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Early versus delayed closure of open fractures
Injury, Int. J. Care Injured (2007) 38, 890—895
www.elsevier.com/locate/injury
DEBATE
Early versus delayed closure of open fractures S. Rajasekaran * Department of Orthopaedic & Spine Surgery, Ganga Hospital, Mettupalayam Road, Coimbatore 641 011, India Accepted 8 January 2007
KEYWORDS Open fractures; Primary closure
Summary The desired outcome in the management of Type III open injuries is not merely salvage but a limb which is functional, painless and aesthetically pleasing. The aim is to also achieve this outcome with the least number of reconstructive surgical procedures and minimal hospital stay. This is now possible by the emergence of many new concepts, by which primary closure is one. While the traditional expected standard of care was to leave the wound open and delay closure, the current evidence favours primary closure in open injuries if the following indications are met: (a) debridement performed within 12 h, (b) no skin loss primarily or secondarily during debridement (Ganga Hospital Score [Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg Br 1990;72:125—8]: score of ‘1’ or ‘2’), (c) skin approximation possible without tension, (d) no farmyard of gutter contamination, (e) debridement performed to the satisfaction of the surgeon and (f) no vascular insufficiency. # 2007 Elsevier Ltd. All rights reserved.
Primary closure does have a role in Type III open injuries The question of timing of closure of wounds in open injuries without skin loss is controversial.5,18 The widely accepted standard of care in the management of open wounds is to leave the wound open after debridement and to delay the closure to a later date. Undoubtedly the major concern of closing a wound which is contaminated and potentially infectious is the fear of severe local infection, or infection with tetanus or gas gangrene, which would be a * Tel.: +91 422 2235050; fax: +91 422 2232652. E-mail address: [email protected]. URL: http://www.gangahospital.com
threat to the limb or life of the patient.1,11 This phobia is the result of the experience of treating war wounds at a period of time when antibiotics were not available and the principles of debridement were primitive.3,5,18 In 1974, Brown and Kinman1 reinforced the need to leave the wound open, where they attributed the occurrence of 19 cases of gas gangrene and eight of anaerobic cellulites to a protocol of primary closure. However, many of their conclusions are questionable on closer review of their paper. Of the 27 patients with complications in their series, all patients had severe organic contamination and more importantly inadequacy of debridement was noted by the persistence of ‘‘foreign material’’ such as dirt and organic matter during re-exploration. Many patients also had faecal
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.01.013
Early versus delayed closure of open fractures contamination and the antibiotic regimen was inadequate and inappropriate. The reason for complications in their series seem to be more due to failure of appropriate wound management and noncompliance with surgical principles of debridement, rather than the protocol of primary closure. In a recent study, Russel et al.16 reported the results of 90 of 110 consecutive open tibial fractures reviewed retrospectively and reported a deep infection rate of 27% (12/58) in primary skin closure compared to 3% (1/32) following delayed closure. Eight of the non-unions also followed primary closure, and they advised against primary closure. However, such reports supporting delayed closure of wounds based on prospective trials are rare. In contrast there are numerous studies reporting better results after primary closure.2,3,5,6,7,9,10 The concept of primary closure was strongly advocated even in 1948 by Davis and Erie,3 who advised ‘‘immediate closure so as to restore the environmental state of the deeper cells; and their innate defense mechanism’’. They reported a series of 110 consecutive open fractures over a period of 11 years from 1936 to 1946 and concluded that if the surgeon had the ‘‘armamentarium and ability at the hand for execution of the proper careful debridement, internal fixation, skin-plastic operation, compression dressing, and treatment of shock within the usual time limit, delayed suture seems to add to the risk rather than to diminish it’’. Cole and co-workers9 reported infection rate of 8% (4/ 51) in open fracture of the tibia closed primarily compared to 15% (6/41) of wounds closed by secondary intention. Cullen et al.2 reviewed the records of 83 children with open fractures of the tibial metaphysis and diaphysis over the 10-year period. Fifty-seven (69%) wounds were closed primarily of whom only two (3.5%) had superficial infection. Neither patient required re-debridement and no wound had deep infection or osteomyelitis. They concluded that the rigid dictum of no role for primary closure of the wounds in adults did not apply rigidly to the wounds in children. But similar good results have also been obtained in an adult population.7 De Long et al.5 reported on the results of 119 open fractures treated by aggressive surgical debridement, irrigation with pulsed lavage, appropriate skeletal fixation which involved internal fixation in suitable cases and six forms of wound management. There was no statistical difference in either infection rate or outcome regarding fracture union in both immediate and delayed closure. They concluded that immediate primary closure (with or without second look) is a viable option but emphasised that the decision must be that of an experienced surgeon.
