Open fracture

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An open fracture, also called a compound fracture, is a type of bone fracture (broken bone) that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. An open fracture can be life threatening or limb-threatening (person may be at risk of losing a limb) due to the risk of a deep infection and/or bleeding. Open fractures are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue. [1] Other potential complications include nerve damage or impaired bone healing, including malunion or nonunion. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method. [2] This classification system can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection. [1]

Contents

Diagram of an open, transverse, midshaft radius fracture Rheumatology - Open fracture -- Smart-Servier.png
Diagram of an open, transverse, midshaft radius fracture

Cephalosporins, sometimes with aminoglycosides, are generally the first line of antibiotics and are used usually for at least three days. [3] Therapeutic irrigation, wound debridement, early wound closure and bone fixation core principles in management of open fractures. [4] All these actions aimed to reduce the risk of infections and promote bone healing. The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture. Older people with osteoporosis and soft-tissue problems are also at risk.

Epidemiology

Crush injuries are the most common form of injuries, followed by falls from standing height, and road traffic accidents. Open fractures tend to occur more often in males than females at the ratio of 7 to 3 and the age of onset of 40.8 and 56 years respectively. In terms of anatomy location, fractures of finger phalanges are the most common one at the rate of 14 per 100,000 people per year in the general population, followed by fracture of tibia at 3.4 per 100,000 population per year, and distal radius fracture at 2.4 per 100,000 population per year. [5] Infection rates for Gustilo Grade I fractures is 1.4%, followed by 3.6% for Grade II fractures, 22.7% for Grade IIIA fractures, and 10 to 50% of Grade IIIB and IIIC fractures. [6]

Signs and symptoms

There are a range of characteristics of open fractures as the severity of the injury can vary greatly. Most open fractures are characterized by a broken bone that is sticking out of the skin, but there can also be a broken bone that is associated with a very small "poke-hole" skin wound. Both of these injuries are classified as open fractures. [7] Some open fractures can have significant blood loss. Most open fractures have extensive damage to soft tissues near and around the bone such as nerves, tendons, muscles, and blood vessels. [1]

Causes

Open fractures can occur due to direct impacts such as high-energy physical forces (trauma), motor vehicular accidents, firearms, and falls from height. [8] Indirect mechanisms include twisting (torsional injuries) and falling from a standing position. [8] These mechanisms are usually associated with substantial degloving of the soft-tissues, but can also have a subtler appearance with a small poke hole and accumulation of clotted blood in the tissues. Depending on the nature of the trauma, it can cause different types of fractures: [9] [10]

Common fractures

Bone fractures result from significant trauma to the bone. This trauma can come from a variety of forces – a direct blow, axial loading, angular forces, torque, or a mixture of these. [11] There are various fracture types, including closed, open, stress, simple, comminuted, greenstick, displaced, transverse, oblique. [12] [13]

Pathological fractures

Result from minor trauma to diseased bone. These preexisting processes include metastatic lesions, bone cysts, advanced osteoporosis, etc. [10]

Fracture-dislocations

Severe injury in which both fracture and dislocation take place simultaneously. [9]

Gunshot wounds

Caused by high-speed projectiles, they cause damage as they go through the tissue, through secondary shock wave and cavitation. [10]

Diagnosis

The initial evaluation for open fractures is to rule out any other life-threatening injuries. Advanced Trauma Life Support (ATLS) is the initial protocol to rule out such injuries. Once the patient is stabilised, orthopedic injuries can be evaluated including determining the severity of injury using a classification system. Mechanism of injury is important to know the amount energy that is transferred to the patient and the level of contamination. Every limb should be exposed to evaluate any other hidden injuries. Characteristics of the wound should be noted in detail. Neurology and the vascular status of the affected limb are important to rule out any nerve or blood vessels injuries. High index of suspicion of compartment syndrome should be maintained for leg and forearm fractures. [5]

