An open fracture is defined as an injury where the fracture and the fracture hematoma communicate
with the external environment through a traumatic defect in the surrounding soft tissues and overlying
skin. It should be emphasized that the skin defect may not lie directly over the fracture site and may lie
at a distant site. It may communicate with the fracture under degloved skin. Hence, any fracture
associated with a wound in the same region must be considered to be an open injury until proven
otherwise by surgical exploration. Open fractures are often high-energy injuries and are frequently
associated with life-threatening polytrauma. They are best managed by a team approach in centers that
have appropriate facilities for resuscitation and multispecialty care. Apart from severe bone and soft
tissue involvement, these injuries have other risk factors such as skin degloving, soft tissue crushing,
contamination with dirt and debris, and injury to neurovascular structures. Hence, they are associated
with a high risk of complications, including amputation. Recent developments—such as advances in the
management of polytrauma, the availability of powerful antibiotics, refinement of the techniques of
radical debridement, bone stabilization, and early soft tissue reconstruction—have helped to improve
the outcome considerably. The present challenge of the trauma surgeon is not simply salvage of the limb
but the restoration of maximal function. Patients with a disfigured or painful limb are often very
dissatisfied with the results of treatment and may opt for amputation at the end of a prolonged
treatment regimen. The principles of treatment of open injuries have gradually evolved over the
centuries and many advances have come from the experience gained in treating war injuries. Tscherne
has grouped the developments into four eras of life preservation, limb preservation, infection
prevention, and functional restoration. The problem of contamination was recognized in the 16th
century by Ambroise Paré who emphasized the need for cleaning wounds of all foreign matter and
necrotic tissue and leaving the wound open. The term debridement was coined by Desault in the 18th
century to describe a procedure that involved surgical extension of the wound and the removal of all
necrotic and contaminated tissue. In the absence of antibiotics and aseptic surgical techniques, the
incidence of mortality and amputation following infection was very high. “Lose a limb to save a life” was
an accepted dictum of management as gross infection of open injuries often led to gangrene, septicemia,
and death. In the Franco-Prussian War of 1870, more than 13,000 therapeutic amputations were
performed. Billroth (1829–1894) reported a mortality of 39% following open injuries that led him to
comment, “Perhaps the treatment of no other condition gives me as much satisfaction as that of a
successfully treated open injury.” World War I saw the successful beginning of the “Era of Life
Preservation” as mortality was considerably reduced as a result of the application of the principles of
good resuscitation, thorough debridement, stabilization, and avoiding closing the wounds. Survival
continued to improve as sulfonamides and other antibiotics became available in World War II with more
antibiotics being used during the Korean War. The 1970s saw major advances in both orthopedic and
plastic surgery and the “Era of Limb Preservation” was introduced. The refinement of the principles and
techniques of external fixation allowed rapid and effective stabilization of the skeleton in the presence of
complex fracture patterns. The advent of bone transport and ring fixators led to the possibility of
successful bone regeneration even in the presence of major bone loss. Simultaneous advances in plastic
surgery with the evolution of numerous flaps in different regions of the body together with the
development of microvascular free tissue transfer made reconstruction of composite tissue loss possible.
These advances made limb reconstruction a technical possibility, even in challenging situations. The
availability of antibiotics and the understanding of the need for aggressive debridement and early soft
tissue cover helped to control infection bringing in the “Era of Infection Control.” Meanwhile the
principles of treatment were being constantly refined. Gustilo and Anderson published their landmark
classification scheme for open fractures that brought attention to the importance of the wound and the
need for early soft tissue cover. The seminal work of Godina clearly emphasized the advantages of early
soft tissue cover. The source of the infection was frequently identified to be from the hospital
environment and the principle of “fix and flap” and the indications and advantages of primary skin
suturing were developed. The huge variability in presentation and the challenges inherent in the
management of Gustilo type IIIB injuries led to the development of the Ganga Hospital Open Injury Score
(GHOIS) with specific guidelines for salvage and reconstruction in type IIIB injuries. The availability of
vacuum foam dressings (VFDs) using negative-pressure wound therapy (NPWT) has also proved to be
very useful in wounds that cannot be covered early. It acts as a bridge between the index procedure and
the definitive soft tissue cover procedure. The understanding that open fractures are not in the domain
of any single specialty and must be treated by a combined approach has helped to improve results. The
“orthoplastic approach” where the orthopedic and plastic teams work together from the stage of wound
debridement onward is now recognized as the standard of care and is undertaken in all centers that
regularly treat these injuries. This protocol allows surgeons to undertake a meticulous debridement
without concern about the problems of late reconstruction. It emphasizes the need for early soft tissue
cover and results in better outcomes by reducing complications like infection and nonunion. The
management of open injuries is now in the “Era of Functional Restoration.” Functional restoration is
aided by aggressive wound debridement, early definitive fracture stabilization, and early wound closure
or cover to achieve bone and soft tissue healing as soon as possible. Surgeons have now realized that
success in treatment of open injuries is not merely salvage and they should not succumb to the “triumph
of technique over reason.” Patients are often dissatisfied if they are left with a deformed or painful lower
limb at the end of the treatment and often opt for a secondary amputation. The future will focus on
identifying and understanding factors that affect healing of bone and soft tissues at the molecular and
genetic level so that the treatment can be tailored to each patient and secondary amputations avoided.
There will also be a focus on the development of safe protocols for reconstruction that will facilitate
better function and cosmesis in the shortest possible period of time.