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An evaluation of the results of primary internal fixation in the treatment of open fractures
22
Injury, 6, 22-27
An evaluation of the results of primary internal fixation in the treatment of open fractures B. P. Varma and Y. P. C. Rao Department of Orthopaedics, Institute of Medical Sciences. Banaras Hindu University, Varanasi, India
Summary
An analytical study of 91 open fractures treated during the period 1967-73 has been presented. Fifty-three were treated conservatively, whereas 38 were managed by primary internal fixation. There were 12 cases of deep infection in the conservatively treated group (22.6 per cent), of which 4 had persistent infection in spite of adequate treatment. In contrast to this, the group treated by primary internal fixation showed 5 cases of deep infection
(13.1 per cent). All of these healed after the implants were removed, following union of the fractures. Minor sequestrectomy was performed simultaneously in 3 of them. Analysis of the results showed poor results after 22.6 per cent of fractures with conservative treatment in contrast to 5.2 per cent in the group managed by primary internal fixation. It is felt that judicious application of primary internal fixation in injuries associated with severe soft-tissue damage or multiple fractures is of definite advantage to the patient.
INTRODUCTION mechanization and high-velocity accidents have led to an increase in the incidence of open fractures with extensive soft-tissue injury. There is still a considerable difference of opinion amongst surgeons with regard to the use of primary metallic fixation in the treatment of open Various authors (Soto-Hall and fractures. Horwitz, 1946; Claffey, 1960; Gustillo, Simpson, Nixon, Ruiz, and Indeck, 1969) reported a significantly higher incidence of superficial and deep sepsis in cases treated by primary internal fixation. Other workers (Hicks, I957; McNeur, 1970) have shown that the incidence of infection MODERN
in internally fixed open fractures was no greater than in those treated conservatively. Hence it was thought worth while to compare the results of conservatively treated open fractures with those managed by primary internal fixation.
MATERIALS AND METHODS Ninety-six open fractures in 93 patients were treated during the period March 1967-73 in the Orthopaedic Department of S.S. Hospital, Banaras Hindu University. There were 80 males and 13 females, ranging in age from 6 to 63 years. Falls from a height and traffic accidents accounted for over 50 per cent of the fractures. Fourteen injuries were caused by machine traction belts. Table I shows the various sites in 96 open fractures. Only 44 patients (45.8 per cent) reached the hospital within 12 hours of injury (Table ZZ). There were 5 open fractures of 3-4 days’ duration (Fig. 1A). Depending upon the degree of soft-tissue damage and the initial contamination, the open fractures were classified into three grades (Table ZZZ) according to the classification of Smith (1963). Table I.-Types
of fracture
Bone involved Femur Tibia and fibula Humerus Radius and Ulna Monteggia fracture Olecranon Tota I
No. of fractures 15 36 (segmental 1) 11 32 (segmental 3) 1 1 96
Varma and Rao : Primary Internal Fixation
23
Eighty-eight patients with 91 fractures were followed up for an average of 149 months, with a range from 3 to 66 months. Of these 91 fractures, 53 were treated conservatively whereas 38 were managed by primary internal fixation. TREATMENT Anti-tetanus serum and toxoid were administered to every patient. The patients were resuscitated and were operated on as emergencies under general anaesthesia.
Table I/.-Time interval between injury and arrival at hospital No. of cases
Time(hr.) 6 6-l 2 24 24-48 72-96
3 41 26 21 5
Total
96
At operation, the wound was covered with sterile gauze, and the affected limb was shaved and cleaned. Later the wound itself was thoroughly cleaned with savlon lotion and irrigated with sterile physiological saline. The limb was draped. A thorough wound excision was performed. The wound was again irrigated with saline. The operative field was redraped, and the operating team changed gloves for the internal fixation operation, the instruments for which were kept on a separate trolley. Out of 38 fractures treated by primary internal fixation, 32 were fixed with intramedullary nails, another 4 were fixed with screws, and 2 were plated. One million units of penicillin G with 1 g. of streptomycin were sprayed into the wound, and primary closure was performed only in those cases for which it was felt that there was a reasonable chance of achieving primary union. Wounds with skin loss, or where infection was feared, were left open to be covered secondarily with skin graft except for 1 case in which primary skin grafting was performed. Additional support by plaster cast was provided for upper limb and tibia1 fractures for 6-12 weeks.