Classification

There are a number of classification systems attempting to categorise open fractures such as Gustilo-Anderson open fracture classification, Tscherne classification, and Müller AO Classification of fractures. However, Gustilo-Anderson open fracture classification is the most commonly used classification system. [1] Gustilo system grades the fracture according to energy of injury, soft tissue damage, level of contamination, and comminution of fractures. The higher the grade, the worse the outcome of the fracture. [5]

Gustilo Open Fracture Classification
Gustilo GradeDefinition
IOpen fracture, clean wound, wound <1 cm in length
IIOpen fracture, wound > 1 cm but < 10 cm in length [14] without extensive soft-tissue damage, flaps, avulsions
IIIAOpen fracture with adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma (gunshot and farm injuries) regardless of the size of the wound [14] [15]
IIIBOpen fracture with extensive soft-tissue loss and periosteal stripping and bone damage. Usually associated with massive contamination. [14] [15] Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)
IIICOpen fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury.
Gustilo Type III Open fracture
Specialty Orthopedics

However, Gustilo system is not without its limitations. The system has limited interobserver reliability at 50% to 60%. [5] The size of injury on the skin surface does not necessarily reflect the extent of deep underlying soft tissue injury. Therefore, the true grading of Gustilo can only be done in operating theatre. [5]

Management

Acute management

Urgent interventions, including therapeutic irrigation and wound debridement, are often necessary to clean the area of injury and minimize the risk of infection. [16] Other risks of delayed intervention include long-term complications, such as deep infection, vascular compromise and complete limb loss. [16] After wound irrigation, dry or wet gauze should be applied to the wound to prevent bacterial contamination. Taking photographs of the wound can help to reduce the need of multiple examinations by different doctors, which could be painful. Limb should be reduced and placed in a well-padded splint for immobilization of fractures. Pulses should be documented before and after reduction. [5]

This flowchart describes the treatment steps for an individual with an open fracture. Note: Diagnostic steps such as obtaining imaging are excluded. Flowchart for Treatment of Open Fractures.png
This flowchart describes the treatment steps for an individual with an open fracture. Note: Diagnostic steps such as obtaining imaging are excluded.

Wound cultures are positive in 22% of pre-debridement cultures and 60% of post-debridement cultures of infected cases. Therefore, pre-operative cultures no longer recommended. The value of post-operative cultures is unknown. Tetanus prophylaxis is routinely given to enhance immune response against Clostridium tetani . Anti-tetanus immunoglobulin is only indicated for those with highly contaminated wounds with uncertain vaccination history. Single intramuscular dose of 3000 to 5000 units of tetanus immunoglobulin is given to provide immediate immunity. [5]

Another important clinical decision during acute management of open fractures involves the effort to avoid preventable amputations, where functional salvage of the limb is clearly desirable. [16] Care must be taken to ensure this decision is not solely based on an injury severity tool score, but rather a decision made following a full discussion of options between doctors and the person, along with their family and care team. [16]

Antibiotics

Administration of broad-spectrum intravenous antibiotics as soon as possible (within an hour ideally) is necessary to reduce the risk of infection. [1] However, antibiotics may not provide necessary benefits in open finger fractures and low velocity firearms injury. First generation cephalosporin (cefazolin) is recommended as first line antibiotics for the treatment of open fractures. The antibiotic is useful against gram positive cocci and gram negative rods such as Escherichia coli , Proteus mirabilis , and Klebsiella pneumoniae . To extend the coverage of antibiotics against more bacteria in Type III Gustilo fractures, combination of first generation cephalosporin and aminoglycoside (gentamicin or tobramycin) or a third generation cephalosporin is recommended to cover against nosocomial gram negative bacilli such as Pseudomonas aeruginosa . Adding penicillin to cover for gas gangrene caused by anaerobic bacteria Clostridium perfringens is a controversial practice. Studies has shown that such practice may not be necessary as the standard antibiotic regimen is enough to cover for Clostridial infections. Antibiotic impregnated devices such as tobramycin impregnated Poly(methyl methacrylate) (PMMA) beads and antibiotic bone cement are helpful in reducing rates of infection. [5] The use of absorbable carriers with implant coatings at the time of surgical fixation is also an effective means of delivering local antibiotics. [17]

