to preserve the soft tissue integrity and viability.
3. Relaxing incisions adjacent to the wound can be utilized to prevent excessive tension on wound edges when attempting primary closure.
4. Skin grafting is a coverage option for wounds that cannot be closed primarily and have a healthy underlying wound bed of muscle, paratenon, or subcutaneous tissue.
C. Soft tissue flap coverage
Flaps are dictated by the location and size of the soft tissue defect when primary closure is no longer possible. They are indicated for coverage of exposed vital structures including bone, artery, nerve, or tendon without paratenon.
1. Rotational flap coverage:
a. Mobilization of local tissue with its vascular pedicle to an area in need of soft tissue coverage (▶Fig. 2.5).
b. This is a commonly needed option when addressing soft tissue loss in the leg. The local flap of choice is dictated by the defect location.
c. Flap tissue cannot be from an already devitalized area involved in the initial zone of injury.
2. Free tissue transfer:
a. The process of harvesting tissue with its blood supply and relocating it to a different anatomic location through a new vascular anastomosis.
Fig. 2.4 Negative pressure wound therapy is helpful in soft tissue management by reducing microbial contamination between debridements and facilitation of wound drainage.
Fig. 2.5 The gastrocnemius rotational flap is an excellent treatment option for significant soft tissue defects of the proximal tibia.
b. This provides vascularized tissue to the damaged area.
c. Avoids further functional deficits to an already injured area potentially seen in rotational coverage.
3. Timing of soft tissue coverage:
a. Controversy exists regarding the ideal timing of soft tissue coverage with wide variation in practice from center to center.
b. Current recommendations are to attempt to achieve wound coverage within 7 days of the initial injury but the availability of a flap surgeon and need for multiple debridements may make this a very difficult goal to achieve in some situations.
Summary
Open fractures are associated with a breach in the surrounding soft-tissue envelope leading to direct communication between fractured bone and the outside world. These are often complex injuries commonly associated with significant soft tissue disruption, concomitant neurovascular injuries, and difficult-to-treat fractures that warrant careful assessment and important changes in treatment compared to a similar closed fracture. Thorough excisional debridement of devitalized tissue and contamination, early intravenous antibiotics, local wound antibiotic delivery, fracture stabilization, and timely soft tissue coverage are important components of open fracture management aimed at mitigating complications.
Suggested Readings
Bhandari M, Jeray KJ, Petrisor BA, et al; FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med 2015;373(27):2629–2641
D’Alleyrand JC, Manson TT, Dancy L, et al. Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications? J Orthop Trauma 2014;28(5):288–293
Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev 2004(1):CD003764
Patzakis MJ, Bains RS, Lee J, et al. Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds. J Orthop Trauma 2000;14(8):529–533
Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am 1974;56(3):532–541
Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ, Group LS; LEAP Study Group. The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma. J Bone Joint Surg Am 2010;92(1):7–15
Weber D, Dulai SK, Bergman J, Buckley R, Beaupre LA. Time to initial operative treatment following open fracture does not impact development of deep infection: a prospective cohort study of 736 subjects. J Orthop Trauma 2014;28(11):613–619
3 Closed Fracture Management/Casting
Rahul Vaidya
Introduction
Closed treatment has been the standard of care for all fractures until the 20th century. It remains the most widely used method of fracture management and in one recent review of 7,863 cases, 67% of all fractures were managed nonoperatively. This chapter will provide an overview of reduction techniques, indications for nonoperative fracture management, and outline principles of splint and cast application (▶Video 3.1– ▶Video 3.3).
I. Specific Reduction Techniques and Principles of Casting and Splinting
A. Nondisplaced fractures
1. Almost all nondisplaced fractures can be treated nonoperatively with the exception of the femur and some unusual conditions.
2. The methods of immobilization include: slings, splints, casts, traction, or simply avoiding weight-bearing through the limb.
3. Immobilization will allow secondary bone healing to take place and function to return by 6 weeks to 3 months depending on the bone.
B. Displaced fractures
1. Trauma strong enough to cause a fracture will cause surrounding soft tissue injury including periosteal disruption.
2. Bones are attached to muscles which contract, shorten, angulate, and rotate fracture fragments.
a. The fracture will often heal in the displaced position but the deformities that result may leave the limb or patient compromised and potential loss of function.
b. Most displaced fractures should be reduced to minimize deformity and soft tissue complications, including those that ultimately require operative fixation.
c. Splints provide initial stabilization of displaced fractures. They should allow for swelling and all bony prominences should be adequately padded.
C. Indirect or closed reduction of fractures
1.