891 The phobia that primary closure may lead to increased rate of infection is ill-founded as most acute infections after open injuries are the result of pathogens acquired in the hospital rather than from the site of injury. Gustilo and Anderson8 reported in a prospective study of 326 open fractures; eight patients developed infection of which, five were acquired secondarily in the hospital. In their report of 1073 open fractures, they also advocated primary closure for Type I, and Type II injuries and suitable Type III injuries. They concluded that, ‘‘during the long intervals when such wounds were open, secondary infection usually with Gram negative organisms may be a problem since these organisms are usually difficult to control by antibiotics alone’’. That the infection is frequently hospital acquired is evident, as it is difficult to predict the subsequent infective pathogen on the basis of initial wound culture.4,12,17 In a prospective study, Patzakis et al.12 found that only 18% of infections were caused by the same organism initially isolated in the peri-operative period. The enormity of the problem of hospital-acquired infection in open injuries is a strong factor for primary closure.18 As the fracture site and soft tissue wound is probably most sterile after an adequate debridement by an experienced surgeon, leaving wounds open not only increases infection but heralds further complications of drying and desiccation of exposed tissue especially tendons, periosteum and neurovascular structures. This leads to secondary loss of tissue in subsequent debridements and complicates the management by increasing the number of secondary procedures, in-patient stay cost and reconstructive procedure of a greater magnitude. The disadvantages of leaving an open joint injury open with exposed articular cartilage to dry and desiccate is still more obvious. However, it is also true that undisciplined closure of all wounds will be disastrous. The challenge is to define safe indications for primary closure so that wounds can be selectively closed. This will allow closure of wounds which can be safely closed so that the disadvantage of leaving wounds open will be avoided and also avoidance of wound closure in wounds that should be left open. Towards this goal, we have attempted to define indications for safe primary closure of wounds from 1992. This work was done in a unit which manages more than 250 major open injuries of limbs every year. The unit also has dedicated consultants in anaesthesia, orthopaedics and plastic surgery who work closely from the time of receiving the patient through all the surgical procedures. This has helped to evolve the ‘Ganga Hospital Open Injury Score’ which helps to assess the severity of injury to each component of the limb
892
S. Rajasekaran
Figure 1 Score for covering tissues. (a) Wound without skin loss and not over the fracture site. (b) Wound without skin loss but exposing the fracture site. (c) Wound with skin loss and not over the fracture site. (d) Wound with skin loss and over the fracture site. (e) Circumferential wound with bone circumferentially exposed (from Rajasekaran et al.15).
including the skin separately and help to evolve treatment guidelines.14,15 Appropriate positioning of the joint and the gentle tension to bring the flap to its correct length will make it possible to suture the flap without tension provided there is no skin loss. This has also helped to form a framework of treatment protocols where many injuries are treated by ‘Fix and Close’ protocol.14 The experience has allowed us to define indications for safe closure of primary injuries. The severity of the skin wound is graded from 1 to 515 (Fig. 1). Wounds without skin loss which have an adequate soft tissue bed and can be approximated without tension after debridement are given a score of one if they do not overlie the fracture and two if they expose it. Wounds with primary skin loss or which require extensive debridement of the skin due to friction burns or degloving have a score of three if they are not over the fracture site and four if they expose it. Wounds involving skin loss over the entire circumference of the limb have a score of five. In injuries with a skin score of 1 and 2, it was possible to achieve primary closure with good results.15 In a series of 102 Type IIIA and Type IIIB injuries, it was found that all 35 patients with a score of 1 or 2 could be closed primarily.15 It is to be noted that the size of the wound does not matter provided there is no skin loss either during Injury or at the time of debridement. A case in point is a Type IIIB open injury of tibia shown in Fig. 2 with a 11 cm 4 cm longitudinal laceration exposing the fracture. There was contusion associated with superficial abrasions distally along with partial avulsion of heel pad. The wound was extended for debridement purposes. Thorough debridement of
bone and soft tissue was done and care was taken not to excise the skin margins as it had adequate vascularity. After stabilisation by locking nail, the wound could be closed primarily without tension. There was good healing of all the wounds, although there was marginal skin necrosis initially. The ability to appose the wound without tension is more important than the size, nature, site of the wound or the method of internal fixation used. Managing this wound by fixation and secondary wound management would have resulted in drying and dessication of the periosteum, bone and exposed tendons. Contamination of the wound with hospital organisms is also a possibility that will result in wound infection. A secondary debridement may be necessary which will result in increased tissue loss and ultimately a flap. No other surgical procedure other than the index procedure was necessary and primary healing of bone and soft tissue was achieved. The entire success of the primary closure protocol procedure definitely depends upon meticulous debridement where no contaminated, hypovascular or non-viable tissues are left behind. The involvement of an experienced team during debridement cannot be overemphasised. The high rate of success in our unit is due to the involvement of senior members of orthopaedic and plastic team at the time of debridement. Assessment of the skin wounds requires experience as the wounds in a deformed limb or over a joint do not always reflect correctly the nature of the skin wound. A fractured limb usually shortens and this tends to result in opening and gaping of the wound giving the appearance of skin loss. Once the skeleton is brought to its correct length and the fracture
