The management of open fragility fractures should follow the established principles as for any open fracture of the lower limb with the following additional considerations:
1. From admission, elderly patients should have a comprehensive orthogeriatric assessment promptly, with ongoing geriatric input throughout their hospital stay, coordinated with related services (e.g. falls prevention, rehabilitation, bone health, mental health, primary care, and social services).
2. Consider the use of regional anaesthetic techniques.
3. Consider the use of angle-stable fixation devices to enhance skeletal fixation in osteoporotic bone.
4. In patients who are frail or whose soft tissues place them at unacceptably high risk of flap failure, or those for whom a lengthy soft tissue reconstruction procedure may be unsafe, alternative surgical strategies should be considered.
Open fragility fractures of the lower limb represent an expanding subgroup in whom surgical reconstruction is complicated by poor-quality bone and soft tissues, and whose complex healthcare needs are exacerbated by frailty and the presence of multiple co-morbidities. These challenges are likely to increase as the Office for National Statistics predicts that the number of people aged 75 and over in the UK will rise from 5.2 million in 2014 to 9.9 million in 2039 (1).
The majority of open fragility fractures of the lower limb occur in the tibia and ankle of older women as a result of a fall from standing (2). Despite the low-energy mechanism, there is a high incidence of Gustilo–Anderson III (predominantly IIIA) injuries (3). This reflects the frailty of this patient group and the combined effects that osteoporosis and skin ageing have upon the quality of the bone and integrity of the surrounding soft tissue envelope. Reconstruction is complicated by higher rates of mal-union, non-union, necessity for amputation, and mortality as compared with younger patients with similar injuries (4). These patients frequently have complex ongoing healthcare needs requiring additional support, which influence safe delivery of the established ‘best practice’ surgical interventions.
Social and healthcare needs
Patients with an open fragility fracture should receive prompt comprehensive orthogeriatric assessment to optimise their peri-operative condition. This input should continue throughout the period of hospitalisation and be coordinated with related services—identifying and planning for ongoing health, social, and rehabilitation needs (e.g. falls prevention, bone health, mental health, primary care, and social services).
The management goals of open fragility fractures are the same as for any other open lower limb fracture, delivered by a combined orthoplastic team in a specialist centre with the aim of achieving a stable soft tissue envelope at the time of definitive fracture fixation and within 72 hours of injury. However, this subgroup of patients presents specific challenges that may require some adaptation of established treatment principles. These include the use of regional anaesthetic techniques and alternative modes of peri-operative pain relief to reduce the need for opiate analgesia. The challenges of fracture fixation in osteoporotic bone will be familiar to orthopaedic surgeons; stable fixation through use of locking plates or other similar angle-stable devices may provide more secure fixation than standard techniques. The soft tissue excision should follow the same principles as for any open fracture, but surgeons should appreciate that although the skin wound may be large, open fragility fractures are usually low-energy injuries without severe underlying muscle contusion or periosteal stripping. Large wound extensions may not always be required. Alternatives to complex surgical reconstruction of the open fracture should be considered in light of treating frail patients and those with unacceptably high risks of flap failure (e.g. patients with advanced peripheral vascular and coronary artery disease). For example, acute shortening of the tibia through bone resection may allow primary wound closure in those with transverse wounds that would otherwise require a local or free flap. In some exceptional circumstances, small wounds on the lateral side of the ankle may achieve secondary healing in patients for whom the general condition precludes a more complex procedure. If a local flap is required, this may be raised during the first excision of the wound so that it is ‘pre-conditioned’ and safer to rotate into the defect at the time of definitive wound cover.
Fine wire circular external fixators have a role in complex fracture patterns or those with significant bone loss. For example, most major trauma centres in the UK will treat between 10 and 30 type C pilon (complete articular) fractures per year (5). These injuries have significant soft tissue disruption compounded if the injury is open. Internal fixation carries a high risk of wound complications and management of such open fractures with fine wire circular fixators minimises the additional iatrogenic trauma to the soft tissues. Whilst the use of such external devices necessitates additional care regimes (e.g. pin site care and frame adjustments) and regular outpatient follow-up to pre-empt problems that may follow the physical incumbrance imposed on mobility, the avoidance of potential deep sepsis from wound complications may avert non-union and amputation. The decision to use such devices for open fragility fractures will need an assessment of benefit and risk as well as consideration of the wider implications of care with the fixator in situ and the availability of support services to facilitate this.
The Lower Extremity Assessment Project (LEAP) study (6) showed equivalent functional outcomes for amputation and limb salvage through reconstruction in the most severe tibial fractures at 2 years post-injury but with higher risks of complications, additional surgery, and rehospitalisation in the reconstruction group (6). However, lower limb amputation in the elderly changes the level of mobility drastically as the energy consumption of using a prosthesis, even if at the below-knee level, frequently negates the ability to be independently mobile. Nevertheless, early amputation should be considered where reconstructive options are limited and repeated surgical interventions are unwise in the face of frailty and extensive co-morbidity. The decision to perform an amputation should be with a multidisciplinary team involving orthopaedic and plastic surgical teams, rehabilitation specialists, prosthetists, the patient, their family, and their carers.
The number of open fragility fractures presenting to orthoplastic centres is likely to increase. There will be greater demand on resources to manage this group of patients who have complex health, rehabilitation, and social care needs. Extrapolation of the standards used for adults to the fragility fracture group is appropriate at the current time, with the caveats highlighted earlier. Efforts to carry out high-quality research specifically addressing trauma in the elderly are required to better understand the needs and expectations of this important and growing group of patients.
1. Office for National Statistics. National population projections. 2015 October. https://www.ons.gov.uk/peoplepopulationandcommunity/populationandmigration/populationprojections
2. Court-Brown CM, Biant LC, Clement ND, Bugler KE, Duckworth AD, McQueen MM. Open fractures in the elderly. The importance of skin ageing. Injury. 2014;46(2):189–94.Find this resource:
3. Court-Brown CMC, Bugler KEK, Clement NDN, Duckworth ADA, McQueen MMM. The epidemiology of open fractures in adults. A 15-year review. Injury. 2012;31(6):891–7.Find this resource:
4. Clement ND, Beauchamp NJF, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of tibial diaphyseal fractures in the elderly. Bone Joint J. 2013;95-B(9):1255–62.Find this resource:
5. Sharma H. Incidence of type c pilon fractures. Unpublished survey data, Hull Royal Infirmary, UK. 2016.Find this resource:
6. Bosse MJ, MacKenzie EJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924–31.Find this resource: