CLASSIFICATION AND MANAGEMENT OF

OPEN FRACTURES
Dr Ramachandran MS.,
Dept of orthopedics,
SMS Medical college,
 Introduction
An open fracture is one in which a break in the skin
and underlying soft tissue leads directly into or
communicates with the fracture and its hematoma
 The term compound fracture is non-specific and
hence not used
 When wound occurs in same limb segment as a
fracture , the # must be considered open until proven
otherwise.
CLASSIFICATION
OF OPEN
FRACTURES
OVERVIEW
Communication between health care professionals

Formulating a treatment plan

Decision on limb salvage

Detailed audit of care to ensure optimal management

METHODS OF CLASSIFICATION
 GRADING SYSTEM – focus on severity of limb injury only
Eg: Gustilo Anderson , Tscherne and Gotzen, Byrd and
Spicer etc

SCORING SYSTEM – focuses on limb injury and general

health; also give ‘amputation score’.
Eg: MESS , NISSA ,LSI, PSI etc

 COMPREHENSIVE SYSTEM – combines the above two

systems
Eg: AO system , Ganga hospital score
GRADING SYSTEMS
GUSTILO ANDERSON SYSTEM
 In 1976 , Gustilo and Anderson treated 1025 open fractures
based on his grading system that offered prognosis about
outcome of infected fractures
 In 1984, it was modified and was based on
a. Size of wound
b. Periosteal soft tissue damage
c. Periosteal stripping
d. Vascular injury
 Recently it has emerged that injured limbs are appropriately
categorised by the system after wound excision (Yang EC, Eisler
J.2003)
TYPE DESCRIPTION
I <1cm clean wound

II >1cm laceration with no extensive soft tissue damage, skin flap or

avulsion
IIIa Extensive soft tissue damage or flaps , but adequate coverage of bone or
high energy trauma regardless of size of the wound
(like comminuted or segmental fractures even those of <1cm)

IIIb Extensive soft tissue loss with periosteal stripping and bone exposure
(usually massively contaminated)

IIIc With arterial injury that requires repair regardless of size of soft tissue
wound

 Simple and hence it is widely used

 Poor interobserver reliability especially with inexperienced surgeons
 gun shot injuries , wounds in farm yards are always gradeIII
TSCHERNE SYSTEM
GRADE DESCRIPTION
1 Skin laceration mostly inside out injury with little or no contusion
of skin
2 Skin laceration with circumscribed skin or soft tissue contusion
with moderate contamination
3 Fractures with severe soft tissue injury often with NV injury , severe
bone comminution or compartment syndrome

4 Sub total (remaining soft tissue not exceeding ¼ of limb

circumference) or total amputation

 This system includes compartment syndrome which is not included in

other grading systems
BYRD AND SPICER
TYPE DESCRIPTION
I Both endosteal and periosteal supply intact and surrounding soft tissue
is healthy
II Endosteal supply interrupted but periosteal supply maintained by
surrounding soft tissues
III Devascularised bone fragment and requires flap coverage

 This system lacks sophistication and hence not widely used

SCORING SYSTEMS
MANGLED EXTREMITY SEVERITY SCORE
(MESS)
TYPE CHARACTERISTICS INJURIES POINTS
SKELETAL/ SOFT-TISSUE GROUP
1 Low energy Simple closed #, small calibre gun shot 1
2 Medium energy Open # , D/L , mulltiple level # 2
3 High energy Shot gun blast , high velocity gun shot 3
4 Massive crush Rail road, oil rig accidents 4

SHOCK GROUP
1 Normotensive BP stable in field and OT 0
2 Transiently BP unstable in field but responds to IV 1
hypotensive fluids
3 Prolonged SBP<90 in field and responding to IV 2
hypoptensive fluids only in OT
 MESS Contd…
TYPE CHARACTERISTICS INJURIES POINTS
ISCHEMIA GROUP
1 None Pulsatile limb w/o signs of ischemia 0*
2 Mild Diminished pulses w/o signs of 1*
ischemia
3 Moderate No pulse, sluggish capillary refill, 2*
paraesthesia, motor activity
4 Advanced Pulseless, cool, paralysed, numb, no 3*
capillary refill
AGE GROUP
1 < 30 yrs 0
2 30 – 50 yrs 1
3 > 50 yrs 2

* If ischemia time > 6 hrs, add 2 points.

 MESS Contd…
 It was developed to identify those patients who will
be benefited by primary amputation
 In retrospective analysis, the outcome of injured limb
was either salvage or amputation
A score of 7 or greater is predictive of amputation
 MESS is found to be specific but lacks some
sensitivity which infers that score predicting limb
salvage(<7) is more reliable than score predicting
amputation (> or =7) (Bosse MJ JBJS 83A:412,2001)
OTHER SCORING SYSTEMS
• NISSSA – Nerve injury Ischemia Soft tissue injury
Skeletal injury Shock Age , is more sensitive and more
specific than MESS.
• LSI – Limb Salvage Index
a.This index is applied to limbs with arterial injury
b.Warm ischemia time together with scores for
injured skin , muscle , bone , NV are added to give
total score
c. LSI > or = 6 and grade IIIc gustilo with major
nerve injury are amputated
COMPREHENSIVE
SYSTEMS
 AO System :
 Skin lesions , muscle -tendon , NV , bone injuries are
graded separately
 AO system allows better prediction of outcome when
compared to Gustilo
 Due to its complexity not widely accepted

