CHAPTER I O OPEN FRACTURES OF THE FOOT AND ANKLE: A Management Algorithm

Dauid J. Caldarella, D.P.M.

The objectives in the management of open unsatisfactory results. Open fractures of the foot fractures are to prer.ent infection, facilitate healing, and ankle often involve specific joint and soft and restore function. Established general principles tissue relationships that are necessary to appreciate and further advancements in the management and then restore for return of function. Open of open fractures of the axial skeleton have fractures of the foot and leg must be treated dramatically improved the level of success in treat- appropriately for successful return to pre-injury ing these injuries, and may reduce the incidence of levels. General principles of open fracture manage- ment and anatomic and functional relationships contribute to a specific management algorithm for open fractures of the lower extremity.

CLq,SSIFICATION

The Gustilo classification of open fractures remains the most accepted means of classification, and is based on the nature of the injury, degree of soft tissue involvement, fracture characteristics, and level of contamination. This system of categoriza- tion has been well-studied and also serves as a prognostic indicator as to the statistical outcomes of these injuries based on type (Figs. 1A-1C).

Figure 1A. Gustilo Classiflcation Type L A ftacture with a clean wound less than 1 cm long. There is minimal soft tissr:e involvement, ancl minirnal contamination.

% Figure 18, Gustilo Classification Type II. A fracture u,ith a w-ound Figure 1C. Gustilo Classification Type III. A fracture with a wound greater than 1 cm long. Tl'rere is moclerate soft tissue involvement, and greater than 5 cn-r long. There is extensive soft tissue involvement, ancl moderate contamination. hear'y contamination. There is some degree of periosteal stripping and potential neurovascular injury. CHAPTER 10 6l

MANAGEMENT ALG'ORITHM management algorithm. A detailed inventory, and primary and secondary sulvey are critical for A stepwise approach to the management of open appropriate treatment and avoidance of medical fractures of the foot and leg has been developed by negligence. A comprehensive assessment is the author to provide a pragmatic and practical necessary, and is performed prior to the com- guide for the timely and appropriate treatment mencement of the open fracture management of these injuries (Table 1). The algorithm is based algorithm for specific open lower extremity injuries. on accepted principles specific to the many Wound Assessment The initial wound components and considerations necessary for assessment is vital prior to the initiation of treat- inclusion in the successful management of open ment. A thorough wound inspection should fractures. This iniury, when efficiently managed in include the neurovascular status of the involved a stepwise approach will optimize the likelihood hmb/part, appropriate documentation of the of a successftrl outcome and reduce the risk of injured component, presence of gross deformity, untoward complications and sequelae. assessment of soft tissue injury or loss, degree of contamination, presence of foreign body, and general natlrre of the injury. The wound should be described detail including the location, size, Table 1 in degree of soft tissue and/or bone loss, Ievel of contamination, and relevant associated factors for MANAGEMENT ALMRITHM the medical record. FOR OPEN FRACTURES The initial wound assessment should be performed prior to initial culture. Following inspec- A. Initial Considerations tion, the wound should be covered with an - Triage Patient appropriate sterile dressing and remain stable - Wound Assessment until definitive treatment is undertaken. This - Initial Culture protocol will reduce the risk of acquired - Tetanus Prophylaxis nosocomial infection and further contamination - Antibiotic Selection or complication. - Radiographic Analysis Initial Cultures. Numerous studies have - Operative Planning documented the fact that 50o/o to 700/o of open - Surgical Consent fracture injuries are contaminated at the time of B. Operative Considerations initial presentation. Ail open fractures ate - krigation / D ebridement considered contaminated wounds if evaluated and - Operative Cultures treated within 8 hours from time of iniury. Open - Fracture Stabilization fractures presenting foliowing this B hour "golden - Antibiotic Considerations period" are considered infected wounds. - Operative Follow-Up If an infection should develop following an - Secondary Debridement/Closure open fracture injury, the initial wound cultures - Grafting Considerations procured prior to the initiation of treatment and/ - Primary Amputation or antibiotic therapy may be helpful in the C. Rehabilitation identification of the infecting organism. The attainment of initial cultures has demonstrated a statistically significant correlation between the Initial Considerations initial cultured organism and the organism later found to be a pathogen in the development of Triage. Triage is defined as the medical screening infection in some studies. Although recent of a patient to determine the appropriate sequence controversy exists in the current literature with of treatment. Open fractures can be associated with regard to the value of initial culture in the manage- other traumatic injuries. Individuals presenting with ment of open fractures, it is generally this type of injury often have an established recommended as a judicious and meaningful medical history. A thorough history and examina- component in the management algorithm for open tion is a prerequisite to the initiation of the fracture injury. 62 CHAPTER 10