There has been no agreement on the optimal duration of antibiotics. [1] Studies has shown that there is no additional benefits of risk of infection when giving antibiotics for one day, when compared to giving antibiotics for three days or five days. [5] [18] However, at present, there is only low to moderate evidence for this and more research is needed. [18] Some authors recommended that antibiotics to be given for three doses for Gustilo Grade I fractures, for one day after wound closure in Grade II fractures, three days in Grade IIIA fractures, and three days after wound closure for Grade IIIB and IIIC. [5]

Wound irrigation

There has been no agreement for the optimal solution for wound irrigation. Studies found out that there is no difference in infection rates by using normal saline or other various forms of water (distilled, boiled, or tap). [19] There is also no difference in infection rates when using normal saline with castile soap compared with normal saline together with bacitracin in irrigating wounds. Studies also have shown that there is no difference in infection rates using low pressure pulse lavage (LPPL) when compared to high pressure pulse lavage (HPPL) in irrigating wounds. Optimal amount of fluid for irrigation also has not been established. It is recommended that the amount of irrigation solution to be determined by the severity of the fracture, with 3 litres for type I fractures, 6 litres for type II fractures, and 9 litres for type III fractures. [5]

Wound debridement

The purpose of wound debridement is to remove all contaminated and non-viable tissues including skin, subcutaneous fat, muscles and bones. Viability of bones and soft tissues are determined by their capacity to bleed. Meanwhile, the viability of muscles is determined by colour, contractility, consistency, and their capacity to bleed. The optimal timing of performing wound debridement and closure is debated and dependent on the severity of the injury, resources and antibiotics available, and individual needs. [20] [1] Debridement time can vary from 6 to 72 hours, and closure time can be immediate (less than 72 hours) or delayed (72 hours to up to 3 months). [20] There is no difference in infection rates for performing surgery within 6 hours of injury when compared to until 72 hours after injury. [5] [21] NICE guidelines suggest that the surgical debridement should be done immediately for open fracture that are highly contaminated or where there is a lot of bleeding (vascular compromise). [22] For high-energy open fractures that are not highly contaminated NICE guidelines suggest surgical debridement within 12 hours of the accident, and for other open fractures within 24 hours. [22]

Surgical management

Early fracture immobilisation and fixation helps to prevent further soft tissue injury and promotes wound and bone healing. This is especially important in the treatment of intraarticular fractures where early fixation allows early joint motion to prevent joint stiffness. Fracture management depends on the person's overall well-being, fracture pattern and location, and the extent of soft tissue injury. Both reamed and unreamed intramedullary nailing are accepted surgical treatments for open tibial fracture. [23] Both techniques have similar rates of postoperative healing, postoperative infection, implant failure and compartment syndrome. [23] Unreamed intramedullary nailing is advantageous because it has a lower incidence of superficial infection and malunion compared to external fixation. [24]  However, unreamed intramedullary nailing can result in high rates of hardware failure if a person's weight bearing after surgery is not closely controlled. [24]  Compared to external fixation, unreamed intramedullary nailing has similar rates of deep infection, delayed union and nonunion following surgery. [24] For open tibial fractures in children, there is an increasing trend of using orthopedic cast rather than external fixation. Bone grafting is also helpful in fracture repair. However, internal fixation using plates and screws is not recommended as it increase the rate of infection. [5] Amputation is a last resort intervention, and is determined by factors such as tissue viability and coverage, infection, and the extent of damage to the vascular system. [25]

Wound management and closure

Early wound closure is recommended to reduce the rates hospital-acquired infection. For Grade I and II fractures, wound can be healed by secondary intention or through primary closure. There is conflicting evident to suggest the effectiveness of Negative-pressure wound therapy (vacuum dressing), with several sources citing a decreased risk in infection, [25] [26] and others suggesting no proven benefit. [27]