Early versus delayed closure of open fractures
893
Figure 2 Grade III open injury of the tibia with a 11 cm 4 cm gaping wound exposing the fracture area. There was no skin loss and the skin margins showed active bleeding during debridement. After thorough debridement, the fracture was fixed by an interlocking nail. After the limb length was restored, the wound margins could be easily sutured without any tension. The bone and skin healed well without any complications.
stabilised, many of the wounds appear more linear and approximation of the skin margins without tension is also possible. The presence of degloving of the skin or a flap needs critical assessment of skin viabi-
lity. Large distally based flaps which are traditionally considered non-viable and excised were also found to heal well if there was clinical evidence of skin flap viability and bleeding at margins after debridement.
Figure 3 Type III open injury of the left elbow with fracture of the olichranaor and exposure of the elbow joint. The wound was debrided well, the olichranor fracture fixed by h tension band technique and the wound closed primarily. Both wound and bone healed primarily. The patient regained good elbow movements in 12 weeks time.
894 Fig. 3 shows a Type IIIB injury of elbow with fracture of the olecranon. The wound had a large distally based flap but with bleeding margins. There was capsule damage with exposure of the articular cartilage of the joint. Leaving such a wound open carries multiple disadvantages of drying and desiccation of tissues; secondary loss of tissues in re-debridements, increased chance of hospital acquired infections and retraction of the skin flaps necessitating a flap. The fracture was stabilised by tension band wiring technique and the wound was closed primarily in layers. Both the soft tissues and bone healed primarily and there was a good functional outcome. We have followed the philosophy of closing wounds primarily irrespective of the size and site of the wound if the following criteria are met: debridement performed within 12 h; no skin loss primarily or secondarily during debridement (Ganga Hospital Score15: score of ‘1’ or ‘2’); skin approximation possible without tension; no farmyard of gutter contamination; debridement performed to the satisfaction of the surgeon; no vascular insufficiency. In the same line, the contra-indications for a primary closure were: skin loss primarily or during debridement (Ganga Hospital Score15: skin score of ‘3’ and above); gross contamination with faeces, dirt, stagnant water; farm related injuries, fresh water related accidents; delay in antibiotic initiation >12 h; extensive tissue necrosis during debridement. We have found that approximately one-third of Type III Injuries could be closed primarily with good results. In a prospective study from June 1999 to May 2002, out of 510 consecutive Type III open injuries, 173 were closed primarily.13 Of these, 79 were in tibia. All patients were assessed and resuscitated as per the ATLS protocol and were given tetanus prophylaxis and intravenous antibiotics on admission. Debridement was always done at the earliest possible by a team of orthopaedic and plastic consultants trained in the methods of debridement. The decision to close the wound was then taken by a team depending upon the adequacy of debridement, viability of skin margin and the ability to approximate skin without any tension whatsoever. At an average follow up of 36.5 months, 157 (91%) had uneventful recovery in terms of wound healing,
S. Rajasekaran bone union and deep infection. There were no complications of wound healing for infection in any of the upper limb injuries. In lower limb injuries, good healing was observed irrespective of the size of the wound, grading of the injury at the sight of the wound provided there was no skin loss primarily or at debridement. Complications in wound healing were observed only in 4 (2.3%). Infection was observed in 16 patients (9.1%). Infection was superficial in 11 patients which settled well with intravenous antibiotics. Five patients had deep infection with positive cultures which required debridement. Only one required removal of the implant which ended with non-union. Our experience shows that approximately onethird of Type III injuries without vascular problems are amenable to primary closure if carefully performed by a team highly experienced in debridement and management of open injuries. If this protocol has not been followed, surely the incidence of flap requirement would have been many times higher. These good results are mainly because of immediate closure, which protects the normal internal environment and prevents the additional loss of soft tissues. However, fundamental to the success of such a protocol is a team well experienced in the management of open injuries. A thorough and meticulous debridement, which has converted the open injury into a clean wound, is an absolute must before the wounds can be closed. It is also important that the indications as proposed in the study are also strictly adhered to.
