Open Fractures of the Foot and Ankle
In the past, open fractures were seen as life-threatening injuries, often leading to emergency amputations, especially during times of war like the Franco-Prussian War and the American Civil War. However, advancements in infectious disease management, plastic and reconstructive surgery, and orthopedic techniques have significantly reduced the risks associated with these injuries.
Today, although open fractures of the foot and ankle remain serious and sometimes life-threatening, mortality rates have decreased significantly. In a study of 2386 open fractures, it was found that only 2.3% of all fractures studied were considered open, with 80% resulting from low-energy mechanisms and 17% affecting the foot or ankle.
Despite the historical prevalence of foot and ankle open fractures, there is limited guidance available for surgeons in managing these injuries. This review aims to outline the advancements in open fracture management and demonstrate how these principles can be applied specifically to foot and ankle injuries.
Evaluation
When dealing with any open fractures, the main aims are to save lives, preserve limbs, and maintain function. This starts with a detailed assessment and documentation of the injury environment, including any contaminants present, the condition of nerves and blood vessels, the quality of the skin around the injury, and any associated injuries.
The first step in evaluating a fracture is determining whether there is a connection with the outside environment. Signs like persistent oozing from wounds, injected fluid returning after injection, fat protruding, or gas under the skin on X-rays suggest open fractures. Fractures where the skin looks raised or discolored over the injury site should be treated as if they are about to become open fractures and need timely reduction and stabilization to prevent the skin from breaking open.
Any visible debris in open fractures should be removed immediately, followed by proper realignment and temporary stabilization. Whenever possible, a “one look” approach should be used to minimize exposure of the wound and further tissue damage.
Antibiotic Therapy
Several studies have investigated the most effective antibiotic treatment for open fractures. In one study, researchers induced fractures and contamination with bacteria in rat femurs. They then treated the specimens with antibiotics and surgery within different timeframes: less than 2 hours, between 2 and 6 hours, and between 6 and 24 hours. The study found that delaying antibiotics for 6 or 24 hours significantly increased infection rates, regardless of when surgery was performed.
Another study showed that administering antibiotics within 3 hours of the injury resulted in lower infection rates compared to waiting more than 3 hours, with rates of 4.7% versus 7.4%, respectively.
Timing to Permanent Fixation
For open fractures of the tibia, Gustilo and Anderson recommended avoiding primary internal fixation due to the risk of infection from hardware. Instead, they suggested using traction pins incorporated into a plaster cast for temporary stabilization. However, for many years, there were no specific guidelines regarding internal fixation for foot and ankle fractures.
In 1984, Franklin et al. reported on 38 open ankle fractures, all of which were treated with immediate debridement and internal fixation. They observed no infections and speculated that stabilizing the bones protected the soft tissues, reducing the infection risk. Similarly, Bray et al. conducted a study comparing immediate versus delayed internal fixation in 31 open ankle fractures. They found one infection in each group but noted a trend toward shorter hospital stays in the immediate fixation group.
With the introduction of external fixation, the concept of damage control orthopedics has become increasingly popular. This approach involves using an external fixator for temporary stabilization, which can be applied promptly, even in unstable or severely injured patients. These principles can also be applied to open foot and ankle fractures.
Do you have more questions?Â
What are the potential complications of open fractures in the foot and ankle?
Potential complications of open fractures in the foot and ankle include infection, delayed healing, nonunion, malunion, nerve or blood vessel injury, and chronic pain.
How is an open fracture diagnosed in the emergency setting?
An open fracture in the foot and ankle is diagnosed based on clinical examination, X-rays, and assessment of the wound to determine the extent of soft tissue damage and bone involvement.
What is the immediate treatment for an open fracture of the foot and ankle?
Immediate treatment for an open fracture of the foot and ankle involves controlling bleeding, cleaning the wound, immobilizing the injured limb, and administering intravenous antibiotics to prevent infection.
How soon should surgical intervention be performed for an open fracture of the foot and ankle?
Surgical intervention for an open fracture of the foot and ankle should be performed as soon as possible after initial stabilization to debride the wound, irrigate it thoroughly, and stabilize the fractured bones.