Adjunct Treatments

A limited number of studies have assessed the efficacy of recombinant human bone morphogenetic protein-2 (rhBMP-2) on healing and infection risk. Results are encouraging, but no conclusive answers have been agreed upon to date. [28]

Prophylactic bone grafting, typically performed after the wound has been closed for two weeks but within 12 weeks of injury, may help those treated with external fixation heal faster. Bone graft can be impregnated with antibiotics to theoretically decrease infection risk. [29]

Complications

When a bone is broken and exposed to the outside environment, the probability of infection increases. Both the surrounding soft tissues can become infected, as well as the bone itself, which is called osteomyelitis. Additional complications include the broken bone ends not healing, called non-union, and the broken bone ends healing in an incorrect orientation, called malunion. Open fractures of long bones may cause subsequent damage to surrounding tissue resulting in compartment syndrome. Additionally there is potential for fat embolism development, both requiring acute intervention. [7] [30] Lastly, open fractures commonly occur in the setting of traumatic experiences, and the co-occurrence of these events may lead to chronic pain and mental health disorders. [31] [32] The setting or mechanism of injury of the open fracture can have an effect on the risk of infection, for example, external objects or dirt in the wound increase the risk of infection. [33]

Outcomes

Infection

The infection rate of open fractures depend on characteristics of the injury, type and timing of treatment, and patient factors. [34] Higher rates of infection are associated with a higher Gustilo classification, where the risk of infection with a grade III fracture are up to 19.2% and a grade I or II fracture can have a 7.2% risk of infection. [35] Deep infection is more likely with increasing amounts of time between injury sustainment and antibiotic administration. [34] There is an increased risk of infection in patients who smoke or have diabetes. [34] The most common pathogen implicated in infected open fractures is Staphylococcus aureus. [36]

History

In Ancient Egypt, physicians were diagnosing and treating open fractures. Treatment consisted of manual reduction, where the broken bone is made to be straight again with physical maneuvers, and then application of splints and topical ointments. Splints were constructed using linen and sticks or tree bark. A topical ointment consisting of honey, grease, and lint made from vegetable fiber were then applied daily to the open fracture. However, the Ancient Egyptians noted open fractures to have a poor prognosis, and fifth dynasty graves have been discovered containing people who passed away from open fractures. [37]

During the 19th century Crimean War, the use of plaster-of-paris for the stabilization of open and closed fractures was pioneered. It has been reported that the pioneering Russian surgeon who introduced the novel technique had been inspired by watching sculptors creating works of art. [38]

Before the 1850s, surgeons usually amputated the limbs for those with open fractures, as it was associated with severe sepsis and gangrene which can be life-threatening. It was not until the latter half of the 19th century, when Joseph Lister adopted the aseptic technique in surgeries, that the rate of death from open fractures reduced from 50% to 9%. [5] [39]

Related Research Articles

<span class="mw-page-title-main">Wound</span> Acute injury from laceration, puncture, blunt force, or compression

A wound is any disruption of or damage to living tissue, such as skin, mucous membranes, or organs. Wounds can either be the sudden result of direct trauma, or can develop slowly over time due to underlying disease processes such as diabetes mellitus, venous/arterial insufficiency, or immunologic disease. Wounds can vary greatly in their appearance depending on wound location, injury mechanism, depth of injury, timing of onset, and wound sterility, among other factors. Treatment strategies for wounds will vary based on the classification of the wound, therefore it is essential that wounds be thoroughly evaluated by a healthcare professional for proper management. In normal physiology, all wounds will undergo a series of steps collectively known as the wound healing process, which include hemostasis, inflammation, proliferation, and tissue remodeling. Age, tissue oxygenation, stress, underlying medical conditions, and certain medications are just a few of the many factors known to affect the rate of wound healing.

<span class="mw-page-title-main">Orthopedic surgery</span> Branch of surgery concerned with the musculoskeletal system

Orthopedic surgery or orthopedics is the branch of surgery concerned with conditions involving the musculoskeletal system. Orthopedic surgeons use both surgical and nonsurgical means to treat musculoskeletal trauma, spine diseases, sports injuries, degenerative diseases, infections, tumors, and congenital disorders.