References 1. Brown PW, Kinman PB. Gas gangrene in metropolitan community. J Bone Joint Surg Am 1974;56:1445—51. 2. Cullen MC, Roy DR, Crawford AH. Open fractures of tibia in children. J Bone Joint Surg Am 1996;78:1039—47. 3. Davis AG, Erie MD. Primary closure of compound fracture wounds. J Bone Joint Surg Am 1948;30:405—15. 4. Dellinger EP, Miller SD, Wertz MJ. Risk of infection after open fracture of the arm or leg. Arch Surg 1988;112:1320—7. 5. De Long Jr WG, Born CT, Wei SY, et al. Aggressive treatment of 119 open fracture wounds. J Trauma 1999;46(6): 1049—54. 6. Godina M. Early microsurgical reconstruction of complex trauma of extremities. Plast Reconstr Surg 1986;78:285—92. 7. Gopal S, Majumder S, Batchelor AGB, et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000;82:959—66. 8. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty five open fractures of long bones: retrospective and prospective analysis. J Bone Joint Surg Am 1976;58:453—8. 9. Hope PG, Cole WG. Open fractures of the tibia in children. J Bone Joint Surg Br 1992;74B:546—53.
Early versus delayed closure of open fractures 10. Patzakis MJ, Dorr LD, Ivler D, et al. The early management of open joint injuries. A prospective study of one hundred and forty patients. J Bone Joint Surg Am 1975;57(8): 1065—70. 11. Patzakis MJ, Dorr LD, Hammond W, Ivler D. The effect of antibiotics, primary and secondary closure on clostridial contaminated open fracture wounds in rats. J Trauma 1978;18(1):34—7. 12. Patzakis MJ, Bains RS, Lee J, et al. Prospective randomized double-blinded study comparing single agent antibiotic therapy ciprofloxacin to combination antibiotic therapy in open fracture wounds. J Orthop Trauma 2000;14:529—33. 13. Rajasekaran S. The safety of primary closure in open injuries of limbs. In: American academy of orthopaedic surgeons meeting, paper no. 62; 2006.
895 14. Rajasekaran S, Raja Sabapathy S. A philosophy of care of open injuries based on the Ganga hospital score. Injury: Int J Care Injured 2007;38:137—46. 15. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, et al. A score for predicting salvage and outcome in Gustilo type IIIA & type IIIB open tibial fractures. JBJS (Br) 2006;88B(10):1351—60. 16. Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg Br 1990;72:125—8. 17. Seekamp A, Kontopp H, Schandelmaier P, et al. Bacterial cultures and bacterial infection in open fractures. Eur J Trauma 2002;122(5):259—61. 18. Weitz Marshall AD, Bosse MJ. Timing of closure of open fractures perspectives on modern orthopaedics. J Am Acad Orthop Surg 2002;10(6):379—84.
www.elsevier.com/locate/injury
DEBATE
Early versus delayed closure of open fractures S. Rajasekaran * Department of Orthopaedic & Spine Surgery, Ganga Hospital, Mettupalayam Road, Coimbatore 641 011, India Accepted 8 January 2007
KEYWORDS Open fractures; Primary closure
Summary The desired outcome in the management of Type III open injuries is not merely salvage but a limb which is functional, painless and aesthetically pleasing. The aim is to also achieve this outcome with the least number of reconstructive surgical procedures and minimal hospital stay. This is now possible by the emergence of many new concepts, by which primary closure is one. While the traditional expected standard of care was to leave the wound open and delay closure, the current evidence favours primary closure in open injuries if the following indications are met: (a) debridement performed within 12 h, (b) no skin loss primarily or secondarily during debridement (Ganga Hospital Score [Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg Br 1990;72:125—8]: score of ‘1’ or ‘2’), (c) skin approximation possible without tension, (d) no farmyard of gutter contamination, (e) debridement performed to the satisfaction of the surgeon and (f) no vascular insufficiency. # 2007 Elsevier Ltd. All rights reserved.
