|Year : 2014 | Volume
| Issue : 1 | Page : 64-68
Primary plating osteosynthesis in open fractures
Chandra Prakash Pal, Neeraj Mishra, Karuna Shankar Dinkar, Harish Kumar, Pulkesh Singh, RK Goyal
Department of Orthopaedics, S.N. Medical College, Agra, Uttar Pradesh, India
|Date of Web Publication||6-Jun-2014|
Chandra Prakash Pal
Department of Orthopaedics, S.N. Medical College, Agra, Uttar Pradesh
Source of Support: None, Conflict of Interest: None
Introduction: The management of open fractures poses one of the greatest challenges to orthopaedic surgeons because it not only requires management of a contaminated soft tissue injury involving skin, muscles and neurovascular structures but also treatment of underlying fracture which is also contaminated. Primary internal fixation if done can solve many problems. With the use of internal fixation the fracture remain in good position so that soft tissue injuries can be handled easily and effectively. Materials and Methods: Present study was carried out in 12 skeletally mature patients. All open fractures of upper and lower extremities presenting within 12 hours of trauma were included in study. The wound was then cleaned and injured part was then splinted so that movement of fracture fragment causing further damage could be prevented. In operation theatre wound debridement was done before internal fixation under aseptic conditions. Results: Regarding soft tissue healing all the cases of grade I showed either good (66.67%) or fair (33.33%) results. Out of 4 cases of upper limb, 2 cases (50%) of grade I united within 4 months. One case of grade III of upper limb united in 6 months. Out of 8 cases of lower limb, 3 cases (37.5%) united within 5 months and 4 cases (50%) united within 6 months. One case of grade III fracture tibia showed delayed union, bone grafting was done in this case. Conclusion: We conclude from the study that the judicious selection of cases, skillful management of the injured limb and early rehabilitation is the key for compound fractures.
Keywords: Complication, injured, open fractures, plating, rehabilitation, soft tissue
|How to cite this article:|
Pal CP, Mishra N, Dinkar KS, Kumar H, Singh P, Goyal R K. Primary plating osteosynthesis in open fractures. J Orthop Traumatol Rehabil 2014;7:64-8
|How to cite this URL:|
Pal CP, Mishra N, Dinkar KS, Kumar H, Singh P, Goyal R K. Primary plating osteosynthesis in open fractures. J Orthop Traumatol Rehabil [serial online] 2014 [cited 2019 Aug 19];7:64-8. Available from: http://www.jotr.in/text.asp?2014/7/1/64/134022
| Introduction|| |
Few injuries generally demand as much clinical judgement and generate as much controversy as open fractures. The management of open fractures pose one of the greatest challenge to orthopedic surgeons because it not only requires management of a contaminated soft tissue injury involving skin, muscles and neurovascular structures but also treatment of underlying fracture which is also contaminated. ,,, With dramatic advances in orthopaedics, the line of treatment for open factures has completely changed. ,,,,, We observed that primary internal fixation if done after meticulous and careful debridement and cleaning can solve many of the complications of fracture disease.  Primary internal fixation if done can solve many problems. With the use of internal fixation the alignment of the fracture can be maintained in good position so that soft tissue injuries can be handled easily and effectively and also deformity should be prevented and reconstruction and grafting could be done in a clean field immediately or a later date.  We have undertaken the work with the idea that early internal fixation with plate provide sufficient stability for proper nursing of wound and fracture healing on one hand and initiation of early joint function and rehabilitation on the other hand. The purpose of this study was to evaluate an early aggressive wound management and fracture stability in an attempt to alter the natural history of complex open fractures with respect to union, infection rate and time and cost of hospitalization and rehabilitation.
| Materials and methods|| |
The present study was conducted in department of orthopaedics, S. N. Medical College Agra. 12 patients of either sex were selected from emergency and O.P.D of orthopaedic department. Each patient was subjected to a clinical and radiological examination along with routine pathological examination.
- Open fractures of upper and lower extremities.
- Patients presenting within 12 h preferably within 8-9 h after trauma.
- Skeletally mature patients.
