open fracture- gustilo

OPEN FRACTURES

Open fractures are associated with a soft tissue defect that permits contamination by the outside environment (Fig. 4-1). Historically the difficulty of managing soft tissue and bone defects often meant the incidence of infection was considerable and the requirement for amputation was high. With the advent of improved plastic surgery and fracture fixation techniques, however, complications related to open fractures have diminished, although they still remain a challenge to orthopaedic surgeons.

CLASSIFICATION Although there are other classifications of open fractures, the Gustilo classification has now been adopted worldwide. It is based on the size of the wound, the amount of soft tissue damage or contamination, and the type of fracture. There are three fracture types, with the Gustilo type

4 III fractures divided into three subtypes based on the extent of the periosteal damage, the presence of contamination, and the extent of arterial injury. The classification is shown in Table 4-1. The Gustilo classification has been shown to be prognostic in terms of time of union and the incidence of nonunion and infection, particularly with respect to open fractures of the tibia. However, as with all classification systems, surgeons should be aware of a number of drawbacks. The Gustilo classification was formulated with diaphyseal, rather than metaphyseal or intra-articular, fractures in mind. It was also designed to be used in long bones such as the femur and tibia rather than in smaller bones such as the metacarpals or metatarsals. As with all classifications, it inevitably contains a number of subjective terms such as “significant periosteal stripping” and refers to the length of skin wounds, which will vary considerably with age. It is impossible to avoid these problems in any classification system that is practical to use, and the Gustilo classification has become accepted as the main classification of open fractures.

EPIDEMIOLOGY

Figure 4-1

A Gustilo IIIa open tibial fracture.

Very little is known about the epidemiology of open fractures. The incidence of open fractures varies in different places and in different institutions depending on many factors, including the incidence of road traffic accidents and gunshot injuries. Level 1 trauma centers obviously see more open fractures than smaller peripheral hospitals, but the overall incidence of open fractures is probably similar in many parts of the world. Table 4-2 shows the epidemiology of 960 consecutive open fractures seen in Edinburgh, Scotland, over a 6-year period. It is likely this information is applicable to many parts of the world. The overall incidence of open fractures was 3.2%, with 3.3% in the upper limb, 3.7% in the lower limb, and 0.3% in the limb girdles. Table 4-2 shows the wide variation in the incidence of open fractures. The highest incidence is in tibial diaphyseal fractures, where about 21% are open. Fractures of the femoral diaphysis, hand and foot phalanges, forearm diaphyses, tibial plafond,

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Section I / General Principles

TABLE 4-1 THE GUSTILO CLASSIFICATION OF OPEN FRACTURES Type

Definition

I II

Open fracture with a clean wound 1 cm long and without extensive soft-tissue damage, flaps, or avulsions Either an open fracture with extensive soft-tissue laceration, damage, or loss; an open segmental fracture; or a traumatic amputation. Also: High-velocity gunshot injuries Open fractures caused by form injuries Open fractures requiring vascular repair Open fractures older than 8 hours

III

•1•

IIIa

Adequate periosteal cover of a fractures bone despite extensive soft-tissue laceration or damage High-energy trauma irrespective of size of wound

IIIb

Extensive soft-tissue loss with significant periosteal stripping and bone damage Usually associated with massive contamination

IIIc

Association with arterial injury requiring repair, irrespective of degree of soft-tissue injury

From Gustilo RB, Mendoza RM, Williams DM. Problems in the management of type III (severe) open fractures. A new classification of type III open fractures. J Trauma 1984;24:742–746.

TABLE 4-2 THE INCIDENCE OF OPEN FRACTURES: AN ANALYSIS OF 960 FRACTURES OVER A 6-YEAR PERIOD Gustilo Type (%) Fracture location

Open Fractures (%)

I

II

IIIa

IIIb

IIIc

Average Age (y)

Tibial diaphysis Femoral diaphysis Hand phalanges Foot phalanges Forearm diaphysis Tibial plafond Patella Distal femur Distal humerus Humeral diaphysis Tarsus Tibial plateau Distal forearm Carpus Ankle Proximal forearm Metatarsus Scapula Pelvis Metacarpus Proximal humerus Clavicle Proximal femur Fibula Spine

