Dr. Bradley Petrisor is an orthopaedic surgeon and a professor in the Department of Surgery at McMaster University. His research interests include functional outcome scoring in foot and ankle trauma, trauma outcomes and fluid irrigation techniques in the management of open fractures.  

• Open fractures are common orthopaedic injuries around the world 


• These fractures are at significant risk of infection due in part to broken skin but also to the occurrence of potentially significant soft tissue damage and periosteal stripping - early management to prevent this complication is recommended


• Given the nature of open fractures that are characterized by soft tissue damage, an orthoplastic approach has been increasingly adopted across many settings


• While there is considerable evidence to support an orthoplastic approach in terms of improved patient outcomes, there is still lack of consensus regarding several technical aspects of this approach


• The timing of soft tissue coverage, whether to conduct this within a single or staged procedure, remains a key controversy


• Several informational and guidance documents are available to inform the implementation of an orthoplastic approach, which need to be customized to the local context of practice 

Open fractures are frequently occurring orthopaedic emergencies that have been associated with a risk of infection and healing problems, both of the bone and soft tissues (4). These fractures occur due to a wide range of high-energy and lower-energy incidents. High-energy incidents such as motor vehicle and motorcycle accidents and gunshots, as well as lower-energy incidents such as a simple fall from standing or injury playing sport can both lead to open fractures (4) (5). Open fractures are characterized by an open wound or break in the skin near the site of the broken bone (5). This occurs when there is a fragment of bone breaking through the skin at the time of injury (5). Open fractures are different than closed fractures, where there is no open wound. Given this key difference, open fractures require different management strategies compared to closed fractures. Since the skin is broken in open fractures, bacteria can enter the wound easily and cause infection (5). Therefore, infection prevention is prioritized in the early treatment of open fractures (5). The overall management goals include achieving well-aligned bone union, preventing complications, and restoring function (2). While both patient- and treatment-related factors can influence the ultimate outcomes, it has been noted that early management of open fractures may significantly influence long-term outcomes (2). Despite growing evidence-based practice recommendations, there is still a lack of guidance regarding several aspects of open fracture management – including the type of involvement of plastic surgeons across the continuum of care, even though the nature of the injury itself calls for their expertise throughout the diagnosis and treatment process. In this OE Insight, we present the current approaches for the management of open fractures, as well as highlight aspects of an orthoplastic approach that are still defined by controversies and lack of clarity which present meaningful areas of future research. 

Open fractures are characterized by damage to the soft tissues around the bone, including muscles, tendons, nerves, veins, and arteries and also importantly the periosteum (5). The severity of these fractures depends on the size and number of the fracture fragments, damage to surrounding soft tissues, and the location of the wound and whether soft tissues in that region have good blood supply (5). The settings in which open fractures occur influence the extent of contamination and the greater the damage to bone and soft tissues, the greater the risk of infection (5). 

Exhibit 1 summarizes the main steps for managing open fractures, adapted from an informational guide published by the American Academy of Orthopaedic Surgeons. 

While the importance of plastic surgery in managing open fractures is increasingly recognized, there is still limited evidence available to inform the involvement of plastic surgeons across different stages in the care continuum for this type of fracture. In a seminal study by Gopal et al. (2000), a retrospective review of 84 patients with a severe (Gustilo IIIb or IIIc) open fracture of the tibia after blunt trauma between 1990 and 1998, who were treated by a radical debridement of the wound outside the site of injury, skeletal stabilisation and early soft-tissue cover with a vascularised muscle flap by a combined orthopaedic and plastic surgery service, was conducted (7). The overall findings of this study show that a combined orthopaedic and plastic surgical approach for severe open fractures provides good results and is safe. Delay in flap cover longer than 72 hours was associated with the most problems, including acute infection at the skin graft and chronic infection at the fracture site – 14% of patients with a >72 hours delay in flap cover experienced these outcomes. The authors of this study highlighted the importance of referring patients to a specialist centre when possible. In cases where primary transfer is not possible (e.g., in remote geographical areas), the authors recommended an emergency lavage and debridement of the wound, temporary bridging, external fixation and emergency transfer after consulting with the appropriate referral centre. 

