Duke Orthopedic Journal

: 2019  |  Volume : 9  |  Issue : 1  |  Page : 30--34

Institutional delay in wound coverage increases postoperative complications in patients with traumatic open fractures

Alyssa D Althoff, Russell A Reeves, India S Robinson, William R Barfield, Langdon A Hartsock 
 Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, USA

Correspondence Address:
Dr. Alyssa D Althoff
Department of Orthopaedic Surgery, University of Virginia Health System, Charlottesville, VA


Background: Open fractures often require additional procedures for timely definitive soft-tissue coverage. Delayed coverage is associated with poor outcomes. Thus, we sought to (1) define the incidence and severity of open fractures presenting to our institution, (2) identify soft-tissue coverage methods, and (3) determine the incidence of postoperative complications. Materials and Methods: Patients were identified in our institutional registry through the International Classification of Diseases (ICD)-9 and ICD-10 codes specific for open long-bone and extremity fractures. Descriptive statistics were performed on demographics, injury mechanism, and fracture type (Gustilo–Anderson classification). Fractures requiring coverage (Type IIIB/C), surgical methods, and duration until coverage (mean days ± standard deviation) were recorded. Postoperative complications were also identified. Results: From 2012 to 2017, 243 patients were treated for open long-bone fractures. Blunt trauma accounted for 76.9% (n = 187) of the injuries. Grade III tibia fractures represented the highest incidence (n = 74, 30.4%). Of the IIIB/C injuries, the most common coverage methods were split-thickness skin grafting (n = 24, 32.4%) occurring 16.2 ± 11.5 (range: 3–40) days following injury and rotational flap coverage (n = 22, 29.7%). IIIB/C injuries were complicated by nonunion (n = 11, 14.9%), infection (n = 12, 16.2%), amputation (n = 21, 28.4%), and wound breakdown (n = 7, 9.5%). Conclusions: High-grade open fractures treated without timely definitive coverage can result in complications. Multiple specialties may be required to manage these patients, and it may be beneficial for orthopedic surgeons to obtain skills in skin grafting and rotational muscle flap coverage to decrease time to definitive wound closure.

How to cite this article:
Althoff AD, Reeves RA, Robinson IS, Barfield WR, Hartsock LA. Institutional delay in wound coverage increases postoperative complications in patients with traumatic open fractures.Duke Orthop J 2019;9:30-34

How to cite this URL:
Althoff AD, Reeves RA, Robinson IS, Barfield WR, Hartsock LA. Institutional delay in wound coverage increases postoperative complications in patients with traumatic open fractures. Duke Orthop J [serial online] 2019 [cited 2022 May 22 ];9:30-34
Available from: https://www.dukeorthojournal.com/text.asp?2019/9/1/30/279433

Full Text


Traumatic open long-bone fractures present a challenge within the field of orthopedic trauma. These injuries result in increased risk of infection, nonunion, wound breakdown, and in some cases, subsequent amputation.[1],[2],[3],[4],[5],[6] For severe soft-tissue defects, primary wound closure may not be possible, requiring further surgical reconstruction for definitive coverage. Independent risk factors for the development of postoperative complications include injury severity, most commonly assessed by the Gustilo and Anderson classification system, and delay of >7 days for wound coverage.[1],[2],[3],[4],[5],[6],[7],[8],[9]

To accommodate effective management of open long-bone fractures and subsequent complications, trauma centers utilize the diverse skill set of multiple medical specialists. Our Level 1 trauma center provides surgical care to both an urban and rural patient population in the surrounding area.[10] American College of Surgeons (ACS) verified that Level 1 trauma centers are tasked to provide effective multidisciplinary health-care delivery to the patient including rapid fracture stabilization and wound management. Typically, the objective is to have definitive wound closure within 7 days of injury to prevent deep wound infection and to decrease the chance of nonunion.