<span class="mw-page-title-main">Septic arthritis</span> Inflammation of a joint due to infection

Acute septic arthritis, infectious arthritis, suppurative arthritis, pyogenic arthritis, osteomyelitis, or joint infection is the invasion of a joint by an infectious agent resulting in joint inflammation. Generally speaking, symptoms typically include redness, heat and pain in a single joint associated with a decreased ability to move the joint. Onset is usually rapid. Other symptoms may include fever, weakness and headache. Occasionally, more than one joint may be involved, especially in neonates, younger children and immunocompromised individuals. In neonates, infants during the first year of life, and toddlers, the signs and symptoms of septic arthritis can be deceptive and mimic other infectious and non-infectious disorders.

<span class="mw-page-title-main">Bone fracture</span> Physical damage to the continuity of a bone

A bone fracture is a medical condition in which there is a partial or complete break in the continuity of any bone in the body. In more severe cases, the bone may be broken into several fragments, known as a comminuted fracture. A bone fracture may be the result of high force impact or stress, or a minimal trauma injury as a result of certain medical conditions that weaken the bones, such as osteoporosis, osteopenia, bone cancer, or osteogenesis imperfecta, where the fracture is then properly termed a pathologic fracture.

<span class="mw-page-title-main">Clavicle fracture</span> Medical condition

A clavicle fracture, also known as a broken collarbone, is a bone fracture of the clavicle. Symptoms typically include pain at the site of the break and a decreased ability to move the affected arm. Complications can include a collection of air in the pleural space surrounding the lung (pneumothorax), injury to the nerves or blood vessels in the area, and an unpleasant appearance.

<span class="mw-page-title-main">Hip fracture</span> Broken bone in hip joint region

A hip fracture is a break that occurs in the upper part of the femur, at the femoral neck or (rarely) the femoral head. Symptoms may include pain around the hip, particularly with movement, and shortening of the leg. Usually the person cannot walk.

<span class="mw-page-title-main">External fixation</span> Surgical treatment procedure used to facilitate healing

External fixation is a surgical treatment wherein Kirschner pins and wires are inserted and affixed into bone and then exit the body to be attached to an external apparatus composed of rings and threaded rods — the Ilizarov apparatus, the Taylor Spatial Frame, and the Octopod External Fixator — which immobilises the damaged limb to facilitate healing. As an alternative to internal fixation, wherein bone-stabilising mechanical components are surgically emplaced in the body of the patient, external fixation is used to stabilize bone tissues and soft tissues at a distance from the site of the injury.

<span class="mw-page-title-main">Nonunion</span> Failure of a bone to heal after breakage

Nonunion is permanent failure of healing following a broken bone unless intervention is performed. A fracture with nonunion generally forms a structural resemblance to a fibrous joint, and is therefore often called a "false joint" or pseudoarthrosis. The diagnosis is generally made when there is no healing between two sets of medical imaging, such as X-ray or CT scan. This is generally after 6–8 months.

<span class="mw-page-title-main">Ollier disease</span> Medical condition

Ollier disease is a rare sporadic nonhereditary skeletal disorder in which typically benign cartilaginous tumors (enchondromas) develop near the growth plate cartilage. This is caused by cartilage rests that grow and reside within the metaphysis or diaphysis and eventually mineralize over time to form multiple enchondromas. Key signs of the disorder include asymmetry and shortening of the limb as well as an increased thickness of the bone margin. These symptoms are typically first visible during early childhood with the mean age of diagnosis being 13 years of age. Many patients with Ollier disease are prone to develop other malignancies including bone sarcomas that necessitate treatment and the removal of malignant bone neoplasm. Cases in patients with Ollier disease has shown a link to IDH1, IDH2, and PTH1R gene mutations. Currently, there are no forms of treatment for the underlying condition of Ollier disease but complications such as fractures, deformities, malignancies that arise from it can be treated through surgical procedures. The prevalence of this condition is estimated at around 1 in 100,000. It is unclear whether the men or women are more affected by this disorder due to conflicting case studies.

