General introduction

Motivation for compiling these guidelines

The lower limb is covered by only a limited amount of soft tissue, particularly over the tibia. Consequently, it is a vulnerable area and even an apparently simple injury can lead to big problems. It is estimated that in the Netherlands there are approximately 580 new cases of open fracture of the lower limb each year (Court-Brown, 2012). These figures are based on data from Great Britain. Of these, approximately 250 cases involve extensive soft tissue injury classified as grade III (ABC) in accordance with the classification of Gustilo (Gustilo, 1976). This includes concomitant injury and defects of the skin, subcutaneous tissue and muscle tissue. Generally, there is also damage to the nerves and blood vessels.

 

The higher the grade of soft tissue injury, the higher the risk of disorders of wound healing, infection, non-union, malunion and a poor functional result. The severity of soft tissue injury is often underestimated, at least initially. The skin defect may appear limited but frequently there is considerable damage to the underlying tissues. Definitive grading can therefore only take place after extensive debridement by an experienced team.

 

Research has shown that an open fracture of the lower limb with significant soft tissue injury has a big impact on the patient (Hoogendoorn, 2001), and often has long-term consequences for both patients and their personal environment (MacKenzie, 2005). These national guidelines are intended to improve the quality of care for the patient with open fracture of the lower limb by means of efficient and multidisciplinary treatment. This will result in fewer complications, fewer unnecessary operations, possibly fewer amputations, better functional results and a reduction in morbidity.

 

Definitions and concepts

An open fracture of the lower limb is a multiple fracture, i.e. there is a fracture in both bones of the lower leg – the tibia and fibula. These guidelines are also applicable to isolated open fractures of the tibia.

 

A grade III open fracture of the lower limb is characterised by:

• High energy trauma with extensive soft tissue injury
•  and/or multifragmentary fracture, segmental fracture, or bone loss unrelated to the size of the wound
• And/or severe fragmentation and/or crush injuries
•  and/or severe infection including agricultural accidents

 

Literature

British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS). Standard for the management of open fractures of the lower limb. British Library Cataloguing in Publication Data 2009. ISBN: 978-1-85315-911-4

Court-Brown CM, Bugler KE, Clement ND, et al. The epidemiology of open fractures in adults. A 15-year review. Injury. 2012;43(6):891-7.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thou-sand and twenty-five open fractures of long bones: retrospective and prospective analyses. JBJS Am 1976;58(4):453-8.

Hoogendoorn JM, van der Werken C. Grade III open tibial fracturen: functione-le outcome and quality of life in amputeer versus patients with successful re-constructiion. Injury. 2001;32(4):329-34.

MacKenzie EJ, Bosse MJ, Pollak AN, et al. Long-term persistence of disability following severe lower-limb trauma. Results of a seven-year follow-up. JBJS Am. 2005 87(8):1801-9.