- Patients presenting after 12 h of trauma.
- Patients initially managed by external fixator.
- Patients with open growth plates.
Majority of cases was male in age group of 20 to 40 years with only one female patient [Table 1]. Predominant number of cases (5 cases 41.7%) in the series was of tibia, next in number was fracture femur and fracture radius-ulna 3 cases in each group, with one case of fracture shaft humerus. Out of 12 cases, 6 cases were of grade 1 while 4 cases were of grade 2 and 2 cases were of grade 3. Out of 12 cases 4 cases were of upper extremity and 8 cases were of lower extremity. The management of patient was started as soon as the patient was brought in emergency department. The patients were hospitalized and after taking history, a thorough general, local and systemic examination were done in each case. We have classified the open fractures on the basis of severity of soft tissue and skeletal injuries and mechanism of injury by Gustilo-Anderson classification.  The involved extremity was examined and the wound were examined regarding size, skin loss, degree of contamination and exposed bone and neurovascular damage. The wound was then cleaned and injured part was then splinted so that movement of fracture fragment causing further damage could be prevented. Pre- operative culture of wound prior to first handling of the patient was taken and then appropriate broad spectrum antibiotics were started. Injectable analgesics and tetanus toxoid and gamma globulin 500 units injection were given as per immunization status of the patients. The wound remained covered till the patient was shifted to the operation theatre for definitive procedure.
In operation theatre, wound debridement was done before internal fixation under aseptic conditions. All the tissue with gross contamination and with questionable viability was removed. Muscle viability was evaluated by scully et al., criteria for consistency, contractility, colour and ability to bleed. For internal fixation choice of surgical exposure was influenced by extent and location of wound. Considering the management of soft tissue following three approach were used.
- Wound inclusion in the incision
- Incision made at some distance from the wound leaving a broad skin bridge with a good blood supply.
- Approach through the wound and a small additional incision outside the wound area utilized to apply the fixation device.
In 4 cases (33.3%) the satisfactory reduction and plate fixation was achieved either by extension of injury wound or through the wound without extension. In 8 cases site and size of wound was not appropriate, separate incision was given in 8 cases (66.7%) for separate reduction and internal fixation. Primary closure of the wound was done in 6 cases of grade 1. In 2 cases delayed primary closure was done one case each of grade 2 and 3 were left open after operation and skin grafting was done latter on. None of the grade 3 cases were closed primarily closure was done in these cases either by skin grafting in 1 case or muscle pedicle flap which is local rotational musculocutaneous flap in 1 case [Table 2].
|Table 2: Wound management after stabilization of fracture by primary plating|
Click here to view
After discharge from hospital patients were called for follow up at regular interval. When the wound were present at the time of discharge patient was called at every fortnightly for inspection of wound and needful soft tissue reconstructive procedure. When soft tissue healing was complete then patient was called on once monthly. Minimum period of follow up was 6 months while patients were followed up for maximum period of 18 months. At each follow up progression of bone healing and soft tissue healing were checked periodically both clinically and radio graphically and accordingly further movements of limb were advised.
Assessment of results
The results were assessed taking into consideration the following features:
- Soft tissue and bony healing,
- Infection of soft tissue or bone,
- Range of pain free joint movement,
- Deformity and shortening.
The results can be grouped in four categories as excellent, good, satisfactory or poor.
- Soft tissue healing without infection
- Solid bony union within normal period (within 6 months)
- Pain free joint movements
- No deformity or shortening
- soft tissue healing with or without infection, if present controlled within 3 weeks
- Bony healing within normal duration
- Movements restricted - less than 25% of normal range
- No deformity or shortening
- soft tissue healing with or without infection, if present controlled within 6 weeks
- No evidence of chronic osteomyelitis
- Range of movements more than 50% of normal range.
- Bone healing - delayed union(took 6 to 9 months to heal)
- Shortening if present less than 2 cms.
- Deformity present but functionally and cosmetically acceptable
- Persistent soft tissue infection and/or chronic osteomyelitis
- Range of movements less than 50% of normal range
- Shortening if present more than 2 cms.
