Management of open fractures in the multiple trauma patient

The management of open fractures in the multiple trauma patient is discussed. It is concluded that operative stabilization of the open fracture both enhances the survival of these patients and reduces the complications of the fracture while enhancing extremity function. This procedure must be conducted so as to avoid devascularization of more tissue and especially bone fragments and so that adequate stability is provided. In general, all open fractures are left open with the degree of openness depending upon the magnitude of the soft tissue trauma. In grade I and II open fractures, stabilization can usually be achieved by internal fixation or by a combination of minimal internal fixation (usually lag screws) and external fixation. In grade III open fractures, stabilization is usually best achieved by external fixation. However, the external fixation must be carefully designed to allow the subsequent soft tissue coverage operations which are usually required in third degree open fractures. In general, the external fixator should be viewed as a device to gain sufficient stability for patient mobilization and soft tissue management and not as definitive fracture care. For this reason, in the tibia unilateral frames are usually best and bilateral or trilateral frames should be reserved for segmental defects and severe zonal comminution. Definitive fracture care is then administered after soft tissue healing by cast or internal fixation.