21.2 12.3 10.1 9.0 8.0 6.1 5.7 5.6 5.4 5.3 3.2 2.4 2.1 2.0 1.4 1.0 0.9 0.7 0.6 0.4 0.3 0.2 0.02 0 0

23.5 20.3 32 28.6 48.8 18.2 18.5 30 35.7 68.7 — 30 62.3 13.3 17.5 37.5 27.2 100 — 43.7 — 50 100 — —

19.6 16.9 52.9 52.2 21.9 9.1 48.1 20 50 18.7 30 40 26.1 6.7 42.5 50 36.4 — — 56.3 60 — — — —

23 23.7 5.7 11.9 9.8 45.4 29.6 — 7.1 6.2 36.6 20 10.1 66.6 35 12.5 18.2 — 80 — 40 50 — — —

29.6 30.5 1 — 17.1 27.3 3.7 50 7.1 6.2 23.3 10 1.4 13.3 5 — 18.2 — 20 — — — — — —

4.3 8.5 8.4 7.1 2.4 — — — — — 10 — — — — — — — — — — — — — —

43 32 39 38 35 46 41 43 41 48 35 44 62 33 49 48 38 28 29 43 32 33 40 — —

Chapter 4 / Open Fractures patella, distal femur, distal humerus, and humeral diaphysis are all associated with incidences of more than 5%. In fractures of the metatarsus, scapula, pelvis, metacarpus, proximal humerus, and proximal femur, however, the incidence is very low. If an open fracture does occur in these areas, the injury tends to be very severe. The incidence of open spinal fractures is so low that effectively they are unsurvivable. The only exception to this is gunshot spinal fractures, which are relatively uncommon in civilian practice. Table 4-2 also shows that the age of the patient varies, with younger patients tending to have open fractures of the pelvis, femoral diaphysis, proximal humerus, carpus, and forearm diaphyses as a result of road traffic accidents or other high-energy injuries, with open fractures of the humeral diaphysis, proximal forearm, ankle, and distal forearm occurring in older patients as a result of low-energy injuries. Table 4-2 also shows the incidences of the different Gustilo types for each fracture. The highest incidence of Gustilo type III fractures occurs in the pelvis, carpus, and lower limb. With the exception of open carpal fractures, open upper limb fractures tend to be less severe. In the lower limb there is a high incidence of Gustilo type III fractures in the femoral diaphysis, around the knee, in the tibial diaphysis and plafond, and in the tarsus. Gustilo IIIc fractures are rare but are most commonly seen in high-energy injuries to the tarsus, femoral diaphysis, and tibial diaphysis. They also occur in the fingers and toes, where they are often treated by amputation (see Chapter 37).

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PREOPERATIVE ASSESSMENT ■ ■ A complete history and physical examination is essen-

tial.
Some of the main factors that should be obtained in the history are shown in Box 4-1. ■ Age does not affect patient management, but older patients tend to be osteopenic and the fractures may be associated with greater comminution. ■ Information about general health is important because conditions such as diabetes mellitus, metabolic bone

21

diseases, or neuromuscular conditions may alter the type of operative treatment, and cardiovascular, pulmonary, and other medical comorbidities may affect anesthesia and later intensive care. The preaccident mental and physical state of the patient is important because, for example, a Gustilo type IIIb open tibial fracture in a demented nonambulator with medical comorbidities might well be successfully treated by primary amputation rather than by attempted bone reconstruction. The mode of injury should be carefully established to determine whether the open fracture has occurred as a result of a high- or low-energy injury and whether there is potential for significant fracture contamination.
High-energy injuries associated with significantly greater bone and soft tissue damage, and therefore open fractures following road traffic accidents, falls from a height, crushing injuries, or gunshot injuries, are often more difficult to manage and associated with a worse prognosis than those that occur after a simple fall, a fall downstairs, or a sports injury. The physical examination must include an assessment of other injuries using ATLS principles.
Examination of the limb should include a careful assessment of the vasculature with palpation of the pulses and determination of limb color and distal capillary return. The surgeon should be aware that if the patient is hypotensive or peripherally shut down, an incorrect preoperative assessment of the vascular status of a limb may be made.
If there is any doubt about the vascular supply, a Doppler examination or angiogram should be obtained. Examination of the neurological status of the limb is also important.
Abnormal sensation or motor power may suggest intracranial, spinal, or peripheral nerve damage.
A peripheral nerve lesion associated with a limb fracture suggests considerable soft tissue injury and probably a poor prognosis for the limb.