- Deformity-functionally and cosmetically not acceptable
The different parameters were recorded carefully, regularly during the stay of patient in the hospital and during regular follow up visits to evaluate and assess the efficacy of this procedure.
| Results|| |
Total of 12 patients of compound injury were treated by primary plating osteosynthesis. Out of which 6 cases were of grade I, 4 cases were of grade II and 2 cases were of grade 3. Regarding soft tissue healing all the cases (6 cases) of grade 1 showed good results in 4 cases (66.67%) and fair in 2 cases (33.33%). While in grade II cases 1 case showed good result, 2 cases showed fair results while in one result was satisfactory. One case of grade III showed satisfactory result while 1 case showed poor result.
Soft tissue of all cases of grade I healed within 3 weeks. While 2 cases of grade II healed within 3 weeks. None of grade 3 wound healed in a period less than 6 weeks. One case of grade III and 1 case of grade II took more than 3 months time to heal, due to infection. With regard to union of bone, out of 4 cases of upper limb, 2 cases (50%) of grade I united within 4 months. One case of grade III of upper limb united in 6 months. Out of 8 cases of lower limb, 3 cases (37.5%) united within 5 months and 4 cases (50%) united within 6 months. One case of grade III fracture tibia showed delayed union, bone grafting was done in this case. Regarding infection none of the cases of grade I injury had infection. Out of 4 cases of grade II, two cases (16.67%) had superficial infection. Out of 2 cases of grade III, 1 case developed superficial infection while in 1 case there developed chronic osteomyelitis. In total, out of 12 cases 4 cases (33.33%) had infection. Out of which 3 cases (25%) had superficial infection while 1 had deep infection [Table 3].
In majority of the cases loss of range of free movement around adjacent joint was less than 10%.In 2 cases limitation of movement was between 10-25%. Only 1 case showed more than 25% limitation of free range of motion.
| Discussion|| |
The present study was conducted with the purpose to delineate the role of primary plating osteosynthesis in the management of open fractures with the particular reference to infection, soft tissue damage and bony healing and joint function. ,,,,, In this series, 91.66% (11 cases) patients were male and 75% cases were from the age group of 20-40 years. This male and young age dominance could very well be attributed to the fact in Indian social structures males particularly in this age group are much exposed to accident on road as well on other fields. 10 cases (83.33%) in the series reported between 3 to 12 hours after sustaining the trauma due to lack of communication and transport facilities. Only 2 patients could reach the hospital within 3 hours both of them were from urban areas. Most of the cases (75%) either received no first aid or received first aid in the form of unsterile dressing.
In our series 11 (91.66%) patients presented within 9 hours out of which 1 developed infection. We observed that chances of infection can be reduced significantly if soft tissue management and fixation of fracture is done as early possible, preferably within 9 hours. We agree with Gustilo et al., (1976),  Chapman et al., (1977) , Rittman et al., (1979) that the adequate debridement is one of the most important pre-requisite for prophylaxis against infection.
Hampton  observed that if infection does occur the internal fixation facilitates the painless regular care of wound without jeopardizing the reduction. Holstad  (1962) was supportive to the opinion that primary osteosynthesis offers a degree of security against serious infection because it provides adequate primary immobilization to fragments. He compared results of 202 cases of open fractures of long bones in which 122 cases were treated conservatively and 78 cases treated by osteosynthesis. He found that complications were more frequent in patients treated conservatively. We observed infection in 4 cases, superficial infection in 3 cases and deep infection in 1 case out of 12 patients treated by primary plating osteosynthesis. Regular and sterile dressing and antibiotic coverage resulted in control of infection and healing in 3 cases with implant in position. However in one case infection was controlled after removal of implant.
Rittmann and Matter (1977) found that antibiotic prophylaxis has no definite advantage in a parallel series. Only deep soft tissue infections are reduced under high prophylactic dose of penicillin and streptomycin. Veliskakis (1956), Gustilo et al., (1969), Chapman et al., (1979) and Gosselin RA et al., (2004) recommended the use of systemic antibiotics before and after surgery in adequate doses. We support the opinion of Patzakis et al., (1974)  that antibiotic prophylaxis has definite value in open fractures. One of qualifying condition is that the antibiotic must be effective against the usual organisms that cause infection. Primarily, it should be broad spectrum covering all common pathogens later it should based on culture and sensitivity.
