International guidelines are often written in, and for, high-resources settings. In resources-limited settings, they may not always be fully applicable. Only basic methods may be available. Always try to adhere to the international standards, and be aware of suboptimal outcomes when deviating from it. But if there is no option for referral, aim for the most suitable technique available.

For definitive fixation of open fractures, open reduction and internal fixation, is the golden standard. Techniques are well described, for example on the AO Surgery Reference website

For the fixation of the bone, a basic treatment ladder can be a useful tool to choose the optimal treatment for your patient. Starting down it goes from very basic to most advanced options. What is best available treatment for your specific patient in your specific setting? Can better treatment outcome be expected if a treatment higher on the ladder is chosen and if the resources of that step are available (or can be made available when referred)?

The higher up the ladder, the higher the complexity of resources needed:

Always take into account the soft-tissue injury and adapt your fracture management accordingly. Factors such as delayed case presentation, the presence of fracture related infection, and a mal- or non-united fracture influences the strategy and outcome can make the treatment highly complex. Orthopedic trauma surgeons and plastic surgeons working in resources limited settings experience that patient present very late, many days to weeks after the injury. Many of these patient already have a fracture related infection on arrival at the hospital and internal fixation might not be the best option for this patients group.

We provide a brief description of the four fixation technique groups:

Casting

Casting is a technique that provides relative stability to a fracture by limiting mobility and maintaining alignment. It serves as a method of temporary stabilization and pain management, especially during referral or as a bridge to surgery.

It is crucial that wound evaluation and management can be performed effectively. To facilitate this, create a window in the cast for direct visualization and assessment.

^{Circular cast with a window for a midshaft tibial open fracture where advanced fixation options and referral were unavailable and amputation was refused.}

Casting is not intended as a definitive treatment for open fractures. However, it may be the only viable option for fracture fixation in a resource-limited setting where advanced fixation methods are unavailable.

In specific cases, particularly for extra-articular fractures of the tibial shaft, definitive casting can be considered if both the soft tissue condition and fracture configuration permit.

Bone healing

Non-operative management of open fractures

Traction

Traction is used in low-resource settings to treat closed femoral fractures. In cases of open fractures, traction generally serves only as a temporary measure, such as prior to patient transfer or while managing multiple trauma cases.

However, for some open fractures, traction may occasionally be the only viable option. For example, for certain rare proximal femur fractures that are unsuitable for casting or external fixation, or for larger tibial wounds that cannot be cast with a window.

The primary goal should always be to pursue more definitive care.

Various traction techniques are available depending on the fracture location, including:

• Pin traction - Pin traction through the distal femur, proximal tibia, or calcaneus
• Skin traction - Plaster or bandage traction applied to the tibia or foot
• K-wire traction - K-wire traction techniques may be considered for open fractures of the fingers, although in some cases, amputation may be the more appropriate option

Non-operative management of open fractures

^{Proximal tibia pin traction in an intra-articular distal femur fracture.}

Modular external fixation

External fixation in high resources settings is primarily intended for temporary stabilization while awaiting the readiness of the patient and soft tissue condition for definitive internal fixation.

Although regarded as substandard, with certain technical adaptations, external fixation can serve as a practical solution for definitive fracture treatment in resource-limited settings.

In cases with high risk for infection, external fixation may be more suitable than internal fixation.

It offers several advantages, including:

1 Universal applicability across most extremity fracture types

2 Reduced technical demands

3 Lower costs compared to internal fixation, as components can be sterilized and re-used 

When using a modular external fixator as the definitive fixation method, it is crucial to strictly follow the correct procedural steps to prevent premature loosening of pins, as well as fracture-related infection and non-union. 

Applying an external fixator

Definitive fixation with an external fixator

^{Modular external fixation of an open proximal tibia fracture}

Internal Fixation

Internal fixation involves the surgical application of osteosynthesis material directly onto or into the fractured bone. It requires advanced resources and specific surgical expertise. Internal fixation should only be performed if:

1 Immediate wound closure if possible, with either:

• Primary wound closure, or
• The wound is covered with a flap during the same procedure.

AND

2 You have sufficient confidence in soft tissue viability and the wound is not heavily contaminated

If adequately performed, this method provides the necessary alignment and stability, making it suitable for complex fractures, intra-articular injuries, and cases where anatomic reduction is required.

Example - A treatment strategy may be to convert to internal fixation after temporary external fixation when soft tissues have healed, or flap surgery is performed in the same procedure.

Ring fixation

External ring fixators consist of spanned K-wires and sometimes half-pins attached to rings positioned above and below a fracture, forming a highly stable construct to stabilize or correct bone position in a controlled and adjustable way.

External ring fixators are also known as Ilizarov frames or circular frames.

There are many different brands offering ring fixation systems that provide advantages over the normal modular external fixation systems. Modern systems can have a hexapod design that allows for controlled, gradual, and multi-dimensional adjustments in all planes (length, rotation, angulation, translation).

These advanced variations provide the technique for addressing bone defects, limb lengthening and gradual correction of malunions. Computer software-based planning is used to adjust a frame for optimal bone alignment and soft tissue healing.

Although very suitable as spanning frame of a fracture, ring fixators are mostly used as treatment for patients with complex open fractures. Particularly when there is significant bone loss or large soft tissue defects that cannot be covered primarily with optimal fracture reduction.

The basic surgical technique a ring fixator for definitive treatment of open fractures can be highly suitable in resource limited settings.

However, despite their theoretical suitability for low-resource settings, modern ring fixation systems are in practice most often confined to tertiary referral centres where specialised expertise and resources are available.