Advances in treating exposed fractures

The management of exposed fractures has been discussed since ancient times and remains of great interest to present-day orthopedics and traumatology. These injuries are still a challenge. Infection and nonunion are feared complications. Aspects of the diagnosis, classification and initial management are discussed here. Early administration of antibiotics, surgical cleaning and meticulous debridement are essential. The systemic conditions of patients with multiple trauma and the local conditions of the limb affected need to be taken into consideration. Early skeletal stabilization is necessary. Definitive fixation should be considered when possible and provisional fixation methods should be used when necessary. Early closure should be the aim, and flaps can be used for this purpose.

Exposed fractures/diagnosis; Exposed fractures/classification; Wounds and injuries

Authorship

Pedro Nogueira Giglio ^** Corresponding author. E-mails: pedrongiglio@gmail.com, gigliopedro@gmail.com (P.N. Giglio).

Department of Orthopedics and Traumatology, Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, BrazilUniversidade de São PauloBrazilSão Paulo, SP, BrazilDepartment of Orthopedics and Traumatology, Hospital das Clínicas, School of Medicine, Universidade de São Paulo, São Paulo, SP, Brazil

Alexandre Fogaça Cristante

José Ricardo Pécora

Camilo Partezani Helito

Ana Lucia Lei Munhoz Lima

Jorge dos Santos Silva

* Corresponding author. E-mails: pedrongiglio@gmail.com, gigliopedro@gmail.com (P.N. Giglio).

Conflicts of interest The authors declare no conflicts of interest.

SCIMAGO INSTITUTIONS RANKINGS

Tables

Tables (7)

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Table 1
Gustilo classification for exposed fractures.

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Table 2
AO classification for soft-tissue injury in exposed fracture cases.

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Table 3
Tcherne classification for soft-tissue injuries associated with exposed fractures.

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Table 4
Sequence of initial attendance for multiple trauma victims according to the ATLS.

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Table 5
Phases of sequential attendance for multiple trauma victims.

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Table 6
Recommendations for prophylaxis against tetanus in high-risk wounds.a

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Table 7
Severity score for mutilation of extremity.

Table 1 Gustilo classification for exposed fractures.

I– Low energy, exposure less than 1 cm, low degrees of contamination and comminution.

II –Exposure of between 1 cm and 10 cm, contamination, soft-tissue injury and moderate comminution.

III –Exposure greater than 10 cm, high degree of soft-tissue injury and contamination.

IIIA – Primary coverage is possible.

IIIB – Primary coverage is not possible.

IIIC – Arterial injury requiring repair.

Table 2 AO classification for soft-tissue injury in exposed fracture cases.

Skin injury

IO 1 – Punctiform skin injury from inside to outside.

IO 2 – Skin injury with contused edges from outside to inside, smaller than 5 cm.

IO 3 – Skin injury larger than 5 cm, with devitalized edge.

IO 4 – Injury encompassing the full thickness, with severe contusion, loss of skin or extensive degloving.

Muscle injury

MT 1 – No muscle injury.

MT 2 – Circumscribed muscle injury, in one compartment only.

MT 3 – Considerable muscle injury, in two compartments.

MT 4 – Muscle defect, tendon laceration and extensive contusion.

MT 5 – Compartmental syndrome, crushing syndrome and broad injury zone.

Neurovascular injury

NV 1 – No neurovascular injury.

NV 2 – Isolate neurological injury.

NV 3 – Localized vascular injury.

NV 4 – Extensive segmental vascular injury.

NV 5 – Combined neurovascular injury, including subtotal or total amputation.

Table 3 Tcherne classification for soft-tissue injuries associated with exposed fractures.

Fr. 1 – Skin lacerated by bone from inside to outside, little or no skin contusion and simple fractures resulting from indirect trauma.

Fr. 2 – Skin laceration or circumferential contusion and moderate contamination, including all cases exposed due to direct trauma.

Fr. 3 – Extensive soft-tissue injuries, generally associated with vascular or neurological injury. Includes fractures relating to ischemia, severe bone comminution, compartment syndrome, injuries in rural settings and high-velocity gunshot wounds.

Fr. 4 – Partial or total amputations (separation of important anatomical structures, especially vessels, with total ischemia).

Table 4 Sequence of initial attendance for multiple trauma victims according to the ATLS.

A – Keep the airways open and protect the cervical spine.

B – Maintain adequate ventilation.

C – Ensure circulation and perfusion.

D – Evaluate neurological injuries.

E – With wider exposure, assess other injuries and protect against hypothermia.

Table 5 Phases of sequential attendance for multiple trauma victims.

1st phase – Resuscitation (first hours)

2nd phase – Stabilization (one to 48 h). Control over damage in order to avoid hypotension, acidosis and coagulopathy.

3rd phase – Regeneration (after the second day).

4th phase – Reconstruction and rehabilitation (weeks).

Table 6 Recommendations for prophylaxis against tetanus in high-risk wounds.a

History of immunization	Vaccine	Anti-tetanus immunoglobulin
Less than 3 doses or unknown	Yes	Yes
Last dose less than 5 years ago	No	No
Last dose 5 to 10 years ago	Yes	No
Last dose more than 10 years ago	Yes	No

^a
High-risk wounds include exposed fractures, wounds due to firearms or cold weapons, wounds with retention of a foreign body and punctiform wounds caused by sharp objects.

Table 7 Severity score for mutilation of extremity.

Musculoskeletal injury
Low energy	1
Medium energy	2
High energy	3
Extremely high energy	4

Limb ischemia
Pulse low or absent, perfusion normal	1
Pulse absent, perfusion low	2
Cold limb, paralyzed, insensitive	3

Shock
Systolic arterial pressure always > 90 mmHg	0
Transitory hypotension	1
Persistent hypotension	2

Age
<30 years	0
Between 30 and 50 years	1
>50 years	2

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