<span class="mw-page-title-main">Gunshot wound</span> Injury caused by a bullet

A gunshot wound (GSW) is a penetrating injury caused by a projectile shot from a gun. Damage may include bleeding, bone fractures, organ damage, wound infection, and loss of the ability to move part of the body. Damage depends on the part of the body hit, the path the bullet follows through the body, and the type and speed of the bullet. In severe cases, although not uncommon, the injury is fatal. Long-term complications can include bowel obstruction, failure to thrive, neurogenic bladder and paralysis, recurrent cardiorespiratory distress and pneumothorax, hypoxic brain injury leading to early dementia, amputations, chronic pain and pain with light touch (hyperalgesia), deep venous thrombosis with pulmonary embolus, limb swelling and debility, and lead poisoning.

<span class="mw-page-title-main">Le Fort fracture of skull</span> Type of head injury

The Le Fortfractures are a pattern of midface fractures originally described by the French surgeon, René Le Fort, in the early 1900s. He described three distinct fracture patterns. Although not always applicable to modern-day facial fractures, the Le Fort type fracture classification is still utilized today by medical providers to aid in describing facial trauma for communication, documentation, and surgical planning. Several surgical techniques have been established for facial reconstruction following Le Fort fractures, including maxillomandibular fixation (MMF) and open reduction and internal fixation (ORIF). The main goal of any surgical intervention is to re-establish occlusion, or the alignment of upper and lower teeth, to ensure the patient is able to eat. Complications following Le Fort fractures rely on the anatomical structures affected by the inciding injury.

<span class="mw-page-title-main">Taylor Spatial Frame</span>

The Taylor Spatial Frame (TSF) is an external fixator used by podiatric and orthopaedic surgeons to treat complex fractures and bone deformities. The medical device shares a number of components and features of the Ilizarov apparatus. The Taylor Spatial Frame is a hexapod device based on a Stewart platform, and was invented by orthopaedic surgeon Charles Taylor. The device consists of two or more aluminum or carbon fibre rings connected by six struts. Each strut can be independently lengthened or shortened to achieve the desired result, e.g. compression at the fracture site, lengthening, etc. Connected to a bone by tensioned wires or half pins, the attached bone can be manipulated in three dimensions and 9 degrees of freedom. Angular, translational, rotational, and length deformities can all be corrected simultaneously with the TSF.

<span class="mw-page-title-main">Mandibular fracture</span> Medical condition

Mandibular fracture, also known as fracture of the jaw, is a break through the mandibular bone. In about 60% of cases the break occurs in two places. It may result in a decreased ability to fully open the mouth. Often the teeth will not feel properly aligned or there may be bleeding of the gums. Mandibular fractures occur most commonly among males in their 30s.

The Gustilo open fracture classification system is the most commonly used classification system for open fractures. It was created by Ramón Gustilo and Anderson, and then further expanded by Gustilo, Mendoza, and Williams.

<span class="mw-page-title-main">Femoral fracture</span> Broken femur, at shaft or distally

A femoral fracture is a bone fracture that involves the femur. They are typically sustained in high-impact trauma, such as car crashes, due to the large amount of force needed to break the bone. Fractures of the diaphysis, or middle of the femur, are managed differently from those at the head, neck, and trochanter; those are conventionally called hip fractures. Thus, mentions of femoral fracture in medicine usually refer implicitly to femoral fractures at the shaft or distally.

<span class="mw-page-title-main">Pilon fracture</span> Medical condition

A pilon fracture, is a fracture of the distal part of the tibia, involving its articular surface at the ankle joint. Pilon fractures are caused by rotational or axial forces, mostly as a result of falls from a height or motor vehicle accidents. Pilon fractures are rare, comprising 3 to 10 percent of all fractures of the tibia and 1 percent of all lower extremity fractures, but they involve a large part of the weight-bearing surface of the tibia in the ankle joint. Because of this, they may be difficult to fixate and are historically associated with high rates of complications and poor outcome.