Fig. 1.-A, Three-day-old cornminuted fractures of the tibia and fibula. B, Primary healing of the wounds and well consolidated fractures after primary medulkuy nailing.
Table /M-Grade
of open fracture
Group No internal fixation Primary internal fixation*
Grade 1 7 2
Grade 2
Grade 3
Total
27 26
56 40
*The presence of severe soft-tissue damage, or multiple fractures were the main criteria in selecting cases for internal fixation.
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
24 In cases treated without internal fixation, the fractures were reduced following toilet and set in plaster casts. Stitches were removed after 14 days and a fresh well-fitting plaster cast was applied. Fourteen wounds were left open at first, but were covered
with split skin grafts after 2-3 weeks through windows in the plaster casts. The wounds which failed to heal were regularly dressed through windows in the plaster casts. These cases with infection received antibiotics for 3-6 weeks according to the bacterial sensitivity tests.
Table /l/.--Soft-tissue Type of healing Primary healing Delayed healing Deep infection
Tab/e V.-Bone
Deformity Shortening
ple fractures of rij pht forearm bones with severe soft-tissue damage caused by machine traction belt. There is a segmen ltal fracture of the ulna, with dislocation of the radial flead.
No internal fixation (53 fractures) 35 (66 per cent) 6 (11.3 per cent) 12 (22.6 per cent) (8 healed after removal of sequestrum)
Primary internal fixation (38 fractures) 26 7 5 (Healed metal 3 minor
(68.4 per cent) (18.4 per cent) (13.1 per cent) after removal of following union. sequestrectomies)
healing
State of union United Ununited
healing
No internal fixation (53 fractures)
Primary internal fixation (38 fractures)
48 (90.5 per cent) 5 ( 9.4 per cent) Bone grafting 1 8 6
32 (84.2 per cent) 6 (15.7 per cent) Bone grafting 4 healed Nil 1
ture 18 months afterr the in&zy. This was treated by primary medulla1 *y nariling of radius and ulna with primary wo und clos ure. The ulnar nail was extracted because aIf ulceral ion over the end of the nail.
Varma and Rao : Primary Internal Fixation
25
RESULTS
implant after the fracture had united. Three of these required minor sequestrectomy. Table Y shows the results of bone healing in the two groups. Thirty-six fractures (94.8 per cent) in
Table IV shows the soft-tissue healing pattern in the two groups. achieved in 77.3
Complete wound healing was per cent of the conservatively
Tab/e V/.-Average
time taken for radiological union of open fractures
Bone
No internal fixation (time in wee&s)
Primary internal fixation (time in weeks)
a: 17 17 12
20 23 29 21 13
Femur Tibia Humerus Radius and ulna Ulna
Tab/e V//.-Final
results
Group No internal
Excellent
Satisfectory
(66.033p5er cent)
(11.3 pe9 cent)
(68.4 itr
(26.3 izr cent)
Poor
T&at
fixation
53 (22.6 iir
cent)
Primary internal fixation
38 cent)
(5.2 pe’r cent)
Excellent-Complete soft-tissue healing and bony union, without deformity or shortening and with full joint function. Satisfactory-As in excellent, but with a range of 90” in the major joints. Poor-Persistent infection or non-union or gross deformity, more than 1 f inches shortening in the lower limb or less than 30” joint motion.