Examination of the Open Wound ■ Ideally the open wound should not be examined by

BOX 4-1 IMPORTANT FEATURES OF THE CLINICAL HISTORY AND PHYSICAL EXAMINATION History Age General health Specific comorbidities Previous disability Alcohol and drugs Ambulatory status Residence Cause of injury High or low energy Potential for infection Other injuries

Previous injuries Physical Examination Other injuries Limb vascularity Peripheral pulses Capillary refill Hypotension Neurological status Skin and soft tissue damage

every member of the medical and nursing staff prior to surgery!
If possible, a digital image of the wound should be obtained soon after the patient is admitted to the hospital, so that it, rather than the wound, can be repeatedly examined. This policy has been shown to be associated with a lower infection rate. ■ It is important, however, that the surgeon examine the wound carefully.
The location and extent of the wound may allow a preoperative determination of the need for plastic surgery, particularly if it is obvious there will be exposed subcutaneous bone after debridement. The presence of skin degloving should be noted.
The length of the wound is used in the Gustilo classification, and a loose relationship exists between wound

22

Section I / General Principles

Figure 4-2

Anteroposterior and lateral radiographs of the fracture shown in Figure 4-1. Radiographs taken after intramedullary nailing are shown in Figure 33-7 in Chapter 33.

length and prognosis, but it should never be assumed a small wound necessarily carries a good prognosis because there may be significant associated contamination and tissue damage. ■ The number of skin wounds should be determined. Two or three small wounds placed close together strongly indicates a high-energy injury and degloving in the area. ■ The degree of wound and skin contamination should be assessed, as should the presence of bone fragments in the wound. ■ The apparently intact tissues of the limb should also be examined because there may be other injuries or evidence of skin tattooing from the road or from a vehicle wheel having passed over the limb.

Radiological Examination


There are a number of features that the surgeon

should look for when examining the radiographs (Box 4-2). ■ MRI and CT scans are rarely required in the acute situation but may be helpful in open pelvic, intra-articular, carpal, and tarsal fractures. ■ Angiography may be required in Gustilo IIIb or IIIc fractures. In the polytraumatized patient, the surgeon must decide if a delay for further imaging is appropriate.

TREATMENT Surgeons tend to concentrate on the method of fracture treatment when treating open fractures, but a number of procedures are involved if their treatment is to be successful. (Box 4-3).

■ Usually, only anteroposterior and lateral radiographs are

required (Fig. 4-2).
They should include adjacent joints and any associated injuries.

BOX 4-2 IMPORTANT RADIOLOGICAL FEATURES IN OPEN FRACTURES The location and morphology of the fracture The presence of comminution signifying a high-energy injury ■ Secondary fracture lines that may displace on treatment ■ The distance the bone fragments have traveled from their normal location. Wide displacement suggests bone avascularity ■ Bone defects suggesting missing bone ■ Gas in the tissues

BOX 4-3 PROCEDURES INVOLVED IN THE TREATMENT OF OPEN FRACTURES Debridement Skin Fat and fascia Muscle Bone Wound closure Antibiotics Intravenous Bead pouch technique Fracture stabilization Secondary debridement Soft tissue cover

Chapter 4 / Open Fractures

23

Debridement ■ The most important procedure in the treatment of open

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■

■

■

fractures is debridement, or wound excision.
All devitalized or contaminated tissue must be removed. Until relatively recently, it was difficult to reconstruct large soft tissue and bone defects, and surgeons tended to be conservative with tissue resection. With the introduction of improved surgical fixation and bone reconstruction techniques, and particularly with the development of free flaps and distally based fasciocutaneous flaps, it is now much easier to reconstruct tissue defects. Therefore the primary surgical debridement should be aggressive when required. The literature suggests that debridement should be performed within 6 hours of the injury.
No clinical evidence indicates the results of debridement after 6 hours are worse than the results prior to 6 hours, but logic dictates that debridement should be done as soon as possible after injury and there should be no unnecessary delay. The basic rules of debridement are given in Box 4-4.

