What is an open fracture, how to treat it, and what should you pay attention to?

With the rapid development of industry and transportation today, high-energy injuries and multiple injuries are becoming more common, open fractures are becoming more complicated, more difficult to handle, and require higher treatment requirements. So what should be paid attention to in the treatment of open fractures?

1. Initial treatment: When assessing the injury, don’t just focus on the classic version

Severe open fractures are often accompanied by associated injuries. The initial assessment and treatment can be simply summarized as saving lives first, then treating the disease, and treating the whole body first, then the local area. In the local treatment of open fractures, whether the soft tissue injury is properly treated is the key factor in determining the patient's prognosis.

2. First surgery: careful consideration of whether to do a large or small surgery

For severe open fractures, doctors need to deal with not only soft tissue defects, fractures, and bone exposure, but also muscle and tendon ruptures or defects and blood vessel and nerve damage. The so-called major initial surgery is to perform a certain fracture fixation, possible limb structure and function reconstruction, and wound repair in the first stage; the so-called minor surgery is to perform debridement, temporary fracture external fixation, and necessary structural reconstruction. This is actually a problem of grasping the indications of the orthopedic damage control (DCO) principle or the early comprehensive treatment (ETC) principle.

It is generally believed that patients with severe open fractures may have hemodynamic instability, hypothermia, acid-base imbalance or coagulation disorders. In order to avoid secondary shock caused by surgery, trauma control surgery should be considered. We must keep in mind that for patients with such injuries, the primary task is still to save lives. The formulation of the surgical plan must be a prudent choice made after a detailed and accurate assessment of the injury, comprehensive consideration of the patient's condition, the surgeon's surgical skills, and the hospital's comprehensive treatment level.

3. Timing of debridement: The golden 6 hours is not an absolute principle

Regarding the timing of debridement, the traditional view is the classic 6-hour principle, which believes that within 6 hours, fresh wounds can heal in the first place after thorough debridement and closure. However, the so-called golden period of 6 hours is not absolute. The basic principle of early debridement should be followed in the treatment of open fractures, and it is recommended to be completed within 24 hours. Compared with debridement within 6 hours, factors such as the patient's general condition, adequate preparation, and the participation of experienced senior doctors in the operation have a greater impact on the prognosis.

4. Internal fixation vs. external fixation: key factors to consider when choosing

At present, the controversy over the choice of internal fixation and external fixation for open fractures mainly focuses on three aspects: the selection of fixators for the initial surgery, whether temporary external fixation should be converted into definite internal fixation, and the treatment of late complications of open fractures.

When deciding whether to switch from external fixation to internal fixation, we need to focus on the following factors: 1. Timing of change: Wait until the soft tissue in the surgical area is well covered and infection is controlled. 2. Surgical method: Protect soft tissue, minimally invasive, choose the incision in the thick tissue to avoid incision problems.

Open fractures in various parts of the human body

5. Limb salvage vs amputation: considering limb injury and overall condition

For severe open limb fractures of Gustilo type ⅢB and ⅢC, the treatment often faces the choice of limb salvage or amputation.

In order to scientifically assess the patient's injury and prognosis, domestic and foreign scholars have proposed some quantitative indicators for limb salvage and amputation, such as the Extremity Injury Severity Score (MESS), the Extremity Injury Syndrome Index (MESI), the Limb Loss Index (LSI), etc. Among them, MESS is the most commonly used, but MESS focuses on the damage to the anatomical structure of the limbs and less on the overall condition of the patient. MESI adds consideration of systemic factors, and the scoring system is more comprehensive, especially for patients with ISS1>25 points, shock, and advanced age. It has advantages in weighing whether to amputate or not, and has good specificity.