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Ugeskrift For Laeger Oct 2018Fractures of the ankle joint are among the most frequent fractures encountered in any accident and emergency department. The traditional classification systems, i.e. the... (Review)
Review
Fractures of the ankle joint are among the most frequent fractures encountered in any accident and emergency department. The traditional classification systems, i.e. the Lauge-Hansen- and the Weber classifications, have proven inadequate, when it comes to deciding, whether treatment should be surgical or conservative. About ten years ago, a stability-based classification was proposed in view of the fact, that the stabilisation of osteosynthesis depends on the stability of the ankle joint. The literature shows excellent long-term results for conservatively treated stable ankle joint fractures.
Topics: Algorithms; Ankle Fractures; Fracture Dislocation; Fractures, Open; Humans; Joint Instability; Postoperative Complications; Radiography
PubMed: 30327083
DOI: No ID Found -
Chinese Journal of Traumatology =... Aug 2018The principles of open fracture management are to manage the overall injury and specifically prevent primary contamination becoming frank infection. The surgical...
The principles of open fracture management are to manage the overall injury and specifically prevent primary contamination becoming frank infection. The surgical management of these complex injuries includes debridement & lavage of the open wound with combined bony and soft tissue reconstruction. Good results depend on early high quality definitive surgery usually with early stable internal fixation and associated soft tissue repair. While all elements of the surgical principles are very important and depend on each other for overall success the most critical element appears to be achieving very early healthy soft tissue cover. As the injuries become more complex this involves progressively more complex soft tissue reconstruction and may even requiring urgent free tissue transfer requiring close co-operative care between orthopaedic and plastic surgeons. Data suggests that the best results are obtained when the whole surgical reconstruction is completed within 48-72 h.
Topics: Debridement; Fractures, Open; Humans; Plastic Surgery Procedures; Surgical Wound Infection; Therapeutic Irrigation
PubMed: 29555119
DOI: 10.1016/j.cjtee.2018.01.002 -
British Journal of Hospital Medicine... Dec 2022Open fractures are complex injuries strongly associated with high-energy trauma. Assessment should include the mechanism and place of injury, timing, associated injuries...
Open fractures are complex injuries strongly associated with high-energy trauma. Assessment should include the mechanism and place of injury, timing, associated injuries and comorbidities. The initial management of these fractures, whether in the prehospital setting or emergency department, must include the following in a prompt manner: administration of antibiotics and tetanus prophylaxis, photography, reduction or re-alignment, wound coverage and splintage. Imaging includes plain X-rays and a computed tomography trauma scan, as well as an angiogram if vessel damage is suspected. Collectively, the energy of the mechanism of injury, with the level of contamination, potential for compartment syndrome and vascular damage, determines the operative urgency. Operative management can be a one- or two-stage procedure, because definitive internal skeletal fixation should only be attempted if soft tissue coverage can occur during the same operation. Ideally, all open fractures should be closed within 72 hours. This article explores the evidence for current best practice.
Topics: Humans; Fractures, Open; Tibial Fractures; Fracture Fixation, Internal; Fracture Fixation; Compartment Syndromes; Treatment Outcome; Retrospective Studies
PubMed: 36594765
DOI: 10.12968/hmed.2021.0578 -
Journal of Perioperative Practice May 2022An open fracture is a fracture which communicates with the external environment through a wound in the skin. Severe open fractures are managed by both orthopaedic and... (Review)
Review
An open fracture is a fracture which communicates with the external environment through a wound in the skin. Severe open fractures are managed by both orthopaedic and plastic surgeons to address injuries in both the bone and soft tissue. This review outlines the management of open fractures in the lower limb from the initial patient presentation to operative management (including debridement, skeletal fixation, definitive soft tissue coverage) according to the standards jointly published by the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Additionally, the decision-making between limb salvage or amputation will be explored. Finally, this review will discuss the patient's postoperative care including wound care and management of potential complications that may arise such as infection, flap failure and fracture non-union.
Topics: Fracture Fixation; Fractures, Open; Humans; Lower Extremity; Retrospective Studies; Soft Tissue Injuries; Tibial Fractures; Treatment Outcome
PubMed: 34214004
DOI: 10.1177/17504589211012150 -
Injury Jun 2022Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high...