While prior studies have evaluated postoperative complications following severity-stratified open fractures presenting to a tertiary care center,[2] no study has evaluated the institutional incidence of and complications from open fractures within the state of South Carolina. In fact, effective management of traumatic open fractures at an institutional level within our state is unknown, potentially impacting quality of care. Accordingly, we sought to (1) define the incidence and severity of the open fractures presenting to our Level 1 trauma center, (2) identify coverage methods and timing, and (3) determine the incidence of postoperative complications.

 Materials and Methods

Institutional review

The Institutional Review Board approved this study for detailed chart review. A retrospective chart review of patients who were treated for traumatic open long-bone fractures presenting to our institution between 2012 and 2017 was performed. Patients were identified using relevant extremity International Classification of Diseases (ICD)-9 and ICD-10 codes for the management of open foot, tibia, femur, and humerus. A secondary cross-reference of ICD-10 codes for skin coverage, graft, or amputation was performed to identify definitive surgical management in patients requiring soft-tissue coverage or amputation as definitive management. Patients with <8 weeks of follow-up and orthopedic multitrauma were excluded in an effort to better correlate outcomes with presenting open fractures.

Demographic data collected on each patient included age, gender, race, injury type, and injury mechanism. The incidence of fracture, by extremity location and severity based on the Gustilo–Anderson open fracture classification, was recorded. Time until definitive coverage was assessed for open tibia fractures. In addition, postoperative complications such as wound breakdown, infection, delayed amputation, and nonunion were evaluated based on coverage method.

Data analysis

Descriptive statistics were performed on demographics, fracture severity (Gustilo and Anderson classification), coverage methods, and delayed complications. The data were analyzed using IBM SPSS Statistics-version 24 (Armonk, NY, USA).


Between 2012 and 2017, 243 patients were treated for long-bone open fractures at our institute (humerus, femur, tibia, and foot) [Table 1]. The average age of patients was 39.5 ± 16.1 years. Average follow-up time was 6 weeks, as is standard at our institution, and ranged up to 2 years. Open tibia fractures were most common (n = 165, 67.9%), followed by humerus (n = 32, 13.1%), femur (n = 25, 10.2%), and foot fractures (n = 21, 8.6%). Blunt trauma accounted for 76.9% (n = 187) of the injuries.{Table 1}

Grade III tibia fractures represented the greatest prevalence (n = 74, 30.4%). Nineteen (25.7%) of the Grade III tibia fractures were Type IIIC, requiring vascular intervention. Wound coverage most commonly consisted of split-thickness skin grafting (n = 24, 32.4%), followed by rotational flap coverage (n = 22, 29.7%] [Table 2]. Of the IIIB/C injuries, 17 (23.0%) underwent immediate amputation.{Table 2}

Time until definitive soft-tissue coverage was evaluated for the most commonly presenting factures, Type IIIB/IIIC open tibia (n = 42) [Figure 1]. Time until definitive coverage varied based on soft-tissue coverage method. Split-thickness skin graft required the greatest time until definitive management (19.7 ± 17 days [range: 3–40]), followed by rotational flaps occurring 11.7 ± 11.5 days (range: 4–35) and free flaps occurring 11.7 ± 5.0 days (range: 7–17) following presentation. Time to management did not significantly vary based on the year of presentation. Grade IIIB/C injuries (n = 42) were complicated by wound breakdown (n = 7, 16.7%), infection (n = 12, 28.6%), amputation (n = 21, 50.0%), and nonunion (n = 11, 26.2%) [Table 3]. Amputations occurred at an average of 31.0 ± 18.4 days (range: 0–143 days) following injury. Twenty-nine percent (n = 7) of presenting IIIB tibial injuries were managed without complication. A quarter of IIIB tibial injuries (n = 6, 25%) were complicated by nonunion, 16.7% (n = 4) by infection, 8.3% (n = 2) by wound breakdown, and 20% (n = 5) with amputation. Of the four IIIC tibial injuries that did not receive an amputation, 75% (n = 3) were complicated by infection and 1 (25%) by nonunion.{Figure 1}{Table 3}


At a Level 1 center serving the costal part of South Carolina, high-grade open long-bone fractures are treated frequently, with open tibia fractures being the most frequent open fracture. Of the presenting open tibia fractures (n = 165), approximately one quarter were Type IIIB (24) or IIIC (19) injuries.

