength of incisions treated with EGF and TFB-beta. Ann Surg 1988; 208: 788-94. 107. Brown GL, Nanney LB, Griffin J, et al. Enhancement of wound healing by topical treatment with epidermal growth factor. N Engl J Med 1989; 321: 76-9. 108. Schamagl E. Haut-Weichteilersatz am Unterschenkel-Therapie und Prophylaxe der Osteomyelitis. Handchir Mikrochir Plast Chir 1986; 18: 128-34. 109. Paley D, Catagni MA, Argnani F, Villa A, Benedetti GB, Cattanec R. Ilizarov treatment of tibia1 nonunions with bone loss. Clin Orthop 1989; 241: 146-65. 110. Aronson J, Johnson E, Harp JH. Local bone transportation for treatment of intercalary defects by the Ilizarov technique. Clin Grthop 1989; 243: 71-9. 111. Heatley FW. Severe open fractures of the tibia: the courage to amputate. BMJ 1988; 296: 229.
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