Primary closure does have a role in Type III open injuries The question of timing of closure of wounds in open injuries without skin loss is controversial.5,18 The widely accepted standard of care in the management of open wounds is to leave the wound open after debridement and to delay the closure to a later date. Undoubtedly the major concern of closing a wound which is contaminated and potentially infectious is the fear of severe local infection, or infection with tetanus or gas gangrene, which would be a * Tel.: +91 422 2235050; fax: +91 422 2232652. E-mail address: [email protected]. URL: http://www.gangahospital.com
threat to the limb or life of the patient.1,11 This phobia is the result of the experience of treating war wounds at a period of time when antibiotics were not available and the principles of debridement were primitive.3,5,18 In 1974, Brown and Kinman1 reinforced the need to leave the wound open, where they attributed the occurrence of 19 cases of gas gangrene and eight of anaerobic cellulites to a protocol of primary closure. However, many of their conclusions are questionable on closer review of their paper. Of the 27 patients with complications in their series, all patients had severe organic contamination and more importantly inadequacy of debridement was noted by the persistence of ‘‘foreign material’’ such as dirt and organic matter during re-exploration. Many patients also had faecal
0020–1383/$ — see front matter # 2007 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2007.01.013
Early versus delayed closure of open fractures contamination and the antibiotic regimen was inadequate and inappropriate. The reason for complications in their series seem to be more due to failure of appropriate wound management and noncompliance with surgical principles of debridement, rather than the protocol of primary closure. In a recent study, Russel et al.16 reported the results of 90 of 110 consecutive open tibial fractures reviewed retrospectively and reported a deep infection rate of 27% (12/58) in primary skin closure compared to 3% (1/32) following delayed closure. Eight of the non-unions also followed primary closure, and they advised against primary closure. However, such reports supporting delayed closure of wounds based on prospective trials are rare. In contrast there are numerous studies reporting better results after primary closure.2,3,5,6,7,9,10 The concept of primary closure was strongly advocated even in 1948 by Davis and Erie,3 who advised ‘‘immediate closure so as to restore the environmental state of the deeper cells; and their innate defense mechanism’’. They reported a series of 110 consecutive open fractures over a period of 11 years from 1936 to 1946 and concluded that if the surgeon had the ‘‘armamentarium and ability at the hand for execution of the proper careful debridement, internal fixation, skin-plastic operation, compression dressing, and treatment of shock within the usual time limit, delayed suture seems to add to the risk rather than to diminish it’’. Cole and co-workers9 reported infection rate of 8% (4/ 51) in open fracture of the tibia closed primarily compared to 15% (6/41) of wounds closed by secondary intention. Cullen et al.2 reviewed the records of 83 children with open fractures of the tibial metaphysis and diaphysis over the 10-year period. Fifty-seven (69%) wounds were closed primarily of whom only two (3.5%) had superficial infection. Neither patient required re-debridement and no wound had deep infection or osteomyelitis. They concluded that the rigid dictum of no role for primary closure of the wounds in adults did not apply rigidly to the wounds in children. But similar good results have also been obtained in an adult population.7 De Long et al.5 reported on the results of 119 open fractures treated by aggressive surgical debridement, irrigation with pulsed lavage, appropriate skeletal fixation which involved internal fixation in suitable cases and six forms of wound management. There was no statistical difference in either infection rate or outcome regarding fracture union in both immediate and delayed closure. They concluded that immediate primary closure (with or without second look) is a viable option but emphasised that the decision must be that of an experienced surgeon.