Since the incipient days of studies examining the value of an orthoplastic approach for managing open fractures, larger epidemiological studies have been conducted to characterize the role of primary plastic surgery in the complete spectrum of these fractures. In a consecutive review of 3297 open fractures between 1988 and 2009, 12.6% of patients were treated with primary plastic surgery, as well as 5.6% treated with split skin grafting and 7.2% with a flap. (6). A greater proportion of patients with open lower limb fractures required primary plastic surgery (27.9%) compared to those with open upper limb fractures (3.5%). Fractures of the femoral diaphysis (25.3%) and those between the proximal tibia and the midfoot (ranging from 24.6% to 44%) required the most primary plastic surgery. The authors of this study noted that the different rates in the use of flaps observed in similar studies can be explained by severity of the fracture – where increased severity necessitated increased use of flaps in fractures of the proximal, diaphyseal and distal tibia and ankle. The authors also highlighted the importance of considering different contextual factors when interpreting prevalence rates of plastic surgery for open fractures from different studies and the time when these surgeries are conducted (i.e. >72 hours) – as these figures will be influenced by whether only trauma centers were included in the studies versus all hospitals and trauma centers in a region, as well as the level of expertise of the surgeons involved in managing open fractures.

With the increase in uptake of an orthoplastic approach for managing open fractures, there has been a growing body of evidence demonstrating the benefits of this approach for improved patient outcomes. Smith et al. (2021) found that in a paediatric population (aged <16 years) with open tibial fractures, a comprehensive and timely approach to orthoplastic care resulted in 100% union, along with no deep infection and flap failures (8). Yang et al. (2021) presented outcomes of patients with severe open fracture (Gustilo IIIb or IIIc) of the limb who underwent a similar radical orthoplastic approach as patients in the Gopal et al. (2000) study (7), which included successful surgical debridement, fixation, and soft tissue reconstruction in one stage (3). In this study, the overall infection rate was 14.6%, which is lower than the results found in previous studies on high-grade open fractures following a two-stage orthopaedic treatment approach (9) (10). Furthermore, the median time to union was 32 weeks, complementing the findings of previous studies that also used a similar orthoplastic approach for treating severe open fractures (11). Additionally, findings of a recent meta-analysis show that an orthoplastic approach decreases time to bone fixation, use of negative pressure wound therapy, and risk of wound/osteomyelitis infections compared to the nonorthoplastic approach for patients with traumatic lower extremity injuries (12). 

Despite the widespread recognition of the value of an orthoplastic approach for managing open fractures, one of the longest standing areas of opposing recommendations has been the timing of wound coverage. The landmark orthoplastic approach supported by Gopal et al. (2000), which is characterized by a single primary procedure of “fix-and-flap” method, has been described as not pragmatic nor appropriate in many cases (13). Yang et al. (2021) acknowledged that fracture fixation and vascularized soft tissue cover within the first operation is indeed challenging for reconstruction surgeons (3). However, delaying soft tissue cover must be contextualized against the risks associated with this decision. Notably, delayed coverage (even within 72 hours) would be challenging with repeated debridement and has been associated with a higher rate of deep infection (10). 

In terms of the technical elements of surgical management of open fracture, there is a lack of evidence supporting some key practices. For example, a 6 hour rule is recommended for performing surgical debridement, although there are studies that show no significant difference in outcomes with delayed debridement (14). Furthermore, there is lack of agreement on the actual amount of tissue that should be excised, with no clear definition of non-viable tissue (14). 

There is also lack of consensus on various aspects of postoperative care with an orthoplastic approach. For example, in the United Kingdom, where an orthoplastic approach has been increasingly integrated in their open fracture management strategy in recent years, there are no common guidelines for monitoring flaps across plastic surgery units in this country (15). The most common approach implemented in the UK now involves hourly observations in the first 24 hours, one to two-hourly observations in the next 24 hours, and observations every four hours in the third 24 hour period (15).  

Notwithstanding that further evidence and guidance is needed to inform multiple aspects of orthoplastic approach for open fracture management, it is clear based on current evidence that this collaborative care model can help improve several patient important outcomes. Even though there is lack of consensus on every aspect of implementing an orthoplastic approach, there are several informational and guidance documents (such as those listed below) that can help surgeons and care facilities determine how to integrate this approach to their practice – a decision that will inevitably be influenced by the resources and expertise available at the local setting. 

1.    A Review on the Orthoplastic Approach to Lower Limb Reconstruction - https://pubmed.ncbi.nlm.nih.gov/31456609/ 

2.    Setting Up an Effective Orthoplastic Service - https://oxfordmedicine.com/view/10.1093/med/9780198849360.001.0001/med-9780198849360-chapter-20 

3.    Standards of open lower limb fracture care in the United Kingdom - https://pubmed.ncbi.nlm.nih.gov/33485638/