NICE Recommendations Relevant to Open Fractures

In 2016 the National Institute for Clinical and Care Excellence (NICE) published a suite of five trauma-related guidelines, including the Guideline on Complex Fractures NG37. A significant component of this guideline related specifically to open fractures, and each of the relevant recommendations is discussed. Following the publication of the complete trauma Suite of guidelines there was further work by NICE resulting in the formulation of just five Quality Standard Statements; one of these was specific to open fractures. The relevant recommendations from the NICE guideline NG37 and statement from the Quality Standard are presented is this chapter for easy reference. This also allows the concordance that exists between the text in the rest of this book, the Open Fracture BOAST and NICE to be better appreciated.

Open Tibial Fractures in Children

Since the last edition of this book the total number of published articles on the management of open fractures of the tibia in children has trebled. This allows for a further evaluation of similarities and differences in the management of open fractures in children, adolescents and adults. The principles evolving from the evidence published thus far indicate there are greater similarities than there are differences. Early antibiotic administration is important as is the simultaneous delivery of combined orthoplastic care. The techniques of soft tissue reconstruction are similar to those used in adults. Fracture stabilisation will need to factor in the presence of a physis. Bone loss after injury or excision (debridement) is replaced using the same techniques as in adults; an exception is the young (under 6 years of age) child with a small (less than 3 cm) defect that may restitute spontaneously from periosteal callus.

Timing of Soft Tissue Reconstruction

Soft tissue cover of a meticulously and comprehensively excised (debrided) wound is the cornerstone of achieving infection-free fracture union. Planning of the soft tissue reconstruction should ideally occur at the time of wound excision. Definitive soft tissue reconstruction should be performed within 72 hours of the injury unless precluded by patient factors, and at the same time as internal fixation of the fracture. Free flap reconstruction is ideally performed on scheduled lists in specialist orthoplastic centres.

Temporary Wound Dressings

Temporary dressings are used to cover the wound from the time of first aid through to definitive soft tissue closure. Frequent dressing changes should be avoided to reduce contamination by nosocomial organisms. Therefore, the initial dressing should be simple to apply and maintain tissue viability by preventing desiccation, e.g. gauze soaked in normal saline and covered with an occlusive film as per the National Institute for Health and Care Excellence guidance. Following wound excision, a simple non-adherent dressing can be used. Negative pressure wound therapy should not be used to downgrade the requirement for definitive soft tissue reconstruction, which should be achieved within 72 hours of injury. Following internal fixation, definitive soft tissue reconstruction should be performed at the same time.

Timing of Wound Excision

The aim of wound excision is to remove contaminating debris and all devitalised tissue. This should reduce both the bacterial burden and available substrate for microbial colonisation, resulting in fewer deep surgical site infections. In turn, this will lead to improved patient outcomes. The timing of wound excision has been the subject of intense debate. In the past, guidelines have favoured wound excision within 6 hours based on historical animal and human studies. Current data suggest that timing of wound debridement should be determined by the degree of contamination and severity of injury.

Setting Up an Effective Orthoplastic Service

Open fractures can be both limb-threatening injuries and devastating. The true incidence is difficult to ascertain, although it is estimated that open fractures comprise 3.2% of all fractures, with up to 21% of tibial fractures being open. Open fractures are more common in older people, with 296.6/106/year in those under 65 years compared with 323.3/106/year in those aged over 65 years, and 446.7/106/year in over 80-year-olds. Fracture distribution curves demonstrate a bimodal form with similar incidence in the young male population, 15–19 years of age, and females >90 years of age. Only 22.3% of all open fractures are a result of high-energy injuries and most often affect young adults at their most productive time of life. Although the total number of patients with open fractures is relatively small compared with the total number of fractures treated each year, open fractures cause significant morbidity and represent an enormous burden on healthcare resources. Healthcare providers, managers, and clinicians have a duty to improve outcomes and use resources efficiently.

Open Fragility Fractures

Open fractures of the lower limb are increasingly common in older patients in whom surgical reconstruction is complicated by poor-quality bone and soft tissues, and whose complex healthcare needs are exacerbated by frailty and the presence of multiple co-morbidities. These challenges are likely to increase as the Office for National Statistics predicts that the number of people aged 75 and over in the UK will rise from 5.2 million in 2014 to 9.9 million in 2039. The majority of open fragility fractures of the lower limb occur in the tibia and ankle of older women as a result of a fall from standing. Despite the low-energy mechanism there is a high incidence of Gustilo–Anderson III (predominantly IIIA) injuries. This reflects the frailty of this patient group and the combined effects that osteoporosis and skin ageing have upon the quality of the bone and integrity of the surrounding soft tissue envelope. Reconstruction is complicated by higher rates of malunion, non-union, necessity for amputation, and mortality as compared with younger patients with similar injuries. These patients may have complex ongoing healthcare needs requiring additional support that influence safe delivery of the established ‘best practice’ surgical interventions.

Infection

Infection is the most feared and challenging complication in the treatment of open tibial fractures. Microorganisms can adhere as a biofilm on the surface of damaged bone, necrotic tissue, and internal fixation devices, and become resistant to phagocytosis and most antimicrobial agents. Established infection can delay healing and recovery, cause permanent functional loss, and potentially lead to amputation of the affected limb. The incidence of infection after severe open tibial fractures was reported to be over 30% in the 1980s and 1990s. Although there is evidence of a possible reduction in incidence in the past decade, the Lower Extremity Assessment Project (LEAP) study has shown that severe lower extremity trauma continues to be associated with infective complications necessitating additional operative treatment in a significant number of cases. Furthermore, greater bacterial virulence and increasing age and associated co-morbidities of the fracture population ensure that infection after open trauma remains a challenge.

Soft Tissue Reconstruction

Soft tissue coverage of open fractures with well-vascularised tissues should be performed within 72 hours of injury or at the same time as internal fixation. It may be in the form of local or free flaps, and may comprise muscle, fasciocutaneous tissues, or both. Flap selection depends on multiple factors, including the size and location of the defect following wound excision, availability of flaps, and donor site morbidity. Local flaps are usually used to cover defects with a limited zone of injury. Anastomoses for free flaps should be performed outside the zone of injury. Experimental data suggest that coverage with muscle leads to improved healing of fractures. However, there is currently little clinical evidence to support the use of one form of soft tissue cover over another for open fractures of the lower limb. The plastic surgeon must always consider the donor site morbidity of the flap(s) chosen.

Skeletal Stabilisation

In this chapter we draw upon published evidence and the experience of the authors to provide guidance in stabilisation for open tibial fractures. Most orthopaedic surgeons have, through their training, reached higher levels of proficiency and expertise in methods of internal fixation than with external fixation. The difference reflects the greater number of fractures treated with internal fixation methods. Spanning external fixation should provide skeletal stability without impeding access for plastic surgical procedures. This combination of prerequisites has to be met through a mutual understanding of bony and soft tissue requirements at first debridement and at definitive treatment of the open fracture. Many fixator configurations used currently and even advocated for in external fixator manuals simply fail to meet these requirements. Consequently, we provide a clear rationale for the recommendations made and encourage adoption of the principles described.