• Ganga hospital score :

 Includes additional criteria like age >65 , DM , cardio-
respiratory disease , trauma chest/abdomen,
farmyard/sewage contaminations, delay in debridement
>12h
MANAGEMENT OF OPEN
FRACTURES
 INITIAL MANAGEMENT
 ABC of initial management is addressed first
Compressive dressings for extremity hemorrhage
Rule out cervical injuries , chest , abdominal injuries ,
head injuries in polytrauma patients
As soon as possible careful examination of wound is
carried out and serial photographs of wound taken
Atleast sketch diagrams of the limb and wound is
made which is more informative than the descriptive
paragraphs
 Initial wound management
In emergency room :
 Don’t do digital exploration (to avoid infection and
bleeding)
 Obvious FB are removed with forceps
 If patient will undergo formal debridement in<1 hour just
do sterile saline dressing if not irrigate with 1 or 2l of NS
 Povidone dressing alters color and impairs osteoblast
function (controversial) so better avoided
 Patients immunity to tetanus is determined
 IV antibiotics are given as soon as possible
 Debridement and Irrigation
Timing - Debridement done as soon as possible
Skin and wound preparation-dirt and debris removed by gentle scrub brush
Sterile tourniquets kept ready but not used

SUPERFICIAL DEBRIDEMENT:
Traumatic wounds extended – to identify and explore the entire zone of
injury and to access ends of bone fragments
 Skin incisions – extensile longitudinal incision to visualize deep tissue and
can be extended till (N) tissue encountered
 Clearly Nonviable skin and subcutaneous tissue excised but of marginal
viability may be left for later debridement
 Don’t detach skin and subcutaneous tissue from the fascia
 Any nonviable shredded fascia and even the marginally viable ones excised
Extensile longitudinal skin incision
 Contd..
DEEP DEBRIDEMENT:
 Whereas skin tend to tear , fascia split or shred , muscle
because of water content are subjected to hydraulic damage by
fluid waves during injury
 In muscle debridement the concept ‘when in doubt take it out’
 In type I,II and IIIa open # all non-vital and in doubt muscle
can be debrided but IIIb and IIIc removal of entire muscle
compartment may be needed so marginally viable ones are
left for later re-debridement
 Viability of muscle checked by its color ,capacity to bleed,
contractility and consistency(last 2 more reliable)
 Contd..
 Tendons , unless injured beyond repair should be
preserved
 In open wounds tendons are subject to dessication and
hence it should be covered with soft tissues if not with
moist dressings
 In general bone devoid of soft tissue attachment
removed and large ones are utilized provisionally for
skeletal fixation and removed once fixation achieved
 One exception to strict removal of bone without soft
tissue attachment ,is significant portion of articular
surface attached to bone fragment
 Contd..
IRRIGATION:
 After meticulous debridement irrigation of wound is
done
 Most common irrigant used is NS and high volume , low
pressure lavage repeated an adequate number of times
to prevent infection
 Amount used varies , Anglen recommended 6 to 10l for
grade II and III #
 Additives – antiseptics, antibiotics and surfactants can
be used
 Skeletal Stabilisation
Once the vascular repair has been completed and limb
salvaged or irrigation and debridement done ,
stabilisation of bone is next concern
Restoring the length ,rotational and angular
alignment has many benefits for healing of soft tissue
 fracture reduction unkinks NV conduits and helps in
soft tissue healing
 minimising motion of fragments also decreases further
damage, pain and permits mobilisation of joints
 Contd..
METHODS OF SKELETAL STABILISATION:
 Extra osseous immobilisation –Eg: plasters ,weight
bearing casts , splints and skeletal tractions
• Used in Low grade open fractures – Eg: grade I leg bone #
(plasters) and open shaft femoral fractures (skeletal
traction)
 External fixation – Used in high grade open fractures
• excellent access to wound dressing and surveillance
possible
• Pin tract infections (not decreased by dressings; Egol et
al), loosening , osteo-myelitis are some complications
Extra osseous immobilization- skeletal
traction
External fixator
 Contd..
 INTERNAL FIXATION:
• Plates and screws – to minimise complications IV anti
staph antibiotics as soon as possible, sterile dressing ,
meticulous debridement , copious irrigation and
minimal stripping and accurate anatomical reduction in
extraperiosteal plate fixation to be done
• IM Nail- currently the treatment of choice for grade
I,II,IIIa and IIIb fractures as ex-fix devices leads to more
malalignment, nonunions, and delayed return to
function and no substantial decrease in infection when
compared with nails
Internal fixation – plates and screws
IM Nail
 Wound closure and coverage
Wounds without skin loss :
 Tension free primary closure after thorough debridement
 Contraindications for primary closure are
1. Delayed presentation >12hr
2. Delayed administration of antibiotic >12hr
3. Deep seated contamination
4. Immunocompromised
5. NV injury
6. Inability to achieve tension free suture
7. High risk of anaerobic contamination like farm yard injuries
 Contd..
Wounds with skin loss:
 Healing by secondary intention
 Releasing or relaxing incision – donor region may
require SSG in anatomic regions with less tissue
mobility like leg and ankle
 Fascio-cutaneous flap or rotational flaps
Thank you