The following outline is provided as an overview of and topical guide to trauma and orthopaedics:

<span class="mw-page-title-main">Tibia shaft fracture</span> Medical condition

Tibia shaft fracture is a fracture of the proximal (upper) third of the tibia. Due to the location of the tibia, it is frequently injured. Thus it is the most commonly fractured long bone in the body.

<span class="mw-page-title-main">Diabetic foot infection</span> Medical condition

Diabetic foot infection is any infection of the foot in a diabetic person. The most frequent cause of hospitalization for diabetic patients is due to foot infections. Symptoms may include pus from a wound, redness, swelling, pain, warmth, tachycardia, or tachypnea. Complications can include infection of the bone, tissue death, amputation, or sepsis. They are common and occur equally frequently in males and females. Older people are more commonly affected.

Heather A. Vallier is an American orthopaedic surgeon at Cleveland Clinic and was the 36th president of the Orthopaedic Trauma Association and the first ever female president. She is known for developing early appropriate care, the resuscitation criteria now used globally to determine when polytraumatized patients are optimized for orthopaedic trauma surgical intervention.

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  19. ↑ Olufemi, Olukemi Temiloluwa; Adeyeye, Adeolu Ikechukwu (2017). "Irrigation solutions in open fractures of the lower extremities: evaluation of isotonic saline and distilled water". SICOT-J. 3: 7. doi:10.1051/sicotj/2016031. ISSN   2426-8887. PMC   5278649 . PMID   28134091.
  20. 1 2 O'Brien, C.L; Menon, M; Jomha, N.M (2014). "Controversies in the Management of Open Fractures". The Open Orthopaedics Journal. 8 (20): 178–184. doi: 10.2174/1874325001408010178 . PMC   4110387 . PMID   25067972.
  21. ↑ Davies, James; Roberts, Tobias; Limb, Richard; Mather, David; Thornton, Daniel; Wade, Ryckie G. (February 17, 2020). "Time to surgery for open hand injuries and the risk of surgical site infection: a prospective multicentre cohort study" (PDF). Journal of Hand Surgery (European Volume). 45 (6): 622–628. doi:10.1177/1753193420905205. ISSN   1753-1934. PMID   32065001. S2CID   211136445.
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  23. 1 2 Shao, Yinchu; Zou, Hongxing; Chen, Shaobo; Shan, Jichun (August 23, 2014). "Meta-analysis of reamed versus unreamed intramedullary nailing for open tibial fractures". Journal of Orthopaedic Surgery and Research. 9: 74. doi: 10.1186/s13018-014-0074-7 . ISSN   1749-799X. PMC   4145248 . PMID   25149501.
  24. 1 2 3 Fu, Qiang; Zhu, Lei; Lu, Jiajia; Ma, Jun; Chen, Aimin (August 24, 2018). "External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials". Scientific Reports. 8 (1): 12753. Bibcode:2018NatSR...812753F. doi:10.1038/s41598-018-30716-y. ISSN   2045-2322. PMC   6109134 . PMID   30143702.
  25. 1 2 Manway, Jeffrey; Highlander, Peter (November 14, 2014). "Open Fractures of the Foot and Ankle". Foot & Ankle Specialist. 8 (1): 59–64. doi:10.1177/1938640014557072. ISSN   1938-6400. PMID   25398852. S2CID   8695455.
  26. ↑ Schlatterer, Daniel R.; Hirschfeld, Adam G.; Webb, Lawrence X. (January 17, 2015). "Negative Pressure Wound Therapy in Grade IIIB Tibial Fractures: Fewer Infections and Fewer Flap Procedures?". Clinical Orthopaedics and Related Research. 473 (5): 1802–1811. doi:10.1007/s11999-015-4140-1. ISSN   0009-921X. PMC   4385370 . PMID   25595096.
