Open fractures

Please be aware that there are images of wounds on this page

1. Your orthopaedic surgery (fixing the bone)

2. Your plastic surgery (soft tissue reconstruction)

3. What to expect after your surgery

4. Commonly asked questions.

An open fracture is a broken bone that has come through the skin. They are typically caused by high-energy injuries such as road traffic collisions, falls or sports injuries. Urgent treatment is required as open fractures are at much greater risk of infection, and delayed healing of the bone, compared to fractures with intact skin. Bone infection can be difficult to treat and in a worst-case scenario, amputation of the limb might be required, although this is unusual.

As the skin over the fracture has been broken, infection can spread easily to the fracture site. Patients with open fractures require urgent surgery performed by orthopaedic and plastics surgeons working together to remove any debris, clean the wound and remove any unhealthy tissue.

This is known as debridement and often leads to a larger wound in the skin. Debridement is crucial as any dead tissue or bone left in the wound can lead to infection. Antibiotics and a tetanus booster are given at the same time.

After the debridement is complete, and if the wound can be closed (stitched together), the bone can be fixed together internally (internal fixation).

If internal fixation doesn’t work, you will be fixed together externally as a temporary measure (external fixation), and the wound will be covered, usually with a suction dressing (picture below). You will then return to theatre in the next few days for final bone fixation by the orthopaedic surgeon and soft tissue reconstruction by the plastic surgeon in a joint operation.

Suction dressing

You will meet with the Orthopaedic and Plastic Surgery Team before the operation. They will make sure it is safe for you to have surgery and will be happy to answer any questions you may have. The surgeons participating in this operation will be highly trained professionals, who have years of experience and have been involved in a lot of these kind of operations before.

You may also have:

•  Photographs taken of your soft tissue wound that will be used during the reconstruction, as well as for comparison before and after your operation. These pictures are only taken with your informed consent; do not include your face; are managed confidentially; and are kept in your notes and/or into a secure BSUH NHS Trust computer server.
• Scans that use special dye (angiograms), such as CT or MRI, may be used to evaluate the blood vessels that supply your limb(s) and help with operative planning

Open fractures almost always need surgery to put the bone back and hold it there while it heals. This can be done in a number of ways. Examples are shown below. Your surgeon will discuss with you what he/she feels is in your best interest.

External fixation is when pins or wires into the bone are attached to rings or rods outside the limb. External fixators are used commonly as a temporary measure but can also be used as the final treatment and removed once the bone has healed.

External fixation of the bone

Internal fixation is when either a rod inside the bone or plates on the surface of the bone are fixed to the bone with screws. These generally stay in forever but can be removed if there are any problems, but this is very uncommon.

Intramedullary nail or rod bony fixation

Plate and screws bony fixation

In an open fracture there can be significant damage to, and loss of, the skin and muscle around the fracture. In order to reduce the risk of infection to the bone and metalwork, the wound must be closed when the bone is fixed. Unless it is a very small hole that can be closed, a soft tissue reconstruction is required. These operations are usually long (can take all day), and a general anaesthetic is most commonly used, unless otherwise advised from the Anaesthetic team.

Depending on the size and location of the wound, as well as the cause, the Plastic Surgery team may use:

• A skin graft: A very thin layer of skin, equivalent to a deep graze, usually taken from the upper thigh or buttocks. This tends to be used when the bone is still well covered with muscle.
  

  Recently healed skin graft donor site on the thigh.

  

  Meshed skin graft.

• A local flap: This method uses skin next to the wound, which is partially detached and rotated in order to cover the wound. This often creates a secondary skin defect which requires a simple skin graft, this is performed at the same time.
  

  Skin and fat flap mobilised to cover wound on leg with secondary wound resurfaced with skin graft.

  

  Calf muscle transferred to cover a wound at the front of the leg (picture from www.bapras.org.uk)

  

  Diagram depicts a muscle taken from the thigh to cover a wound over
  an open fracture on the other leg; the donor site is closed directly,
  and the muscle flap is covered with a skin graft (picture from www.bapras.org.uk).

• A distant ‘free’ flap: A block of tissue is taken, along with its blood vessels, from a distant part of your body (the donor site) and placed into the wound. This may be in a composite form, which is skin and fat or muscle, or may be just muscle. The blood vessels are then re-attached to the recipient site using microsurgical techniques and the transplanted tissue lives on its new location. The donor site is either stitched closed or may need to be resurfaced with a skin graft. Muscle flaps without skin also require a skin graft on top.