Open tibia fractures present a challenge because there is minimal native soft-tissue coverage and limited blood supply.[11] Providing timely coverage within 7 days has previously been described to decrease complication risks,[1],[4] yet the average time to coverage at our institution occurred >2 weeks following injury (16.2 ± 11.5 days, range: 3–40). In the setting of delayed coverage of Type IIIB and IIIC tibia injuries, 71% (n = 17) of presenting IIIB tibial injuries involved a subsequent complication. A quarter of IIIB tibial injuries (n = 6) were complicated by nonunion, 16.7% (n = 4) by infection, 8.3% (n = 2) by wound breakdown, and 20% (n = 5) by amputation. Of the IIIC tibial injuries that did not receive an immediate amputation, 75% (n = 3) were complicated by infection, and 25% (n = 1) were complicated by nonunion, despite an average young age (39.5 ± 16.1 years).

Prior studies have measured similar outcome variables. Historically, the rates of infection have been reported to range from 10% to 50% for Type IIIB, and 25% to 50% for Type IIIC injuries,[12],[13] with lack of standardization of time or type of definitive coverage. More recently, Khatod et al.[14] analyzed 178 patients with open tibia fractures and found an overall infection rate of 22.6%. Eight (66.7%) Type IIIB and five (62.5%) Type IIIC injuries developed acute soft-tissue infections, and two individuals developed subsequent osteomyelitis. In our evaluation of IIIC injuries, we found notably increased immediate amputation rates (n = 14, 77.8%), in addition to increased infection (75%) and nonunion (25%) rates of the remaining fractures.

This is the first institutional-level study in South Carolina to evaluate open long-bone fracture management, stratified by postoperative complications based on injury severity and timely management. Prior literature demonstrates that a delay in definitive soft-tissue coverage is associated with higher risks of postoperative complications in patients having undergone surgical management for open long-bone fractures.[2],[15] In a retrospective review of 69 patients treated for acute tibial fractures, D'Alleyrand et al.[2] demonstrated that flap placement beyond the 7 days mark increased infection risk by 11% and surgical risk by 16% (P < 0.04). Harley et al.'s study of 227 open long-bone fractures reported an association between lower complication rates and time to definitive coverage at < 1 day.[16] In addition, contrary to our results, recent data suggest an increasing trend toward limb salvage, rather than immediate amputation in lower extremity trauma.[17] Although the South Carolina population comprised individuals with a high comorbidity burden,[10] a health-care-related modifiable risk factor for postoperative complications following open extremity fractures requiring soft-tissue coverage is time to definitive flap coverage.[18],[19] This retrospective review did not analyze the decision-making process to proceed with amputation instead of limb salvage.

It was previously demonstrated that access to a trauma facility with well-trained specialists to provide timely coverage is an important factor affecting flap placement success.[5] Hammer et al.[5] found that time to coverage and surgical expertise for Type III tibial fractures had the most impact on potentiating good outcomes. Unfortunately, our Level 1 trauma center does not consistently meet this timeline for management, resulting in a higher incidence of infection and nonunion for IIIC fractures, but not for IIIB fractures.

Improving the institutional delay in wound coverage is likely multifaceted. Currently, open fractures requiring coverage at our institution are managed by two different departments: orthopedic surgery and plastic surgery. In a resource-limited environment, comanagement by different surgical teams can be difficult to coordinate. Operating room (OR) time is limited for urgent trauma cases, and the condition of the patient can be a limiting factor. Plastic surgeons may have other cases that compete for OR time with cases requiring urgent soft-tissue coverage after trauma. Soft-tissue coverage is not explicitly taught in orthopedic surgery residency, as fracture management is a mainstay of training. To achieve better patient care for our patients, a care paradigm shift may be helpful. It may be beneficial for orthopedic trainees to obtain additional skills necessary to manage soft-tissue reconstruction definitively. Training should be designed to prepare the developing surgeon for a variety of practice environments and patient populations, in an effort to provide self-sufficiency in managing open fractures. As a result, the orthopedic trauma team at our institution is considering incorporated teaching of local rotational flap coverage into the current residency training program.