Chapman and Mahoney (1979)  suggested that all wounds irrespective of nature of soft tissue injury should be left open for consideration of delayed primary or secondary closure. Matter and ritman (1977) recommended that all wounds of open fracture should be left open irrespective of severity of injury. We performed primary closure with drainage tube in all the 6 cases of grade I and out of these none developed any necrosis of edges or any infection. Delayed primary closure with drainage tube in 2 cases had excellent results and soft tissue healed within 3 weeks. All grade III cases were left open for subsequent skin grafting and muscle pedicle flaps, 1 for each case.
We agree with Gustilo and other authors that converting an open fracture into a closed fracture as early as possible provide the best environment for fracture healing and prevent late secondary late secondary infection. Successful delayed primary closure is dependent upon a clean wound free of necrotic tissue and closure without tension. 
We observed that it is better to leave all the wounds open except in clean cases of grade I injury, where primary closure can be done, if required with drainage tube. Post operatively, on 5 th to 7 th day, acute inflammation subsides and infection if existing becomes apparent. At this stage we are in better position to decide, whether delayed primary closure is to be under taken or the wound should be left open for debridement, secondary suturing or skin grafting or muscle pedicle flaps whenever possible.
| Conclusion|| |
We conclude from the study that the judicious selection of cases, skilful management of the injured limb and early rehabilitation is the key for compound fractures. Infection is one of the most important problems in the management of open fractures, which determine the final outcome. In grade I and grade II lesions with no or minimal contamination, primary or delayed primary closure should be the choice. In grade III lesions, leave the wound open for secondary healing or by skin grafting. Antibiotic prophylaxis has definite value in open fractures. Early plating facilitates soft tissue care and bone healing and helps in cure of infection as well as early joint rehabilitation.
| References|| |
|1.||Chapman MW, Mahoney M. The role of early internal fixation in the management of open fractures. Clin Orthop Relat Res 1979;138: 120-31. |
|2.||Hertel R, Lambert SM, Muller S, Ballmer FT, Ganz R. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg 1999;119:7-12. |
|3.||Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg 2006;88:2739-48. |
|4.||Rittman WW, Perren SM. Cortica/ bone healing after internal fixation and infection. 1979;138:120-31. |
|5.||Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr. A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma 1999;13:78-84. |
|6.||Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma 2002;16:484-90. |
|7.||Ketenjian AY, Shelton ML. Primary internal fixation of open fractures: A retrospective study of the use of metallic internal fixation in fresh open fractures. J Trauma 1972;12:756-63. |
|8.||Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH. Outcomes in open tibia fractures: Relationship between delay in treatment and infection. J Trauma 2003;55:949-54. |
|9.||Zalavras CG, Marcus RE, Levin LS, Patzakis MJ. Management of open fractures and subsequent complications. J Bone Joint Surg Am 2007;89:884-95. |
|10.||Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-8. |
|11.||Artz CP, Sakoy Y, Scully RE. An evaluation of the surgeon's criteria for determining the viability of muscle during débridement. AMA Arch Surg 1956;73:1031-5. |
|12.||Chapman MW. The role of intramedullary fixation in open fracture. Clin Orthop Relat Res 1986;212:26-34. |
|13.||Patzakis MJ, Harvey JP Jr, Ivler D. Role of antibiotics in the management of open fractures. J Bone Joint Surg 1974;56;532-41. |
|14.||Hampton OP Jr. Basic principles in management of open fractures. J Am Med Assoc 1955;159:417-9. |
|15.||Holstad HA, Bo O. Losed fractures of the tibial shaft. Operative versus conservative treatment. J Oslo City Hosp 1966;16:277-89. |
|16.||Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev 2004;1: CD003764. |
[Table 1], [Table 2], [Table 3]