Tab/e V///.-Infection fixation, as reported
rate in open fractures in various series
treated with
primary
internal
infection rate (per cent) No Primary internal fixation internal fixation
Author
Hicks (1957) Valiskakis (1959) Claffey (1960) Gustillo, Simpson, Nixon, Ruiz, and lndeck McNeur (1970) Ketenjian and Shelton (1972) Present series
or without
13
(1969)
treated group, whereas it was 86.8 per cent in the group treated by primary internal fixation. There were 12 cases of deep infection (22.6 per cent) in the conservatively treated group, of which 8 healed following extrusion/removal of a sequestrum. The infection failed to heal in 4 cases in this group, all of which were initially classified as grade 3 open fractures. On the other hand, all the 5 cases (13.1 per cent) with deep infection in the group treated by primary internal fixation healed following removal of the
s 6.68 6 22.6
14.8 16.2 21 .o 11.6 3.6 7.6 13.1
the group treated by primary internal fixation united in perfect anatomical alignment (Figs. lB-3), with minor shortening in a case of a May-old fracture of the humerus in which the bone end had to be trimmed. Four of these had secondary canctllous bone grafting for delayed union. Two fractures (5.2 per cent) have not united. One of these was a fracture of the olecranon followed up for 6 months after being f%ced with a screw. It resulted in excellent elbow function. In another case of a severely damaged
26
Injury: the British Journal of Accident
Surgery Vol. ~/NO. 1
forearm and hand crushed in a thrashing machine, the ulna has failed to unite. In the conservatively treated group, 4 fractures with persistent frank sepsis failed to unite (7.5 per cent). Deformity occurred in 8 cases and shortening in 6 cases in this group. The average time required for radiographic evidence of union was uniformly more in the group treated by
primary internal fixation than in the conservatively treated group, except in the case of the femur (Table VI). The results in relationship to soft-tissue healing, bone healing, deformity, shortening, and joint function are shown in Table VII. Excellent results were achieved in 68.4 per cent of cases treated by primary internal fixation as compared to 66.03 per
Fig. 4.-Multiple fractures of the forearm bones with segmental fracture of the radius and extensive softtissue damage. There was a closed fracture of the humerus in the same limb.
Fig. 5.-Well injury.
Fig. 6.-Showing
healed fracture 12 months after the
extent of the soft-tissue damage healed by primary intention.
Varma and Rao : Primary Internal Fixation
cent in the conservatively treated group. The difference was striking when one considers the incidence of poor results, which was 22.6 per cent in the conservatively treated group as compared to 5.2 per cent in the group treated by primary internal fixation. Both cases with poor results in the latter group were injuries sustained in a threshing machine, which resulted in marked stiffness of finger joints. All the cases with poor results in the conservatively treated group had been classified as grade 2 and grade 3 open fractures initially. DISCUSSION An analysis of the results presented above showed that the incidence of deep infection was more frequent in the conservatively treated group than in the internally fixed fractures. Table VIII summarizes the incidence of sepsis in open fractures treated conservatively as well as by primary internal fixation, as reported in the literature by other workers. Further, the results in the present series showed a higher incidence of poor results in the conservatively treated open fractures than in the group treated by primary internal fixation. Although conservative treatment was successful in 77.3 per cent of fractures, the poor results occurred mainly in open fractures with severe softtissue damage. In contrast to this, open fractures with extensive soft-tissue damage that were treated by primary internal fixation, showed remarkably good soft-tissue healing (Figs. 4-6). The result of treatment in an open fracture depends mainly on the type of injury and degree of wound contamination, and on the initial surgical management of the wound. Hampton (1955) emphasized the important role played by adequate reduction of the fracture in the prevention of wound infection. With the fragments held in good apposition, dead space in which contaminated blood clot and wound exudate can collect is avoided, pressure of fragments against the under surface of the skin that might cause necrosis does not occur, and wound margins are more easily approximated without tension. Further, if infection does occur, the internal fixation facilitates painless, regular care of the wound without jeopardizing the reduction. The results presented here show that deep infection seen in 5 fractures in the group treated by primary internal tixation did not prove to be detrimental to fracture healing, and the infection healed after removal of the implant following fracture union. This is in conformity with the observations of