BACKGROUND
Despite the low incidence of pilon fractures amongst lower limb injuries, their high impact nature presents difficulties in surgical management and recovery. The high complication rate and long recovery times presents a challenge for surgeons and patients. Current literature is varied, with no universal treatment algorithm. We aim to highlight differences in outcomes and complications between open and closed pilon fractures, and between patients treated by open reduction internal fixation (ORIF) or fine wire fixator (FWF) for open and closed fracture subgroups.
METHODS
This retrospective study was conducted at a major trauma centre including 135 patients over a 6-year period. Primary outcome was AOFAS score at 3, 6, and 12-months post-injury. Secondary outcomes included time to partial weight-bear (PWB) and full weight-bear (FWB), bone union time, and complications during the follow-up time. AO/OTA classification was used (43A: n = 23, 43B: n = 30, 43C: n = 82). Interobserver agreement was high for bone union time (kappa=0.882) and AO/OTA class (kappa=0.807).
RESULTS
Higher AOFAS scores were seen in ORIF groups of both open and closed fractures, compared to FWF groups. The difference was not statistically significant apart from 12-month AOFAS score of 43C open fractures (p = 0.003) and in 43B closed fractures 3 and 6 months post-injury (p<0.001 and p<0.001, respectively). The majority of ORIF subgroups, open and closed fractures, also had shorter time to PWB, FWB, time to union, and follow-up. Statistically significant differences were seen in the following cases: ORIF-treated 43B closed fracture subgroup had shorter time to PWB and FWB (p<0.001 and p = 0.017, respectively), ORIF-treated 43C closed fractures had shorter time to union (p = 0.005). Common complications for open fractures were non-union (24%), post-traumatic arthritis (16%); for closed fractures they were post-traumatic arthritis (24%), superficial infection (21%). All occurred more frequently in FWF-treated patients.
CONCLUSION
Most ORIF-treated subgroups in either open or closed pilon fractures showed better primary and secondary outcomes than FWF-treated subgroups, yet few were statistically significant. Overall, our use of a two-staged approach involving temporary external fixation, followed with ORIF or FWF achieved low complication rates and good functional recovery.
Topics: Ankle Fractures; Arthritis; Fracture Fixation, Internal; Fractures, Closed; Fractures, Open; Humans; Retrospective Studies; Tibial Fractures; Treatment Outcome
PubMed: 35300868
DOI: 10.1016/j.injury.2022.03.018 -
Journal of Orthopaedic Surgery and... Apr 2018Open pelvic fractures are rare but represent a serious clinical problem with high mortality rates. The purpose of this study was to evaluate the outcomes of open pelvic... (Review)
Review
BACKGROUND
Open pelvic fractures are rare but represent a serious clinical problem with high mortality rates. The purpose of this study was to evaluate the outcomes of open pelvic fractures in our clinic and to compare the results from our patient group with those of closed fractures and with the literature from the past decade.
METHODS
Data of patients older than 16 years of age who were admitted to our hospital with a pelvic fracture between January 1, 2004, and December 31, 2014, were analyzed. The collected data were patient demographics, mechanism of injury, RTS, ISS, transfusion requirement during the first 24 h, Gustilo-Anderson and Faringer classification, number and type of interventions complications, mortality, and length of stay.
RESULTS
Twenty-four of 492 patients (5% of all pelvic fracture patients) had an open fracture. Their mean age was 36 years, the mean ISS was 31, and the mean number of transfused packed red blood cells was 5.5. These numbers were all significantly higher than in the patients with a closed fracture, although they were comparable to other studies with open fractures. The mortality was 4% in the open group versus 14% in the closed group (p = 0.23). The reported mortality in the literature ranges between 4 and 45%.
CONCLUSION
Open pelvic fractures are relatively rare but are a cause of significant morbidity. In this series, we treated patients with open pelvic fractures successfully, with a survival rate of 96%. There was no significant difference in survival rate between open and closed pelvic fractures. Compared with other studies, the mortality in our study was relatively low.