891 The phobia that primary closure may lead to increased rate of infection is ill-founded as most acute infections after open injuries are the result of pathogens acquired in the hospital rather than from the site of injury. Gustilo and Anderson8 reported in a prospective study of 326 open fractures; eight patients developed infection of which, five were acquired secondarily in the hospital. In their report of 1073 open fractures, they also advocated primary closure for Type I, and Type II injuries and suitable Type III injuries. They concluded that, ‘‘during the long intervals when such wounds were open, secondary infection usually with Gram negative organisms may be a problem since these organisms are usually difficult to control by antibiotics alone’’. That the infection is frequently hospital acquired is evident, as it is difficult to predict the subsequent infective pathogen on the basis of initial wound culture.4,12,17 In a prospective study, Patzakis et al.12 found that only 18% of infections were caused by the same organism initially isolated in the peri-operative period. The enormity of the problem of hospital-acquired infection in open injuries is a strong factor for primary closure.18 As the fracture site and soft tissue wound is probably most sterile after an adequate debridement by an experienced surgeon, leaving wounds open not only increases infection but heralds further complications of drying and desiccation of exposed tissue especially tendons, periosteum and neurovascular structures. This leads to secondary loss of tissue in subsequent debridements and complicates the management by increasing the number of secondary procedures, in-patient stay cost and reconstructive procedure of a greater magnitude. The disadvantages of leaving an open joint injury open with exposed articular cartilage to dry and desiccate is still more obvious. However, it is also true that undisciplined closure of all wounds will be disastrous. The challenge is to define safe indications for primary closure so that wounds can be selectively closed. This will allow closure of wounds which can be safely closed so that the disadvantage of leaving wounds open will be avoided and also avoidance of wound closure in wounds that should be left open. Towards this goal, we have attempted to define indications for safe primary closure of wounds from 1992. This work was done in a unit which manages more than 250 major open injuries of limbs every year. The unit also has dedicated consultants in anaesthesia, orthopaedics and plastic surgery who work closely from the time of receiving the patient through all the surgical procedures. This has helped to evolve the ‘Ganga Hospital Open Injury Score’ which helps to assess the severity of injury to each component of the limb
892
S. Rajasekaran
Figure 1 Score for covering tissues. (a) Wound without skin loss and not over the fracture site. (b) Wound without skin loss but exposing the fracture site. (c) Wound with skin loss and not over the fracture site. (d) Wound with skin loss and over the fracture site. (e) Circumferential wound with bone circumferentially exposed (from Rajasekaran et al.15).
including the skin separately and help to evolve treatment guidelines.14,15 Appropriate positioning of the joint and the gentle tension to bring the flap to its correct length will make it possible to suture the flap without tension provided there is no skin loss. This has also helped to form a framework of treatment protocols where many injuries are treated by ‘Fix and Close’ protocol.14 The experience has allowed us to define indications for safe closure of primary injuries. The severity of the skin wound is graded from 1 to 515 (Fig. 1). Wounds without skin loss which have an adequate soft tissue bed and can be approximated without tension after debridement are given a score of one if they do not overlie the fracture and two if they expose it. Wounds with primary skin loss or which require extensive debridement of the skin due to friction burns or degloving have a score of three if they are not over the fracture site and four if they expose it. Wounds involving skin loss over the entire circumference of the limb have a score of five. In injuries with a skin score of 1 and 2, it was possible to achieve primary closure with good results.15 In a series of 102 Type IIIA and Type IIIB injuries, it was found that all 35 patients with a score of 1 or 2 could be closed primarily.15 It is to be noted that the size of the wound does not matter provided there is no skin loss either during Injury or at the time of debridement. A case in point is a Type IIIB open injury of tibia shown in Fig. 2 with a 11 cm 4 cm longitudinal laceration exposing the fracture. There was contusion associated with superficial abrasions distally along with partial avulsion of heel pad. The wound was extended for debridement purposes. Thorough debridement of
bone and soft tissue was done and care was taken not to excise the skin margins as it had adequate vascularity. After stabilisation by locking nail, the wound could be closed primarily without tension. There was good healing of all the wounds, although there was marginal skin necrosis initially. The ability to appose the wound without tension is more important than the size, nature, site of the wound or the method of internal fixation used. Managing this wound by fixation and secondary wound management would have resulted in drying and dessication of the periosteum, bone and exposed tendons. Contamination of the wound with hospital organisms is also a possibility that will result in wound infection. A secondary debridement may be necessary which will result in increased tissue loss and ultimately a flap. No other surgical procedure other than the index procedure was necessary and primary healing of bone and soft tissue was achieved. The entire success of the primary closure protocol procedure definitely depends upon meticulous debridement where no contaminated, hypovascular or non-viable tissues are left behind. The involvement of an experienced team during debridement cannot be overemphasised. The high rate of success in our unit is due to the involvement of senior members of orthopaedic and plastic team at the time of debridement. Assessment of the skin wounds requires experience as the wounds in a deformed limb or over a joint do not always reflect correctly the nature of the skin wound. A fractured limb usually shortens and this tends to result in opening and gaping of the wound giving the appearance of skin loss. Once the skeleton is brought to its correct length and the fracture
Early versus delayed closure of open fractures
893
Figure 2 Grade III open injury of the tibia with a 11 cm 4 cm gaping wound exposing the fracture area. There was no skin loss and the skin margins showed active bleeding during debridement. After thorough debridement, the fracture was fixed by an interlocking nail. After the limb length was restored, the wound margins could be easily sutured without any tension. The bone and skin healed well without any complications.
