After initial stabilization at the emergency department, it's recommended to make a treatment plan. This treatment plan should follow universal principles but it may require adaptation to the resources available.

This chapter gives a framework how to make the an adequate treatment plant that addresses both the bone problem and the soft tissue damage. In an effective orthoplastic approach the fractures fixation methods and timing affect the choices for soft tissue management and visa versa.

Multidisciplinary approach

Treatment choices should depend on the fracture, the soft tissue injury, the general condition of the patient and their comorbidity. In high income settings, a multidisciplinary approach is recommended because there a different specialists that to address the different aspects of the condition other the patient.

Existing open fracture guidelines provide an essential framework for good clinical care, but guidelines alone may not provide clinicians with the practical knowledge required to translate these recommendations into treatment.

In high-income settings, guidelines such as the BOA/BAPRAS open fracture guideline recommend a multidisciplinaire approach. This means a close collaboration between orthopedic trauma surgeons and plastic reconstructive surgeons.

If you work in a resources limited setting without access to a plastic surgeon, be aware of the different skill sets needed to treat the bone and the soft tissues. If you work in a setting where specialist care or adequate skills are not available, consider referral at an early stage. If referral is no option for your patient select the best possible treatment strategy that can be performed by your team that addresses both bone, the soft tissue and comorbidities.

The integrated treatment plan

A patient with an open fracture may need complex, long-term treatment. A well-thought-through integrated treatment plan is essential, and it should be evaluated continuously.

To make an integrated treatment plan, you need to decide which treatment the patient needs, who should be involved and where the patient should be treated. Both for bones and tissues involved.

Include the option of early amputation if the patient’s health, motivation or resources for a potentially long rehabilitation period are lacking. In some cases, enhanced recovery after amputation is beneficial for the patient’s early return to mobilization and work.

If you want to get more insight in reconstructive surgery treatment plans how to make a treatment plan for burn wounds for further guidance on developing a treatment plan.

Goals of treatment

The treatment will depend on findings of the primary and secondary surveys and aims to:

• Pain management - Provide adequate pain management.
• Wound healing - Optimize the patient's condition for adequate wound healing.
• Infection control - Perform debridement and prevent wound colonization and infection with AB
• Fixation of the fracture
• Restoration of Function - Restore structures that are essential for the function of the extremity.
• Coverage - Assure long-term soft tissue coverage of vital structures.
• Appearance - Obtain a satisfactory appearance of the extremity.

Factors determining the treatment plan

A number of factors affect the treatment plan. These range from the characteristics of the soft tissue defect itself to the condition of the patient and the context of the treatment facility:

Amputation

While we strongly believe in the power of limb salvage, and we recommend referral to ensure better care, if possible, amputation can be the best option for an open fracture patient. Given the high risk of poor outcomes and potentially prolonged and complicated recovery, limb amputation should be discussed as a viable alternative with the patient when the injury is very severe. This option may lead to shorter hospital admission and can offer a good quality of life, provided that adequate aftercare, including physiotherapy and prosthetics, is available.

International standards

Understanding the highest standards is essential to adapt treatment in various settings. This wiki follows the BAPRAS/BOA guidelines where possible.¹

Key points of management of open fractures according to the BAPRAS/BOA guidelines include:

1 Multidisciplinary team - Open fractures are best treated by a joint venture of orthopedic and plastic surgeons.

2 Debridement - Debridement should be performed using fasciotomy lines for wound extension where possible.

3 Timing of initial debridement

• Immediately for highly contaminated wounds (agricultural, aquatic, sewage) or when there is an associated vascular compromise (compartment syndrome or arterial disruption producing ischemia).
• Within 12 hours of injury for other solitary high-energy open fractures.
• Within 24 hours of injury for all other low-energy open fractures.

4 Clean surgery and temporarily fixation following debridement - Once debridement is complete, any further procedures carried out at that same sitting should be regarded as clean surgery. This means fresh instruments should be used and a re-prep and drape of the limb performed before proceeding. Temporary fixation is needed, preferably with modular external fixation, when definitive fixation and soft tissue management are not performed yet.

5 Decision to amputate - When a decision whether to perform limb salvage or delayed primary amputation is indicated, this should be based on a multidisciplinary assessment when the condition of the patients allows this. Its recommended to involve a orthopedic surgeon, a plastic surgeon, a rehabilitation specialist, the patient, and their family or carers in this decision. When indicated, a delayed primary amputation should be performed within 72 hours of injury.

6 Timing of definitive fixation and definitive soft tissue coverage - Open fractures of long bones, the hindfoot, or midfoot require fixation and definitive soft tissue coverage within 72 hours of the injury if this cannot be performed at the same time as the debridement.

7 Coupling internal stabilization and soft tissue cover - Definitive internal stabilization should only be carried out when it can be immediately followed by definitive soft tissue cover.

How to refer an open fracture patient?

When considering referral, think whether the patient will truly be better off at the receiving hospital. Consider the availability of safe transport and the availability of financial means for both transfer and treatment.