Skin ■ Skin is very resistant to direct trauma but susceptible to

■

■

■

■

■

shearing forces, the plane of cleavage being outside the deep fascia. Shearing forces may produce extensive degloving injuries, which particularly affect the lower limb and may be circumferential. Elderly patients are particularly at risk of degloving, and circumferential degloving in an elderly multiply injured patient may require amputation (Fig. 4-3). Isolated skin wounds caused by direct trauma can be treated by local excision of the contaminated wound edges. If there are several wounds in close proximity, they should be excised en bloc, as there will be extensive associated soft tissue damage. After the initial skin excision, it is important to examine for skin degloving. All degloved skin should be resected until dermal bleeding is encountered.

Figure 4-3

Degloving associated with a Gustilo IIIb fracture. The degloving was circumferential.

■ If a large area of degloved skin is excised, split skin graft

can be harvested from the excised skin for later use. ■ After the initial skin excision, the surgeon should extend

the open wound to allow adequate exposure of the underlying bone and soft tissues.
There are no indications not to do this. Even small skin incisions may be associated with considerable contamination. ■ The direction and length of the skin extensions will depend on the location and size of the open wound, but ideally extensions should be longitudinal and, where possible, follow normal surgical approaches.

Fat and Fascia ■ All devitalized fat must be removed. ■ The extent of fat necrosis may well be greater than was

apparent preoperatively, and extensive fat resection with excision of the overlying skin may be required in some cases. ■ Fascial resection rarely presents a problem, but it should be borne in mind that foreign material may spread between the deep fascia and the underlying muscles.

Muscle ■ All devitalized muscle should be removed. ■ It can be difficult to assess muscle viability fully at the

BOX 4-4 SURGICAL PRINCIPLES OF DEBRIDEMENT ■ With the exception of low-velocity gunshot wounds,

■ ■ ■ ■

which can be treated with antibiotics and local wound care, all open fractures require surgical debridement. Failure to do this constitutes inadequate treatment. All affected tissue planes should be explored. The bone ends must be exposed and carefully examined for contamination and soft tissue stripping. All devitalized and contaminated tissue should be excised and all devitalized bone fragments removed. The wound should not be closed primarily.

initial debridement, particularly if the patient is hypotensive.
The classic signs of muscle viability are color, consistency, contractility to mechanical stimulation, and bleeding.
Muscle bleeding is probably the best test of viability, but the surgeon should be guided by the appearance and consistency of the muscle.
Muscles that are shredded or disintegrate on touch should be excised.
It is often easier to determine muscle viability at a relook debridement 36 to 48 hours after the initial exploration. By this time the patient’s condition has stabilized and muscle vascularity is easier to determine.

Section I / General Principles

24 Bone

■ Most of the contaminating bacteria are normal skin

■ Resection of bone should be dealt with in the same way

as soft tissue resection. ■ All devitalized separate bone fragments should be removed regardless of their size. ■ As with muscle, it may be difficult to determine bone vascularity, and if the surgeon is concerned about the viability of periosteal or muscle attachment to a bone, it may be advantageous to reexamine the bone fragments during the re-look procedure.

Lavage

■

■

■

■ Lavage with fluids such as normal isotonic saline or an-

tibiotic solutions is an essential part of the debridement procedure. ■ Ten to 15 liters of lavage fluid should be used to remove bone clots and other devitalized debris and ideally reduce the level of bacterial contamination. ■ Some experimental evidence indicates that the addition of antibiotics is associated with a lower infection rate, but there is no clinical evidence of the usefulness of antibiotic solutions.

■

Wound Closure ■ Open wounds should not be closed primarily.
There is no logical reason to do so because all

wounds that have been adequately debrided can be closed only under tension. ■ If wound closure is possible, it should be undertaken at the re-look procedure 36 to 48 hours after the initial surgery. ■ Primary wound extensions can be closed, but there is no practical advantage if the main wound is being left open.
Even closure of the wound extensions may cause tissue tension. ■ The only exception to the rule about closing wounds primarily is if a primary flap is undertaken.
This is not always logistically possible, and if it is done, it deprives the surgeon of the opportunity to reexamine the soft tissues at a re-look procedure.
In expert hands, primary flap cover can be associated with good results, although it is unlikely the results will be better than those associated with a re-look procedure and wound closure within 48 hours of the injury.
Vacuum-assisted closure (VAC) systems have been used for a number of years to close skin defects with good results. At the moment, they cannot be recommended for the closure of open wounds related to fractures in view of the time taken for the soft tissues to close and the consequent risk of infection.