27
McNeur (1970). In contrast to this, all the 4 fractures with persistent sepsis in the conservatively treated group failed to unite. Alho, Koskinen, and Malmberg (1972) have shown that surgical treatment of osteomyelitis following fracture was successful in all the cases in which primary internal fixation had been performed initially. It is, however, not the purpose of this paper to advocate indiscriminate use of primary internal fixation of open fractures. Adequate wound toilet is of prime importance in the treatment of open fractures, but we feel that judicious use of primary internal fixation in experienced hands is of definite advantage in injuries associated with extensive soft-tissue damage or skin loss, in injury to the neurovascular bundle in patients with multiple fractures or in open joint fractures, such as fracture-dislocations of the ankle and fractures of the olecranon. Acknowledgements Thehelp rendered by Mr. 0. P. Gupta, Mr. G. C. Saxena, Mr. D. K. Mathur, and Mr. Bhatnagar with the photographic work is gratefully acknowledged. REFERENCES
ALHO, A., KOSKINEN,E. V. S., and MALMBERG,H. (1972). ’ Osteomyelitis in non-operative and operative fracture treatment. A survey of 49 adult patients ‘, Clin. Orthop., 82, 123. CLAFFEY,T. (1960), ‘Open fractures of the tibia ‘, J. Bone Jr Surg., 42B, 407. GUSTILLO,R. B., SIMPSOPI’, L., NIXON, R., RUIZ, A., and INDECK, W. (1969), ‘ Analysis of 5 I1 open fractures ‘, Clin. Orthop., 66, 148. HAMPTON, 0. P., jun. (1955), ‘ Basic principles in management of open fractures ‘, J. Am. med. Ass., 159,417. HICKS, J. H. (1957). ’ The relationship between metal and infection ‘. Proc. R. Sot. Med.. SO. 842. KETFINIIAN,A. Y., and SHELTON, M.' L. (1972). ‘ Primary internal fixation of open fractures: A retrospective study of the use. of metallic internal fixation in fresh open fractures ‘, J. Traumu, 12,756. MCNEUR, J. C. (1970). ‘The management of open skeletal trauma with particular reference lo internal fixation ‘, J. Bone Jt Surg., 52B, 54. SMITH, H. (1963), in Campbell’s Operotive Orthopuedics, Vol. I, 4th ed., (ed. GRENSHAW,A. H.)
pp. 385-387. St. Louis: Mosby. S~TO-HALL, H., and HORWITZ,J. (1946), ‘ The treatment of compound fractures of the femur ‘, J. Am. med. Ass., 130, 128. VALISKAKIS,K. P. (1959), ‘ Primary internal fixation in open fractures of the tibia1 shaft--the problem of wound healing ‘, J. Bone Jr Surg., 41B, 342.
to:Requests for reprints should be addrczrrd Dr. B. P. Vamm, M.S., M.S.(Orth.), Readerin Orthopaedics, Instituteof Medical Sciences.BanerasHindu Univcrsily,Varanasi221005,India.
Injury, 6, 22-27
An evaluation of the results of primary internal fixation in the treatment of open fractures B. P. Varma and Y. P. C. Rao Department of Orthopaedics, Institute of Medical Sciences. Banaras Hindu University, Varanasi, India
Summary
An analytical study of 91 open fractures treated during the period 1967-73 has been presented. Fifty-three were treated conservatively, whereas 38 were managed by primary internal fixation. There were 12 cases of deep infection in the conservatively treated group (22.6 per cent), of which 4 had persistent infection in spite of adequate treatment. In contrast to this, the group treated by primary internal fixation showed 5 cases of deep infection
(13.1 per cent). All of these healed after the implants were removed, following union of the fractures. Minor sequestrectomy was performed simultaneously in 3 of them. Analysis of the results showed poor results after 22.6 per cent of fractures with conservative treatment in contrast to 5.2 per cent in the group managed by primary internal fixation. It is felt that judicious application of primary internal fixation in injuries associated with severe soft-tissue damage or multiple fractures is of definite advantage to the patient.
INTRODUCTION mechanization and high-velocity accidents have led to an increase in the incidence of open fractures with extensive soft-tissue injury. There is still a considerable difference of opinion amongst surgeons with regard to the use of primary metallic fixation in the treatment of open Various authors (Soto-Hall and fractures. Horwitz, 1946; Claffey, 1960; Gustillo, Simpson, Nixon, Ruiz, and Indeck, 1969) reported a significantly higher incidence of superficial and deep sepsis in cases treated by primary internal fixation. Other workers (Hicks, I957; McNeur, 1970) have shown that the incidence of infection MODERN
in internally fixed open fractures was no greater than in those treated conservatively. Hence it was thought worth while to compare the results of conservatively treated open fractures with those managed by primary internal fixation.