Topics: Adolescent; Adult; Aged; Aged, 80 and over; Blood Transfusion; Colostomy; Female; Fracture Fixation, Internal; Fractures, Open; Humans; Length of Stay; Male; Middle Aged; Multiple Trauma; Pelvic Bones; Pelvic Infection; Rectum; Trauma Severity Indices; Treatment Outcome; Young Adult
PubMed: 29653551
DOI: 10.1186/s13018-018-0793-2 -
Military Medicine May 2022Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are... (Review)
Review
INTRODUCTION
Extremity trauma is the most common battlefield injury, resulting in a high frequency of combat-related extremity wound infections (CEWIs). As these infections are associated with substantial morbidity and may impact wounded warriors long after initial hospitalization, CEWIs have been a focus of the Infectious Disease Clinical Research Program (IDCRP). Herein, we review findings of CEWI research conducted through the IDCRP and discuss future and ongoing analyses.
METHODS
Military personnel with deployment-related trauma sustained between 2009 and 2014 were examined in retrospective analyses through the observational Trauma Infectious Disease Outcomes Study (TIDOS). Characteristics of wounded warriors with ≥1 open extremity wound were assessed, focusing on injury patterns and infection risk factors. Through a separate trauma-associated osteomyelitis study, military personnel with combat-related open fractures of the long bones (tibia, femur, and upper extremity) sustained between 2003 and 2009 were examined to identify osteomyelitis risk factors.
RESULTS
Among 1,271 wounded warriors with ≥1 open extremity wound, 16% were diagnosed with a CEWI. When assessed by their most severe extremity injury (i.e., amputation, open fracture, or open soft-tissue wound), patients with amputations had the highest proportion of infections (47% of 212 patients with traumatic amputations). Factors related to injury pattern, mechanism, and severity were independent predictors of CEWIs during initial hospitalization. Having a non-extremity infection at least 4 days before CEWI diagnosis was associated with reduced likelihood of CEWI development. After hospital discharge, 28% of patients with extremity trauma had a new or recurrent CEWI during follow-up. Risk factors for the development of CEWIs during follow-up included injury pattern, having either a CEWI or other infection during initial hospitalization, and receipt of antipseudomonal penicillin for ≥7 days. A reduced likelihood for CEWIs during follow-up was associated with a hospitalization duration of 15-30 days. Under the retrospective osteomyelitis risk factor analysis, patients developing osteomyelitis had higher open fracture severity based on Gustilo-Anderson (GA) and the Orthopaedic Trauma Association classification schemes and more frequent traumatic amputations compared to open fracture patients without osteomyelitis. Recurrence of osteomyelitis was also common (28% of patients with open tibia fractures had a recurrent episode). Although osteomyelitis risk factors differed between the tibia, femur, and upper extremity groups, sustaining an amputation, use of antibiotic beads, and being injured in the earlier years of the study (before significant practice pattern changes) were consistent predictors. Other risk factors included GA fracture severity ≥IIIb, blast injuries, foreign body at fracture site (with/without orthopedic implant), moderate/severe muscle damage and/or necrosis, and moderate/severe skin/soft-tissue damage. For upper extremity open fractures, initial stabilization following evacuation from the combat zone was associated with a reduced likelihood of osteomyelitis.
CONCLUSIONS
Forthcoming studies will examine the effectiveness of common antibiotic regimens for managing extremity deep soft-tissue infections to improve clinical outcomes of combat casualties and support development of clinical practice guidelines for CEWI treatment. The long-term impact of extremity trauma and resultant infections will be further investigated through both Department of Defense and Veterans Affairs follow-up, as well as examination of the impact on comorbidities and mental health/social factors.
Topics: Amputation, Traumatic; Anti-Bacterial Agents; Communicable Diseases; Extremities; Fractures, Open; Humans; Military Personnel; Osteomyelitis; Retrospective Studies; Soft Tissue Injuries; Wound Infection
PubMed: 35512376
DOI: 10.1093/milmed/usab065 -
Injury Dec 2020Grade III open fractures of the lower extremity are serious injuries and are difficult to reconstruct. The optimal treatment for such injuries is unclear. We aimed to... (Review)
Review
BACKGROUND
Grade III open fractures of the lower extremity are serious injuries and are difficult to reconstruct. The optimal treatment for such injuries is unclear. We aimed to determine the safety and efficacy of orthoplastic reconstruction, using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation for Gustilo grade IIIB/C open tibial fractures.