Gram-positive rods and cocci remain the and surgically approached accordingly. Many open predominant pathogens associated with infection fracture injuries of the foot and ankle involve secondary to open fractures, however gram- joint surfaces, therefore preseruation of joint negative rods are statistically becoming more structure and anatomic alignment are necessary for prevalent. Initial cultures containing gram-negative satisfactory functional outcome. The fractures are organisms predispose an open fracture iniury to classified and an appropriate operative plan is a higher risk of subsequent and problematic devised based on the extent of soft tissue injury infection. and the radiographic analysis. Tetanus Prophylaxis. Due to the fact that the Operatiue Planning. Attentive and pragmatic majority of open fractures are either contaminated or operative planning are essential in the management infected at the time of presentation, attention to of open fracture injuries. Decisions regarding tetanlls history and curent tetanus status is of incision placement, debridement, method of paramount impofiance. It is important to implement fracture stabllization, intraoperative culture appropriate tetanus prophylaxis prior to exlension of procurement and handling, soft tissue coverage, the management algorithm for open fractures. use of surgical drains and antibiotic considerations Antibiotic Selection. Numerous studies have are itemized. The successful management of open directed attention to the prevalence of contamina- fracture injuries may be complicated by lack of tion in open fractures of the axial skeleton. comprehensive and timely decision making or Attending surgeons often underestimate or oversight. An algorithmic approach, as presented, misinterpret the presence of contamination by serves as a practical template for treatment. clinical examination alone. It is well-known that Surgical Consent. Open fractures comprise a the risk of infection following open fracture is a potentially significant and complicated injury. direct function of the type and number of Appropriate and timely management of these bacteria present following definitive irrigation and injuries enhances the potential for a successful debridement. The microbiology of open fractures is outcome. Infection, poor healing, revisional presently increasing, with the appearance of more debridement, additional surgery, utllization and cases involving gram-negative organisms. Specific removal of fixation devices, amputation, and a antibiotic therapy and regimens used in the potential lengthy rehabilitation need to be management of open fractures continues to be discussed with the patient and documented. These confusing, and the published data and current injuries can often lead to a variabTe course of recommendations continue to be controversial. treatment which is dependent on multiple factors The majority of the well-performed research following the initial assessment and management. data support the use of antibiotics, and their All potential sequelae should be discussed with the efficacy in the management of open fractures is patient and family concerning the nature of the well-established. The goal of antimicrobial therapy injury and potential complications. is directed toward initiation of rapid therapeutic concentrations of antibiotic to the tissues involved. Operative Considerations This will reduce or eliminate the number of Irrigation and Debridement. All open fractures are contaminating bacteria given wound. in a considered surgical emergencies. Operative treat- Antibiotic administration in open fracture manage- ment should ideally be initiated within 5 to B hours ment should be considered therapeutic not and following injury. The singularly most imporrant prophylactic, and is appropriately initiated as soon component in open fracture management is timely as possible following patient triage. and copious irrigation, and adequate debridement Radiograpbic Analysis. Plain radiography is of all devitalized tissue, including bone. The indicated in all suspected open fracture injuries contribution of injured and devitalized tissue to involving the lower extremity. Multiple views are resultant infection and complications in wound and evaluated and comprise an important component fracture healing ate well-documented. Many of preoperative planning. Attention should focus studies on this topic demonstrate a diminished cell on soft tissue coverage and the corresponding mediated response to injury, as devitalized tissues open fracture injuries and patterns. Comminution remaining in the wound serve as a potential or and isolated bone fragments should identified be actual nidus for poor healing and/or infection. CFIAPTER 10 63