MATERIALS AND METHODS Ninety-six open fractures in 93 patients were treated during the period March 1967-73 in the Orthopaedic Department of S.S. Hospital, Banaras Hindu University. There were 80 males and 13 females, ranging in age from 6 to 63 years. Falls from a height and traffic accidents accounted for over 50 per cent of the fractures. Fourteen injuries were caused by machine traction belts. Table I shows the various sites in 96 open fractures. Only 44 patients (45.8 per cent) reached the hospital within 12 hours of injury (Table ZZ). There were 5 open fractures of 3-4 days’ duration (Fig. 1A). Depending upon the degree of soft-tissue damage and the initial contamination, the open fractures were classified into three grades (Table ZZZ) according to the classification of Smith (1963). Table I.-Types
of fracture
Bone involved Femur Tibia and fibula Humerus Radius and Ulna Monteggia fracture Olecranon Tota I
No. of fractures 15 36 (segmental 1) 11 32 (segmental 3) 1 1 96
Varma and Rao : Primary Internal Fixation
23
Eighty-eight patients with 91 fractures were followed up for an average of 149 months, with a range from 3 to 66 months. Of these 91 fractures, 53 were treated conservatively whereas 38 were managed by primary internal fixation. TREATMENT Anti-tetanus serum and toxoid were administered to every patient. The patients were resuscitated and were operated on as emergencies under general anaesthesia.
Table I/.-Time interval between injury and arrival at hospital No. of cases
Time(hr.) 6 6-l 2 24 24-48 72-96
3 41 26 21 5
Total
96
At operation, the wound was covered with sterile gauze, and the affected limb was shaved and cleaned. Later the wound itself was thoroughly cleaned with savlon lotion and irrigated with sterile physiological saline. The limb was draped. A thorough wound excision was performed. The wound was again irrigated with saline. The operative field was redraped, and the operating team changed gloves for the internal fixation operation, the instruments for which were kept on a separate trolley. Out of 38 fractures treated by primary internal fixation, 32 were fixed with intramedullary nails, another 4 were fixed with screws, and 2 were plated. One million units of penicillin G with 1 g. of streptomycin were sprayed into the wound, and primary closure was performed only in those cases for which it was felt that there was a reasonable chance of achieving primary union. Wounds with skin loss, or where infection was feared, were left open to be covered secondarily with skin graft except for 1 case in which primary skin grafting was performed. Additional support by plaster cast was provided for upper limb and tibia1 fractures for 6-12 weeks.
Fig. 1.-A, Three-day-old cornminuted fractures of the tibia and fibula. B, Primary healing of the wounds and well consolidated fractures after primary medulkuy nailing.
Table /M-Grade
of open fracture
Group No internal fixation Primary internal fixation*
Grade 1 7 2
Grade 2
Grade 3
Total
27 26
56 40
*The presence of severe soft-tissue damage, or multiple fractures were the main criteria in selecting cases for internal fixation.
Injury: the British Journal of Accident Surgery Vol. ~/NO. 1
24 In cases treated without internal fixation, the fractures were reduced following toilet and set in plaster casts. Stitches were removed after 14 days and a fresh well-fitting plaster cast was applied. Fourteen wounds were left open at first, but were covered
with split skin grafts after 2-3 weeks through windows in the plaster casts. The wounds which failed to heal were regularly dressed through windows in the plaster casts. These cases with infection received antibiotics for 3-6 weeks according to the bacterial sensitivity tests.
Table /l/.--Soft-tissue Type of healing Primary healing Delayed healing Deep infection
Tab/e V.-Bone
Deformity Shortening
ple fractures of rij pht forearm bones with severe soft-tissue damage caused by machine traction belt. There is a segmen ltal fracture of the ulna, with dislocation of the radial flead.
No internal fixation (53 fractures) 35 (66 per cent) 6 (11.3 per cent) 12 (22.6 per cent) (8 healed after removal of sequestrum)
Primary internal fixation (38 fractures) 26 7 5 (Healed metal 3 minor
(68.4 per cent) (18.4 per cent) (13.1 per cent) after removal of following union. sequestrectomies)
healing
State of union United Ununited
healing
No internal fixation (53 fractures)
Primary internal fixation (38 fractures)
48 (90.5 per cent) 5 ( 9.4 per cent) Bone grafting 1 8 6
32 (84.2 per cent) 6 (15.7 per cent) Bone grafting 4 healed Nil 1
ture 18 months afterr the in&zy. This was treated by primary medulla1 *y nariling of radius and ulna with primary wo und clos ure. The ulnar nail was extracted because aIf ulceral ion over the end of the nail.