stabilised, many of the wounds appear more linear and approximation of the skin margins without tension is also possible. The presence of degloving of the skin or a flap needs critical assessment of skin viabi-
lity. Large distally based flaps which are traditionally considered non-viable and excised were also found to heal well if there was clinical evidence of skin flap viability and bleeding at margins after debridement.
Figure 3 Type III open injury of the left elbow with fracture of the olichranaor and exposure of the elbow joint. The wound was debrided well, the olichranor fracture fixed by h tension band technique and the wound closed primarily. Both wound and bone healed primarily. The patient regained good elbow movements in 12 weeks time.
894 Fig. 3 shows a Type IIIB injury of elbow with fracture of the olecranon. The wound had a large distally based flap but with bleeding margins. There was capsule damage with exposure of the articular cartilage of the joint. Leaving such a wound open carries multiple disadvantages of drying and desiccation of tissues; secondary loss of tissues in re-debridements, increased chance of hospital acquired infections and retraction of the skin flaps necessitating a flap. The fracture was stabilised by tension band wiring technique and the wound was closed primarily in layers. Both the soft tissues and bone healed primarily and there was a good functional outcome. We have followed the philosophy of closing wounds primarily irrespective of the size and site of the wound if the following criteria are met: debridement performed within 12 h; no skin loss primarily or secondarily during debridement (Ganga Hospital Score15: score of ‘1’ or ‘2’); skin approximation possible without tension; no farmyard of gutter contamination; debridement performed to the satisfaction of the surgeon; no vascular insufficiency. In the same line, the contra-indications for a primary closure were: skin loss primarily or during debridement (Ganga Hospital Score15: skin score of ‘3’ and above); gross contamination with faeces, dirt, stagnant water; farm related injuries, fresh water related accidents; delay in antibiotic initiation >12 h; extensive tissue necrosis during debridement. We have found that approximately one-third of Type III Injuries could be closed primarily with good results. In a prospective study from June 1999 to May 2002, out of 510 consecutive Type III open injuries, 173 were closed primarily.13 Of these, 79 were in tibia. All patients were assessed and resuscitated as per the ATLS protocol and were given tetanus prophylaxis and intravenous antibiotics on admission. Debridement was always done at the earliest possible by a team of orthopaedic and plastic consultants trained in the methods of debridement. The decision to close the wound was then taken by a team depending upon the adequacy of debridement, viability of skin margin and the ability to approximate skin without any tension whatsoever. At an average follow up of 36.5 months, 157 (91%) had uneventful recovery in terms of wound healing,
S. Rajasekaran bone union and deep infection. There were no complications of wound healing for infection in any of the upper limb injuries. In lower limb injuries, good healing was observed irrespective of the size of the wound, grading of the injury at the sight of the wound provided there was no skin loss primarily or at debridement. Complications in wound healing were observed only in 4 (2.3%). Infection was observed in 16 patients (9.1%). Infection was superficial in 11 patients which settled well with intravenous antibiotics. Five patients had deep infection with positive cultures which required debridement. Only one required removal of the implant which ended with non-union. Our experience shows that approximately onethird of Type III injuries without vascular problems are amenable to primary closure if carefully performed by a team highly experienced in debridement and management of open injuries. If this protocol has not been followed, surely the incidence of flap requirement would have been many times higher. These good results are mainly because of immediate closure, which protects the normal internal environment and prevents the additional loss of soft tissues. However, fundamental to the success of such a protocol is a team well experienced in the management of open injuries. A thorough and meticulous debridement, which has converted the open injury into a clean wound, is an absolute must before the wounds can be closed. It is also important that the indications as proposed in the study are also strictly adhered to.
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