![]() ![]() The Orthopaedic Trauma Association (OTA) – open fracture classification (OTA-OFC) was devised using 5 categories deemed to be essential for classifying open fracture severity (skin injury, muscle injury, arterial injury, contamination and bone loss). An ideal classification system should guide treatment decisions rather than the treatment determining the classification retrospectively. Finally, the Gustilo-Anderson classification incorporates treatment concepts into the classification. Another limitation of the classification system is when it is applied preoperatively, underestimation of the extent of soft tissue injury is common, as the original study described grading of open fractures while in the operating room, following debridement. The classification was initially described for open tibia fractures and used vague language which has been shown to have low interobserver agreement, with only 60% agreement amongst observers. Unfortunately, the Gustilo-Anderson classification has several limitations. The most well-known classification system was described by Gustilo and Anderson in 1976, which was modified in 1984. However, there continues to be limitations with available classification systems for open fractures and universal acceptance of a single classification system has yet to occur. In order to make decisions about surgical timing, the open wound and the extent of soft tissue injury must be quantified in a way that can be easily communicated between surgeons. This narrative review will evaluate current literature and provide up-to-date recommendations for surgical timing for open fracture management to optimize patient outcomes. As per the 2015 American College of Surgeons Trauma Quality Improvement Program recommendations on open fracture management, intravenous (IV) antibiotics should be started within 60 minutes of presentation to hospital, patients should be evaluated for tetanus vaccination requirements on presentation to hospital, they should be taken to the operating room (OR) for irrigation and debridement (I&D) within 24 hours, and soft tissue coverage should be performed within 7 days of injury. The optimal surgical timing for management of open fractures continues to be debated with new evidence-based clinical studies questioning open fracture management dogma. With advances in management of open fractures, the utility of well-known classification systems including the Gustilo-Anderson classification and Mangled Extremity Severity Score need to be re-evaluated in favor of up-to-date classification systems which better guide management and predict prognosis. Whereas debates on the optimal irrigation pressure and solution have been answered by multicenter randomized controlled trials, further research is required to determine the optimal irrigation volume and timing of wound closure. Additionally, orthopaedic surgeons and vascular surgeons should collaborate on the sequence of management of open fractures with associated vascular injury. New evidence supports initial debridement within 24 hours with the appropriate surgical team. However, the “ six-hour rule” for initial open fracture debridement and revascularization has come into question. Early intravenous antibiotics and tetanus prophylaxis remain instrumental in infection prevention. Open fractures are complex injuries requiring the orthopaedic surgeon to consider both the bone injury as well as associated soft tissue injury. Ĭontroversy exists over the optimal management of open fractures as new clinical studies question open fracture management dogma. The work cannot be changed in any way or used commercially without permission from the journal. This is an open access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The study was deemed exempt from Institutional Review Board and Animal Use Committee review. The authors have no conflicts of interest to disclose. ![]() Address: Departments of Surgery and Community Health Sciences, Cumming School of Medicine, McCaig Tower, 3134 Hospital Drive, NW Calgary, AL T2N 5A1, Canada. ASection of Orthopaedic Surgery, Department of Surgery, University of Calgary, Calgary, CanadaīDepartment of Community Health Sciences, University of Calgary, Calgary, Canada. ![]()
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