Varma and Rao : Primary Internal Fixation
25
RESULTS
implant after the fracture had united. Three of these required minor sequestrectomy. Table Y shows the results of bone healing in the two groups. Thirty-six fractures (94.8 per cent) in
Table IV shows the soft-tissue healing pattern in the two groups. achieved in 77.3
Complete wound healing was per cent of the conservatively
Tab/e V/.-Average
time taken for radiological union of open fractures
Bone
No internal fixation (time in wee&s)
Primary internal fixation (time in weeks)
a: 17 17 12
20 23 29 21 13
Femur Tibia Humerus Radius and ulna Ulna
Tab/e V//.-Final
results
Group No internal
Excellent
Satisfectory
(66.033p5er cent)
(11.3 pe9 cent)
(68.4 itr
(26.3 izr cent)
Poor
T&at
fixation
53 (22.6 iir
cent)
Primary internal fixation
38 cent)
(5.2 pe’r cent)
Excellent-Complete soft-tissue healing and bony union, without deformity or shortening and with full joint function. Satisfactory-As in excellent, but with a range of 90” in the major joints. Poor-Persistent infection or non-union or gross deformity, more than 1 f inches shortening in the lower limb or less than 30” joint motion.
Tab/e V///.-Infection fixation, as reported
rate in open fractures in various series
treated with
primary
internal
infection rate (per cent) No Primary internal fixation internal fixation
Author
Hicks (1957) Valiskakis (1959) Claffey (1960) Gustillo, Simpson, Nixon, Ruiz, and lndeck McNeur (1970) Ketenjian and Shelton (1972) Present series
or without
13
(1969)
treated group, whereas it was 86.8 per cent in the group treated by primary internal fixation. There were 12 cases of deep infection (22.6 per cent) in the conservatively treated group, of which 8 healed following extrusion/removal of a sequestrum. The infection failed to heal in 4 cases in this group, all of which were initially classified as grade 3 open fractures. On the other hand, all the 5 cases (13.1 per cent) with deep infection in the group treated by primary internal fixation healed following removal of the
s 6.68 6 22.6
14.8 16.2 21 .o 11.6 3.6 7.6 13.1
the group treated by primary internal fixation united in perfect anatomical alignment (Figs. lB-3), with minor shortening in a case of a May-old fracture of the humerus in which the bone end had to be trimmed. Four of these had secondary canctllous bone grafting for delayed union. Two fractures (5.2 per cent) have not united. One of these was a fracture of the olecranon followed up for 6 months after being f%ced with a screw. It resulted in excellent elbow function. In another case of a severely damaged
26
Injury: the British Journal of Accident
Surgery Vol. ~/NO. 1
forearm and hand crushed in a thrashing machine, the ulna has failed to unite. In the conservatively treated group, 4 fractures with persistent frank sepsis failed to unite (7.5 per cent). Deformity occurred in 8 cases and shortening in 6 cases in this group. The average time required for radiographic evidence of union was uniformly more in the group treated by
primary internal fixation than in the conservatively treated group, except in the case of the femur (Table VI). The results in relationship to soft-tissue healing, bone healing, deformity, shortening, and joint function are shown in Table VII. Excellent results were achieved in 68.4 per cent of cases treated by primary internal fixation as compared to 66.03 per
Fig. 4.-Multiple fractures of the forearm bones with segmental fracture of the radius and extensive softtissue damage. There was a closed fracture of the humerus in the same limb.
Fig. 5.-Well injury.
Fig. 6.-Showing
healed fracture 12 months after the
extent of the soft-tissue damage healed by primary intention.