Although this work provides some insight into management and complications of traumatic open long-bone fractures at an institutional-level in South Carolina, it is subject to limitations. Inherent to chart review is miscoding of information; however, we tried to limit this using two independent researchers evaluating respective charts simultaneously and minimized by ICD-9 and 10 coding cross-reference. The retrospective nature of the study lacks the standardization of surgical indications for treatment or timing of surgery. The observational evaluation does not lend itself to drawing causation conclusions from the data provided. In addition, the findings of the current study potentially lack applicability to a larger patient population while attempting to evaluate open fracture and soft-tissue coverage at a single-institution level.


Open fractures without timely definitive coverage often result in increased complications. Complications such as wound breakdown, infection, nonunion, and amputation are frequent. Multiple specialties may be required to manage these patients, and it may be beneficial for orthopedic surgeons to obtain skills in skin grafting and rotational muscle flap coverage to decrease time to definitive wound closure.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.


1Cierny G 3rd, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results. Clin Orthop Relat Res 1983;178:54-63.
2D'Alleyrand JC, Manson TT, Dancy L, Castillo RC, Bertumen JB, Meskey T, et al. Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications? J Orthop Trauma 2014;28:288-93.
3Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer P, Smith RM. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000;82:959-66.
4Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453-8.
5Hammer R, Lidman D, Nettelblad H, Ostrup L. Team approach to tibial fracture 37 consecutive type III cases reviewed after 2-10 years. Acta Orthop Scand 1992;63:471-6.
6Hertel R, Lambert SM, Müller S, Ballmer FT, Ganz R. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg 1999;119:7-12.
7Sinclair JS, McNally MA, Small JO, Yeates HA. Primary free-flap cover of open tibial fractures. Injury 1997;28:581-7.
8Hohmann E, Tetsworth K, Radziejowski MJ, Wiesniewski TF. Comparison of delayed and primary wound closure in the treatment of open tibial fractures. Arch Orthop Trauma Surg 2007;127:131-6.
9Pollak AN, McCarthy ML, Burgess AR. Short-term wound complications after application of flaps for coverage of traumatic soft-tissue defects about the tibia. The lower extremity assessment project (LEAP) study group. J Bone Joint Surg Am 2000;82:1681-91.
10US Census Bureau. New Census Data Show Differences between Urban and Rural Populations. Census Bureau QuickFacts. Available from: https://www.census.gov/newsroom/press-releases/2016/cb16-210.html. [Last accessed on 2019 Dec 06].
11Gustilo RB, Simpson L, Nixon R, Ruiz A, Indeck W. Analysis of 511 open fractures. Clin Orthop Relat Res 1969;66:148-54.
12Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 1989;243:36-40.
13Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics 1987;10:1781-8.
14Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson WH, et al. Outcomes in open tibia fractures: Relationship between delay in treatment and infection. J Trauma 2003;55:949-54.
15Wettstein R, Schürch R, Banic A, Erni D, Harder Y. Review of 197 consecutive free flap reconstructions in the lower extremity. J Plast Reconstr Aesthet Surg 2008;61:772-6.
16Harley BJ, Beaupre LA, Jones CA, Dulai SK, Weber DW. The effect of time to definitive treatment on the rate of nonunion and infection in open fractures. J Orthop Trauma 2002;16:484-90.
17MacKenzie EJ, Bosse MJ, Kellam JF, Burgess AR, Webb LX, Swiontkowski MF, et al. Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma. J Trauma 2002;52:641-9.
18Choudry U, Moran S, Karacor Z. Soft-tissue coverage and outcome of gustilo grade IIIB midshaft tibia fractures: A 15-year experience. Plast Reconstr Surg 2008;122:479-85.
19Webb LX, Bosse MJ, Castillo RC, MacKenzie EJ; LEAP Study Group. Analysis of surgeon-controlled variables in the treatment of limb-threatening type-III open tibial diaphyseal fractures. J Bone Joint Surg Am 2007;89:923-8.