Open Fractures of the Foot and Ankle

Open fractures occur when a fracture site communicates directly or indirectly with the external environment through a soft tissue wound. These injuries pose a high risk of infection, soft tissue damage, and long-term functional impairment. Historically, open fractures were associated with high rates of infection, sepsis, and even death.

Historical Perspective

In earlier centuries, particularly during the Franco-Prussian War and the American Civil War, open fractures were often fatal or required immediate amputation due to the absence of antibiotics and sterile surgical techniques. With advancements in infectious disease management, antibiotic therapy, reconstructive surgery, and orthopedic fixation methods, survival rates and outcomes have dramatically improved.

Modern studies indicate that while open fractures remain serious injuries, mortality and amputation rates have dropped significantly. In a review of 2,386 open fractures, only 2.3% were classified as open injuries, with 17% involving the foot or ankle and 80% caused by low-energy trauma. Despite these improvements, management of open fractures in the foot and ankle remains complex, and evidence-based guidelines are limited compared to other fracture types.

Evaluation

The initial priorities in open fracture management are to preserve life, salvage the limb, and maintain function. A meticulous evaluation includes assessing the wound, surrounding skin, and neurovascular status, as well as documenting environmental contamination and associated injuries.

Open fractures are diagnosed by identifying communication between the wound and fracture site. Key diagnostic indicators include persistent wound drainage, visible fat droplets, air under the skin on X-rays, or injected saline emerging from the wound. Even if the skin is intact but severely discolored or tense over the fracture, the injury should be treated as an impending open fracture to prevent skin necrosis and conversion to an open injury.

All visible debris must be removed promptly, followed by gentle irrigation, reduction, and temporary stabilization. The “one look” principle—minimizing repeated wound exposure—is recommended to prevent further contamination and soft tissue damage.

Antibiotic Therapy

Early administration of antibiotics remains one of the most critical factors in preventing infection. Experimental studies have shown that delaying antibiotic administration beyond six hours dramatically increases infection risk, regardless of surgical timing.

Clinical evidence supports the “three-hour rule,” demonstrating that patients receiving antibiotics within three hours of injury have infection rates of 4.7%, compared to 7.4% for those treated later. The findings highlight that early antibiotic initiation—even before definitive debridement—is vital for reducing infection risk.

Timing of Permanent Fixation

Historically, internal fixation in open fractures was discouraged due to infection risk. In 1976, Gustilo and Anderson advised against immediate internal fixation, recommending traction or external immobilization instead. However, later evidence challenged this approach.

In 1984, Franklin et al. reported favorable outcomes in 38 open ankle fractures treated with immediate internal fixation following debridement, observing no infections and improved wound protection due to stabilized bone fragments. Similarly, Bray et al. compared immediate and delayed fixation in 31 open ankle fractures, finding no difference in infection rates but shorter hospital stays with immediate fixation.

With the evolution of damage control orthopedics, temporary external fixation has become a preferred initial stabilization method for complex or unstable patients. It provides rapid fracture alignment, facilitates soft-tissue care, and allows delayed conversion to internal fixation once infection risk and swelling are minimized.

Modern Surgical Principles

Today, the principles guiding open fracture management in the foot and ankle emphasize:

• Prompt debridement and irrigation to remove contaminants and necrotic tissue.

• Early antibiotic therapy within the first three hours of injury.

• Stabilization using either external or internal fixation to protect soft tissues and allow healing.

• Soft tissue coverage using local or free flaps when necessary to reduce infection and promote wound healing.

Research Spotlight

Recent research highlights the growing role of arthroscopically assisted internal fixation (AAORIF) in treating foot and ankle fractures. A 2021 systematic review analyzed 32 studies involving more than 1,500 patients with pilon, ankle, and calcaneal fractures. The findings suggest that using arthroscopy during fracture fixation allows surgeons to directly visualize joint surfaces, identify hidden cartilage or ligament injuries, and achieve more precise bone alignment—all with smaller incisions and minimal soft-tissue disruption. While arthroscopy improved anatomical reductions and offered comparable or slightly better functional outcomes than traditional open techniques, evidence remains limited. The review concludes that arthroscopy is a promising but still adjunctive tool, warranting more high-quality studies before becoming standard in foot and ankle fracture management. (“Recent study on arthroscopically assisted fixation improving fracture visualization and alignment – see PubMed.“)

Summary and Key Takeaways

• Open fractures of the foot and ankle are serious but far less fatal today due to modern orthopedic and infection control advances.

• Early and meticulous evaluation is essential, including wound assessment, contamination control, and neurovascular examination.

• Antibiotic therapy within three hours of injury significantly reduces infection risk.

• Immediate internal fixation after proper debridement can be safe and may promote soft-tissue recovery.

• External fixation is valuable for temporary stabilization in unstable patients or those with severe soft tissue injury.

• The principles of damage control orthopedics—rapid stabilization and staged reconstruction—are particularly effective for complex foot and ankle open fractures.

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