It is often difficult to differentiate non-viable anatomic reduction of fracture fragments is tissue, particulady subcutaneous tissue and muscle, accomplished through internal fixation in the foot from healthy surrounding tissue. Tissues which are and ankle as indicated. Severe soft tissue loss and questionable should be removed, and further comminution of bone may require the placement debridement may be necessary for definitive of external fixators. identification and debridement. Bone fragments Open reduction and internal fixation provides which do not maintain a function in the overall an optimal environment for primary union of bone stability of the fracture are also excised. Gentle fragments, and allows early rehabilitative range of pulsed irrigation in copious volume is motion. Internal fixation has been documented in recommended for mechanical lavage of foreign several studies to serve as an effective method of material and reduction of potential bacterial fracture stabilization, and is preferable to closed pathogens. Studies suggest that copious volume in a immobilization. The advantages of rigid bone pulsed delivery method is of much greater stabilization and the resultant positive effects on importance, then usage of topical antibiotics for soft tissue healing oufweigh the possibility of reduction of bacteria counts. Following repeated irri- complications secondary to infection. A11 internal gation and debridement of all devilalized tissue and fixation should remain in place until a point in time foreign material, the surgical wound is redraped, and when the tixation is no longer necessary. sterile instfllmentation is introduced for the remain- Most intra-articular fractures which commonly ing components of surgical intervention. occur in the lower extremity, coupled with Intra-operatiue Cultures. The value of intra- adequate soft tissue coverage, are well suited for operative cultures is of critical imporlance in the internal fixation methods of fracture repair. management of open fractures. Appropriately External fixation is indicated in those fractures with obtained deep tissue cultures at the onset of gross contamination, proven infection and surgical intelention, and following satisfactory comminution of bone. External frames and fixators debridement have historically been established are useful in the acute management of certain open as a recommended protocol. Gram's stain and deep fractures and also provide for secondary and cultures procured appropriately rn a controlled adjunctive procedures such as repeat wound environment can be used to direct antibiotic debridement and soft tissue transfers. External therapy should infection develop. Positive cultures fixators are also useful as temporary initial marrage- obtained following complete and aggressive ment prior to internal fixation placement in certain debridement and irrigation provide the most cases. Once the fracture is stabilized, treatment can reliable laboratory resource in determining the be continued through internal fixation. organism(s) responsible for subsequent infection. Antibiotic Considerations. The clinical use of Positive cultures taken prior to irrigation antibiosis, specific antibiotic regimens and the and debridement and negative cultures following duration of antibiotic therapy is a controversial and irrigation and debridement generally indicate exhausting subject matter. Most well-structured successful perioperative management, aod prospective randomized studies on the use of reduction of contamination. Clinical wound follow- antibiotics in the management of open fractures up and correlation is mandatory and gram stain support their judicious use. Antibiotic use in the and culture results should be utilized as an management of open fractures is considered important, yet still adjunctive tool. therapeutic and not prophylactic. In this context, Fracture Stabilization. Fracture stabilization is selection of antibiotic therapy is directed toward of prime impofiance for satisfactory healing in suspected pathogens. Clinical studies have demon- open fracture management. Anatomic reduction strated a historical predominance of gram-positive and alignment of fracture fragments optimize the organisms, namely Staphylococcus aureus as the opportunity for primary bone healing and early most common primary pathogen resulting in an rehabilitation. Additionally, fracture stabrlization infection following open fracture. Gram-negative influences the healing response of soft tissues organisms, including pseudomonas, enterobacter, through the influx of revascularization and the and other resistant pathogens ate becoming promotion of host defense mechanisms involved in increasingly pathogenic in some patient popula- the healing processes. Immediate and precise tions and geographic centers in open fracture 64 CFIAPTER 10

infection. Nosocomial multiresistant otganisms and tissue. Fufiher debridement may be necessary compromised hosts can account for increasing depending on the nature of the original injury and infection rates and added difficulty in the success- soft tissue damage. Many crush injuries with ful management of these injuries. associated open fractures lead to severe soft tissue Antibiotic usage in the treatment of open damage, which can progress over time. Repeat fractures is directed towards gram-positive surgical evaluation and debridement are often organisms. Gustilo recommends first and second foutine. generation cephalosporins in the management of Primary closure is usually not indicated in the Type I and iI open fractures. An additional amino- initial management of open fractures. Primary glycoside is recommended for Type III open closure of uninjured soft tissue, opened for addi- fractures and those injuries with significant tional exposure to the fracture injury, can be contamination. Many appropriate alternatives performed, and is reseled in these scenarios. It exist depending on the clinical scenario and can also be done in uncomplicated Type I injuries. drug tolerances. Gra,fting Consicleratiozs. Soft tissue augmen- The duration of antibiotic therapy has been tation and adequate wound coverage are carefully examined, and a range of one dose to contributory to successful outcomes when foufieen days of therapy has been recommended. indicated, and should be instituted relatively early Patzakis et al. have compared antibiotic regimens in the treatment plan. Early wound coverage of 3, 5 and 10 days and recommend a 3-day course consisting of rotational flaps, free tissue grafts and of appropriate antibiotic therapy following open musculofascial transfer provide the necessary fracture injury. Overall an infection rate of 3.30/o coverage for wound healing to continue. compares favorably with the infection rate seen Ideally, approptrate management and with longer therapy duration as suggested by other application of the algorithm will lead to an authors. Gustilo recommends a 3-day course as infection-free healing. As early as 3 to 10 days well, including as a rationale, sufficient time for following open fracture, soft tissue coverage final growth of wound cultures, comparison with should be performed. Many authors recommend longer courses proven to be statistically insignificant, ceftain timing of coverage, however, general and the fact that antibiotic toxicity is generally recommendations are clear that eady coverage will directly correiated with duration of therapy. optimize wound healing. Infection rates following open fractures Bone grafting, if necessary, is delayed for two comprise varying statistical outcomes depending weeks or longer depending on wound characteris- on injury type. Type I injuries are repofied to have tics and iniury type. More severe injuries may an infection rate of 00/o to 9.0%. Type II injuries are require additional time prior to bone grafting. Soft reported to become infected in 7.Bo/o to 15.00/o of tissue coverage needs to be adequate and viable, cases. Type III injuries and subsequent infections prior to osseous repair. Infection must be develop in 73.7o/o lo 55.00/o of cases. Type IIIB completely resolved, and delayed grafting can still comprise the highest risk injuries, and Type IIIC be performed adequately at longer post-injury injuries are often treated with primary amputation, intervals. thus reducing the incidence of subsequent Primary Amputation. In severe injury infection in this category. involving either soft tissues, neurovascular Operatiue Follota-Lp, Careful follow-up and structures or bone, primary amputation of a given obseruation are indicated in these injury patterns. pafi or entire segment is sometimes indicated. The Attention to wound progression and tissue mangled extremity severity score (MESS) is an demarcation, as well as culture results will direct objective measure of severity of injury based on a continued antibiotic therapy and further point system (Table 2). A MESS score of 7 or debridement. greater generally has a 7000/o predictability value for Seconclary Debridement/Closure. Following amputation. This selves as a useful model for initial treatment and postoperative care, secondary decision making relative to the indication for debridement and/or primary closure are generally primary amputation. indicated. Care is taken to debride all non-viable CFLAPTER 10 65