What are the goals of surgical management for open fractures of the foot and ankle?
The goals of surgical management for open fractures of the foot and ankle include reducing the risk of infection, promoting bone healing, restoring alignment and stability, and minimizing soft tissue damage.
How is infection prevented in open fractures of the foot and ankle?
Infection prevention in open fractures of the foot and ankle involves thorough wound debridement, irrigation with saline solution, administration of prophylactic antibiotics, and appropriate wound coverage.
What types of surgical techniques are used to stabilize open fractures in the foot and ankle?
Surgical techniques used to stabilize open fractures in the foot and ankle may include external fixation, intramedullary nailing, plate and screw fixation, or hybrid fixation methods depending on the specific fracture pattern and soft tissue condition.
How long does it take for an open fracture of the foot and ankle to heal?
The time required for an open fracture of the foot and ankle to heal varies depending on factors such as the severity of the injury, patient’s overall health, and the effectiveness of treatment, but it typically takes several months.
What is the role of physical therapy in the rehabilitation of open fractures in the foot and ankle?
Physical therapy plays a crucial role in the rehabilitation of open fractures in the foot and ankle by promoting range of motion, strength, proprioception, and functional recovery to optimize long-term outcomes.
Can open fractures in the foot and ankle lead to long-term complications such as chronic pain or disability?
Yes, open fractures in the foot and ankle can lead to long-term complications such as chronic pain, stiffness, instability, joint arthritis, and functional limitations, especially if not managed appropriately.
What are the criteria for determining when weight-bearing can be resumed after an open fracture of the foot and ankle?
Weight-bearing after an open fracture of the foot and ankle depends on factors such as fracture stability, soft tissue healing, pain level, and the specific surgical technique used, and is typically guided by the treating surgeon.
Are there any specific measures to promote wound healing and scar management in open fractures of the foot and ankle?
Yes, measures to promote wound healing and scar management in open fractures of the foot and ankle may include regular wound care, use of topical medications, scar massage, and silicone gel sheets.
How is the risk of compartment syndrome monitored in patients with open fractures of the foot and ankle?
The risk of compartment syndrome in patients with open fractures of the foot and ankle is monitored by assessing for signs and symptoms such as severe pain, swelling, numbness, or weakness, and measuring compartment pressures if indicated.
What follow-up care is needed after surgical treatment for an open fracture of the foot and ankle?
Follow-up care after surgical treatment for an open fracture of the foot and ankle includes regular wound checks, X-rays to monitor fracture healing, physical therapy sessions, and gradual return to weight-bearing and functional activities.
Are there any restrictions on physical activities or sports participation after recovering from an open fracture of the foot and ankle?
Restrictions on physical activities or sports participation after recovering from an open fracture of the foot and ankle depend on factors such as the extent of injury, degree of healing, residual symptoms, and individual patient factors, and should be discussed with the treating physician.
How does smoking or other lifestyle factors affect the outcomes of open fractures in the foot and ankle?
Smoking and other lifestyle factors can negatively impact the outcomes of open fractures in the foot and ankle by impairing wound healing, increasing the risk of infection, and delaying bone union, highlighting the importance of smoking cessation and healthy lifestyle habits.
What are the signs of wound infection to watch for after surgery for an open fracture of the foot and ankle?
Signs of wound infection after surgery for an open fracture of the foot and ankle include increased pain, redness, swelling, warmth, drainage of pus or foul odor from the wound, fever, and systemic symptoms such as malaise or chills.
Are there any specific dietary recommendations to support bone healing and recovery after an open fracture of the foot and ankle?
Yes, a diet rich in protein, vitamins (such as vitamin C and D), minerals (such as calcium and phosphorus), and micronutrients is recommended to support bone healing and recovery after an open fracture of the foot and ankle.
What are the chances of developing post-traumatic arthritis in the foot and ankle after an open fracture?
The chances of developing post-traumatic arthritis in the foot and ankle after an open fracture depend on factors such as the severity of the injury, adequacy of treatment, presence of intra-articular damage, and patient-specific factors such as age and activity level.