Antibiotic Prophylaxis ■ Some 60% to 70% of open wounds are associated with

positive cultures in the emergency department.

■

flora, although more virulent bacteria also gain entry to the wound. Although 7% of bacteria isolated in the initial culture cause later infection, where gram-negative bacteria are recovered from the initial culture, 50% cause later infection. Early antibiotic administration has been useful in both animal and clinical studies, and animal work has shown that the sooner the antibiotics are administered, the lower the infection rate. Most surgeons use a first- or second-generation cephalosporin as prophylaxis for Gustilo type I and II open fractures.
The initial dose should be given as soon as possible after diagnosis with a three-dose intravenous regimen being used. In Gustilo type III open fractures, surgeons may use a three-dose intravenous regimen of a third-generation cephalosporin or a combination of a second-generation cephalosporin and an aminoglycoside.
If there is any chance of clostridial contamination, intravenous penicillin should be given. If the patient is allergic to penicillin, clindamycin or metronidazole should be used.
This is important in open pelvic fractures where the open fracture may have entered the rectum or vagina. A bead pouch technique has recently been introduced to reduce the incidence of late infection.
Antibiotic-impregnated polymethylmethacrylate beads can be placed into the wound after debridement has been undertaken.
These beads usually contain gentamycin or tobramycin.
Evidence indicates that the incidence of infection in open tibial fractures treated by intramedullary nailing decreases from 16% to 4% with the use of a bead pouch technique.
The technique is not a substitute for either a thorough debridement or prophylactic intravenous antibiotics, however.

Fracture Stabilization ■ Open fractures should be treated by surgical stabiliza-

tion. ■ The main exception to this rule is open fractures of the

terminal phalanges of the hand and foot.
In severe open distal phalangeal fractures, K-wire fixation may be used to stabilize the distal phalanx, but generally these fractures are treated by debridement, antibiotic cover, and nonoperative management. The outcome is usually favorable because the blood supply to the terminal phalanges of the hand in particular is good. ■ Cast management is associated with poorer results than operative management in open long-bone fractures. ■ Surgical stabilization minimizes later soft tissue injury and promotes capillary ingrowth.

Chapter 4 / Open Fractures

25

■ There is also good evidence it is associated with a de-

creased infection rate. ■ If plastic surgery is required, fracture stabilization is

mandatory. ■ Traction should not be employed for open fractures. ■ The surgical treatment of different fractures is dis-

cussed in Chapters 10 through 30.

Secondary Debridement ■ It is suggested that all open long-bone and pelvic frac-

tures be reexplored 36 to 48 hours after the initial debridement. ■ Primary flap cover can be undertaken, but the advantages of a secondary debridement are considerable.
Residual contamination can be excised and the vascularity of the soft tissues and bone fragments reassessed once the patient has been stabilized.
It is also an excellent time to carry out definitive soft tissue closure because in the majority of cases there will be no residual contamination or devascularized tissue. ■ If the wound does require further debridement, this should be undertaken, and the patient returned to the operating room 36 to 48 hours later for a further debridement.
This is a particular problem in crush injuries, in which progressive myonecrosis can occur. ■ The wound should not be closed until all devitalized or contaminated tissue has been removed.

Soft Tissue Cover ■ Most open wounds do not require plastic surgery. ■ Increasingly, however, plastic surgery techniques are

being used in open fractures. ■ The most frequently used plastic procedures involve

split skin grafting (Fig. 4-4), local muscle flaps such as the gastrocnemius flap, local flaps such as the proximal or distal fasciocutaneous flap (Fig. 4-5), or free flaps (Fig. 4-6). ■ The commonest free flaps are the latissimus dorsi, rectus femoris, and radial forearm flap.

Figure 4-5

A distally based fasciocutaneous flap use to cover a defect on the leg.