  27. ↑ Iheozor-Ejiofor, Zipporah; Newton, Katy; Dumville, Jo C; Costa, Matthew L; Norman, Gill; Bruce, Julie (July 3, 2018). "Negative pressure wound therapy for open traumatic wounds". Cochrane Database of Systematic Reviews. 2018 (7): CD012522. doi:10.1002/14651858.cd012522.pub2. ISSN   1465-1858. PMC   6513538 . PMID   29969521.
  28. ↑ Okike, Kanu; Bhattacharyya, Timothy (December 2006). "Trends in the Management of Open Fractures: A Critical Analysis". The Journal of Bone and Joint Surgery. American Volume. 88 (12): 2739–2748. doi:10.2106/JBJS.F.00146. ISSN   0021-9355. PMID   17142427.
  29. ↑ Okike, Kanu; Bhattacharyya, Timothy (December 2006). "Trends in the Management of Open Fractures: A Critical Analysis". The Journal of Bone and Joint Surgery. American Volume. 88 (12): 2739–2748. doi:10.2106/JBJS.F.00146. ISSN   0021-9355. PMID   17142427.
  30. ↑ Ali, Parveen; Santy-Tomlinson, Julie; Watson, Roger (November 1, 2014). "Assessment and diagnosis of acute limb compartment syndrome: A literature review". International Journal of Orthopaedic and Trauma Nursing. 18 (4): 180–190. doi:10.1016/j.ijotn.2014.01.002. ISSN   1878-1241.
  31. ↑ Eccles, Simon; Handley, Bob; Khan, Umraz; McFadyen, Iain; Nanchahal, Jagdeep; Nayagam, Selvadurai, eds. (August 1, 2020). "Patient Experience of Open Fracture and Practical Psychological Support". Standards for the Management of Open Fractures. Oxford University PressOxford. pp. 159–168. doi:10.1093/med/9780198849360.003.0017. ISBN   978-0-19-884936-0.
  32. ↑ Sop, Jessica L.; Sop, Aaron (2022), "Open Fracture Management", StatPearls, Treasure Island (FL): StatPearls Publishing, PMID   28846249 , retrieved November 10, 2022
  33. ↑ "Open Fractures - OrthoInfo - AAOS". www.orthoinfo.org. Retrieved March 26, 2023.
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  35. ↑ Kortram, Kirsten; Bezstarosti, Hans; Metsemakers, Willem-Jan; Raschke, Michael J.; Van Lieshout, Esther M.M.; Verhofstad, Michael H.J. (October 2017). "Risk factors for infectious complications after open fractures; a systematic review and meta-analysis". International Orthopaedics. 41 (10): 1965–1982. doi:10.1007/s00264-017-3556-5. hdl: 1765/101009 . ISSN   0341-2695. PMID   28744800. S2CID   23589948.
  36. ↑ Dreyfus, Jill G.; Yu, Holly; Begier, Elizabeth; Gayle, Julie; Olsen, Margaret A. (January 2022). "Incidence and burden of Staphylococcus aureus infection after orthopedic surgeries". Infection Control & Hospital Epidemiology. 43 (1): 64–71. doi:10.1017/ice.2021.65. ISSN   0899-823X. PMID   34034839. S2CID   235199988.
  37. ↑ Blomstedt, Patric (December 2014). "Orthopedic surgery in ancient Egypt". Acta Orthopaedica. 85 (6): 670–676. doi:10.3109/17453674.2014.950468. ISSN   1745-3674. PMC   4259025 . PMID   25140982.
  38. ↑ Peltier, Leonard F. (1990). Fractures: A History and Iconography of Their Treatment. Norman Publishing. ISBN   978-0-930405-16-8.
  39. ↑ Buckwalter, Joseph A. (2000). "Advancing the Science and Art of Orthopaedics: Lessons from History". The Journal of Bone and Joint Surgery. American Volume. 82 (12): 1782–1800. doi:10.2106/00004623-200012000-00012. PMID   11130651 . Retrieved February 22, 2024.
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