Open Fractures of the Foot and Ankle

Open fractures refer to those in which there is a soft tissue gap that connects directly or indirectly with the fracture site. In the past, open fractures have been linked with significant morbidity and mortality due to the risk of infection and sepsis

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.

 

A seasoned orthopedic surgeon and foot and ankle specialist, Dr. Mohammad Athar welcomes patients at the offices of Complete Orthopedics in Queens / Long Island. Fellowship trained in both hip and knee reconstruction, Dr. Athar has extensive expertise in both total hip replacements and total knee replacements for arthritis of the hip and knee, respectively. As an orthopedic surgeon, he also performs surgery to treat meniscal tears, cartilage injuries, and fractures. He is certified for robotics assisted hip and knee replacements, and well versed in cutting-edge cartilage replacement techniques.
In addition, Dr. Athar is a fellowship-trained foot and ankle specialist, which has allowed him to accrue a vast experience in foot and ankle surgery, including ankle replacement, new cartilage replacement techniques, and minimally invasive foot surgery. In this role, he performs surgery to treat ankle arthritis, foot deformity, bunions, diabetic foot complications, toe deformity, and fractures of the lower extremities. Dr. Athar is adept at non-surgical treatment of musculoskeletal conditions in the upper and lower extremities such as braces, medication, orthotics, or injections to treat the above-mentioned conditions.