Varma and Rao : Primary Internal Fixation
cent in the conservatively treated group. The difference was striking when one considers the incidence of poor results, which was 22.6 per cent in the conservatively treated group as compared to 5.2 per cent in the group treated by primary internal fixation. Both cases with poor results in the latter group were injuries sustained in a threshing machine, which resulted in marked stiffness of finger joints. All the cases with poor results in the conservatively treated group had been classified as grade 2 and grade 3 open fractures initially. DISCUSSION An analysis of the results presented above showed that the incidence of deep infection was more frequent in the conservatively treated group than in the internally fixed fractures. Table VIII summarizes the incidence of sepsis in open fractures treated conservatively as well as by primary internal fixation, as reported in the literature by other workers. Further, the results in the present series showed a higher incidence of poor results in the conservatively treated open fractures than in the group treated by primary internal fixation. Although conservative treatment was successful in 77.3 per cent of fractures, the poor results occurred mainly in open fractures with severe softtissue damage. In contrast to this, open fractures with extensive soft-tissue damage that were treated by primary internal fixation, showed remarkably good soft-tissue healing (Figs. 4-6). The result of treatment in an open fracture depends mainly on the type of injury and degree of wound contamination, and on the initial surgical management of the wound. Hampton (1955) emphasized the important role played by adequate reduction of the fracture in the prevention of wound infection. With the fragments held in good apposition, dead space in which contaminated blood clot and wound exudate can collect is avoided, pressure of fragments against the under surface of the skin that might cause necrosis does not occur, and wound margins are more easily approximated without tension. Further, if infection does occur, the internal fixation facilitates painless, regular care of the wound without jeopardizing the reduction. The results presented here show that deep infection seen in 5 fractures in the group treated by primary internal tixation did not prove to be detrimental to fracture healing, and the infection healed after removal of the implant following fracture union. This is in conformity with the observations of
27
McNeur (1970). In contrast to this, all the 4 fractures with persistent sepsis in the conservatively treated group failed to unite. Alho, Koskinen, and Malmberg (1972) have shown that surgical treatment of osteomyelitis following fracture was successful in all the cases in which primary internal fixation had been performed initially. It is, however, not the purpose of this paper to advocate indiscriminate use of primary internal fixation of open fractures. Adequate wound toilet is of prime importance in the treatment of open fractures, but we feel that judicious use of primary internal fixation in experienced hands is of definite advantage in injuries associated with extensive soft-tissue damage or skin loss, in injury to the neurovascular bundle in patients with multiple fractures or in open joint fractures, such as fracture-dislocations of the ankle and fractures of the olecranon. Acknowledgements Thehelp rendered by Mr. 0. P. Gupta, Mr. G. C. Saxena, Mr. D. K. Mathur, and Mr. Bhatnagar with the photographic work is gratefully acknowledged. REFERENCES
ALHO, A., KOSKINEN,E. V. S., and MALMBERG,H. (1972). ’ Osteomyelitis in non-operative and operative fracture treatment. A survey of 49 adult patients ‘, Clin. Orthop., 82, 123. CLAFFEY,T. (1960), ‘Open fractures of the tibia ‘, J. Bone Jr Surg., 42B, 407. GUSTILLO,R. B., SIMPSOPI’, L., NIXON, R., RUIZ, A., and INDECK, W. (1969), ‘ Analysis of 5 I1 open fractures ‘, Clin. Orthop., 66, 148. HAMPTON, 0. P., jun. (1955), ‘ Basic principles in management of open fractures ‘, J. Am. med. Ass., 159,417. HICKS, J. H. (1957). ’ The relationship between metal and infection ‘. Proc. R. Sot. Med.. SO. 842. KETFINIIAN,A. Y., and SHELTON, M.' L. (1972). ‘ Primary internal fixation of open fractures: A retrospective study of the use. of metallic internal fixation in fresh open fractures ‘, J. Traumu, 12,756. MCNEUR, J. C. (1970). ‘The management of open skeletal trauma with particular reference lo internal fixation ‘, J. Bone Jt Surg., 52B, 54. SMITH, H. (1963), in Campbell’s Operotive Orthopuedics, Vol. I, 4th ed., (ed. GRENSHAW,A. H.)
pp. 385-387. St. Louis: Mosby. S~TO-HALL, H., and HORWITZ,J. (1946), ‘ The treatment of compound fractures of the femur ‘, J. Am. med. Ass., 130, 128. VALISKAKIS,K. P. (1959), ‘ Primary internal fixation in open fractures of the tibia1 shaft--the problem of wound healing ‘, J. Bone Jr Surg., 41B, 342.
to:Requests for reprints should be addrczrrd Dr. B. P. Vamm, M.S., M.S.(Orth.), Readerin Orthopaedics, Instituteof Medical Sciences.BanerasHindu Univcrsily,Varanasi221005,India.