METHODS
From April 2018 to April 2019, 15 patients, ranging from 19 to 72 years old, with Gustilo grade IIIB/C open fractures were treated using a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation. This involved wound debridement and removal of free bone fragments, followed by bone cement packing of the defect, external fixation, and vacuum sealing drainage treatment. The final stage involved switching from external to internal fixation and wound repair using a free anterolateral thigh flap. Repair time ranged from 2 to 7 days. Flap size ranged from 25 × 15 cm to 13 × 7cm. Hospital stay ranged from 11 to 50 days (mean, approximately 33.3 days). Bone cement was removed after 6-19 weeks and replaced with autogenic cancellous bone.
RESULTS
All flaps survived without incident. One patient experienced a wound infection, but there were no deep infections. For all patients, bone union was achieved after 4 to 7 months.
CONCLUSION
The use of a primary free anterolateral thigh flap combined with the Masquelet technique and internal fixation is a safe and effective procedure for reconstruction of Gustilo grade IIIB/C open fractures.
Topics: Adult; Aged; Debridement; Fracture Fixation; Fracture Fixation, Internal; Fractures, Open; Humans; Middle Aged; Plastic Surgery Procedures; Soft Tissue Injuries; Tibia; Tibial Fractures; Treatment Outcome; Young Adult
PubMed: 33097199
DOI: 10.1016/j.injury.2020.10.039 -
Hand (New York, N.Y.) Mar 2017Literature on open fracture infections has focused primarily on long bones, with limited guidelines available for open hand fractures. In this study, we systematically... (Meta-Analysis)
Meta-Analysis Review
Literature on open fracture infections has focused primarily on long bones, with limited guidelines available for open hand fractures. In this study, we systematically review the available hand surgery literature to determine infection rates and the effect of debridement timing and antibiotic administration. Searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases and manual bibliography searches were performed. Descriptive/quantitative data were extracted, and a meta-analysis of different patient cohorts and treatment modalities was performed to compare infection rates. The initial search yielded 61 references. Twelve articles (4 prospective, 8 retrospective) on open hand fractures were included (1669 open fractures). There were 77 total infections (4.6%): 61 (4.4%) of 1391 patients received preoperative antibiotics and 16 (9.4%) of 171 patients did not receive antibiotics. In 7 studies (1106 open fractures), superficial infections (requiring oral antibiotics only) accounted for 86%, whereas deep infections (requiring operative debridement) accounted for 14%. Debridement within 6 hours of injury (2 studies, 188 fractures) resulted in a 4.2% infection rate, whereas debridement within 12 hours of injury (1 study, 193 fractures) resulted in a 3.6% infection rate. Two studies found no correlation of infection and timing to debridement. Overall, the infection rate after open hand fracture remains relatively low. Correlation does exist between the administration of antibiotics and infection, but the majority of infections can be treated with antibiotics alone. Timing of debridement, has not been shown to alter infection rates.
Topics: Anti-Bacterial Agents; Debridement; Drug Administration Schedule; Fractures, Open; Hand Injuries; Humans; Surgical Wound Infection; Time Factors
PubMed: 28344521
DOI: 10.1177/1558944716643294 -
Journal of Orthopaedic Trauma Oct 2017Bone defects associated with open fractures require a careful approach and planning. At initial presentation, an emergent irrigation and debridement is required.... (Review)
Review
Bone defects associated with open fractures require a careful approach and planning. At initial presentation, an emergent irrigation and debridement is required. Immediate definitive fixation is frequently safe, with the exception of those injuries that normally require staged management or very severe type IIIB and IIIC injuries. Traumatic wounds that can be approximated primarily should be closed at the time of initial presentation. Wounds that cannot be closed should have a negative pressure wound therapy dressing applied. The need for subsequent debridements remains a clinical judgment, but all nonviable tissue should be removed before definitive coverage. Cefazolin remains the standard of care for all open fractures, and type III injuries also require gram-negative coverage. Both induced membrane technique with staged bone grafting and distraction osteogenesis are excellent options for bony reconstruction. Soft tissue coverage within 1 week of injury seems critical.
Topics: Bone Transplantation; Combined Modality Therapy; Debridement; Female; Fracture Fixation, Internal; Fracture Healing; Fractures, Open; Humans; Injury Severity Score; Male; Patient Care Planning; Prognosis; Plastic Surgery Procedures; Soft Tissue Injuries; Surgical Flaps; Treatment Outcome; Wound Healing
PubMed: 28938387
DOI: 10.1097/BOT.0000000000000980