Table 2

MANGLED EXTREMITY SEVERITY SCORE (MESS)

TYPE CHARACTERISTICS INJURIES POINTS SkeletaVsoft -tissue Group 1 Low energy Stab wounds, simple closed fractures, 1 small-caliber gunshot wounds 2 Medium energy Open or multiple-level fractures, 2 dislocations, moderate crush injuries 3 High energy Shotgun blast (close range), 3 high velocity gunshot wounds 4 Massive crush Logging, railroad, oil rig accidents 4 Shock Group 1 Normotensive hemodynamics BP stable in field and OR 0 2 Transiently hypotensive BP unstable in field but responsive 1 to intravenous fluids 3 Prolonged hypotension Systolic BP less than 9OmmHg in field 2 and responsive to intravenous fluid only in OR Ischemia Group 1 None A pulsatile limb without signs 0* of ischemia 2 Mild Diminished pulses without signs 1* of ischemia 3 Moderate No pulse by Doppler, 2* sluggish capillary refill, paresthesia, diminished motor activity 4 Advanced Pulseless, cool, paralyzed and numb )' without capillary refill Age Group 1 <30 years 0 2 >30 <50 years 1 3 >50 Years 2 * Points x 2 if ischemic time exceeds sk hours. OR-operating room BP-blood pressure

Rehabilitation SUMMARY Open fracture injuries are potentially debilitating, and generally involve extensive rehabilitation. A management algorithm based on current guide Timely and appropriate treatment protocols as scientific data is presented as a primer and discussed within the algorithm, which will increase for the management of open fractures of the lower the likelihood of successful outcomes and reduce extremity. A step-wise approach selves to itemize protracted recovery time. Anatomic reduction of the injury into its relative components. A compre- fractures and careful management of soft tissue hensive understanding of general principles of injury are critical in enhancing the recovery from open fracture management is necessary for this type of injury. optimum treatment and successful outcomes in the management of lower extremity open fractures. 66 CHAPTER 10

BIBLIOGRAPITY Patzakis MJ: Management of open fracture wounds. Instr Course Lect 361367-369, 1987. Patzakis MJ, Harvey JP: The role of antibiotics in the management of Antrum RM, Solomkin A review of antibiotic prophylaxis for open JS: open fractures. J Bone Joint Surg 56A:532-541., 1.974. fractures. Ortbo Reuieu 76:246-254, 1987. Ritmann R, et. al; Open fractures: long term results ln 200 consecutive Beckman S, et al.:Long bone fractures in the polytrauma patient; the cases. Clin Ottho 138: 132-1,40,1979. role of early operative fixation. Am Surg 55:356-358, 1989. Rosenstein BD, et al.: The Use of Bacitracin to preveflt infection in Bonanni F: The Futility of predictive scoring mangled lower of post-operative skeletal wounds. J Bone Joint Surg 71A 427-430, extremities. J Trauma 34: 99-104, 7993. 1989. Gustilo RB: Current concepts in the management of open fractures. Walker ML, et al: Principles of management of gun shot woundsrl.lzzrg Inst Cource lect 36359-366. Gynecol Obstet 17U 97-105, 1990. Gustilo RB, Anderson Prevention JT: of infection in the treatment of !7ilkens J, Patzakis M: Choice and duration of antibiotics in open one thousand and twenty-five open fizctures bones; of long fractures. Ortbo Clin NA 22:433-437 , 1991.. retrospective and prospective analysis. J BoneJoint Sutg 58A: 453- 458, 1.976.