Obviously, there is wide variation in the types of soft tissue treatment used, but an analysis of soft tissue surgery used in the 960 open fractures detailed in Table 4-2 does allow an appreciation of the need for the different types of soft tissue cover (Table 4-3). Of the open fracture, 716 (74.5%) did not need plastic surgery in their management. A number of these patients were very seriously injured and either died or had a primary amputation. The vast majority of patients had their fractures treated successfully without plastic surgery, however. One hundred and forty-one (14.7%) of the open fractures were treated by split skin grafting, 12 (1.2%) by muscle flaps, 76 (7.9%) by local flaps, and 15 (1.6%) by free flap cover. Table 4-3 shows the distribution of the different types of soft tissue cover in different body areas. It shows that the requirement for plastic surgery is highest in the tibia and hindfoot, with about 55% of patients requiring some form of plastic surgery. Open fractures of the tibial diaphysis, plateau, and plafond are associated with the greatest requirement for flap cover. In this series, patients with open distal humerus, metatarsus, proximal femur, clavicle, proximal humerus, and pelvis did not need plastic surgery, although obviously split skin grafting and flap cover will occasionally be required in these fractures.

Figure 4-6 Figure 4-4

A split skin graft used on the leg.

A latissimus dorsi free flap used to cover a defect on the leg. The cosmetic effect is generally better than with a fasciocutaneous flap (see Fig. 4-5).

26

Section I / General Principles

TABLE 4-3 THE REQUIREMENT FOR PLASTIC SURGERY AND THE TYPE OF SURGERY IN OPEN FRACTURES Fracture location

Plastic surgery (%)

Split skin graft (%)

Muscle flap (%)

Local flap (%)

Free flap (%)

Tibial diaphysis Ankle Tibial plafond Carpus Tarsus Forearm diaphysis Tibial plateau Distal femur Femoral diaphysis Patella Metacarpus Distal forearm Proximal forearm Humeral diaphysis Hand phalanges Foot phalanges

55.2 55.0 54.5 46.6 40.0 38.2 30.0 30.0 28.8 18.5 12.5 8.7 6.2 6.2 2.7 2.5

40.1 68.2 16.7 57.1 83.3 71.5 — 100 100 100 100 100 100 100 62.5 100

7.9 — — — — — 66.6 — — — — — — — — —

44.1 27.3 83.3 14.3 8.3 9.5 33.3 — — — — — — — 37.5 —

7.9 4.5 — 28.6 8.3 19.0 — — — — — — — — — —

SUGGESTED READING Court-Brown CM, McQueen MM, Quaba AA, eds. Management of open fractures. London: Martin Dunitz, 1996. Court-Brown CM, Rimmer S, Prakash U, et al. The epidemiology of open long bone fractures. Injury 1998;29:529–534. Erdmann MW, Court-Brown CM, Quaba MM. A five year review of islanded distally based fasciocutaneous flaps on the lower limb. Br J Plast Surg 1997;50:421–427. Gopal S, Giannoudis P, Murray A, et al. The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. J Bone Joint Surg (Br) 2004;86B:861–867. Gustilo RB, Anderson JT. Prevention of infection in the treatment of 1035 open fractures of long bones: retrospective and prospective analysis. J Bone Joint Surg (Am) 1976;58A:453–458. Gustilo RB, Mendoza RM, Williams DM. Problems in the management of type III (severe) open fractures. A new classification of type III open fractures. J Trauma 1984;24:742–746. Hammert WC, Minarchek J, Trzeciak MA. Free-flap reconstruction of traumatic lower extremity wounds. Am J Orthop 2000; 29(Suppl 9):22–26. Haury B, Rodeheaver G, Vensito I, et al. Debridement: an essential component of traumatic wound care. Am J Surg 1978;135:238–242.

Herscovici D, Sanders RW, Scaduto JM, et al. Vacuum-assisted wound closure (VAC therapy) for the management of patients with highenergy soft tissue injuries. J Orthop Trauma 2003;17:683–688. Nieminen H, Kuokkanen H, Tukianinen E, et al. Free flap reconstructions of 100 tibial fractures. J Trauma 1999;46:1031–1035. Olson SA, Finkemeier CG, Moehring HD. Open fractures. In: Bucholz RW, Heckman JD, eds. Rockwood and Green’s fractures in adults, 5th ed. Philadelphia: Lippincott, Williams and Wilkins, 2001. Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic softtissue defects about the tibia. The Lower Extremity Assessment Project (LEAP) Study Group. J Bone Joint Surg (Am) 2000; 82A:1681–1691. Yaremchuk MJ. Acute management of severe soft tissue damage accompanying open fractures of the lower extremity. Clin Plast Surg 1986;13:621–632. Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg 2003;11:212–219. Zalavras CG, Patzakis MJ, Holtom P. Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop 2004;427:86–93.

Author Query

AU1: Is form injuries correct?