high rates of hardware failure if a person's weight bearing after surgery is not closely controlled. compared to external fixation, unreamed intramedullary nailing has similar rates of deep infection, delayed union and nonunion following surgery. for open tibial fractures in children, there is an increasing trend of using orthopedic cast rather than external fixation. bone grafting is also helpful in fracture repair. however, internal fixation using plates and screws is not recommended as it increase the rate of infection. amputation is a last resort intervention, and is determined by factors such as tissue viability and coverage, infection, and the extent of damage to the vascular system. wound management and closure early wound closure is recommended to reduce the rates hospital-acquired infection. for grade i and ii fractures, wound can be healed by secondary intention or through primary closure. there is conflicting evident to suggest the effectiveness of negative-pressure wound therapy (vacuum dressing), with several sources citing a decreased risk in infection, and others suggesting no proven benefit. outcomes infection the infection rate of open fractures depend on characteristics of the injury, type and timing of treatment, and patient factors. higher rates of infection are associated with a higher gustilo classification, where the risk of infection with a grade iii fracture are up to 19.2% and a grade i or ii fracture can have a 7.2% risk of infection. deep infection is more likely with increasing amounts of time between injury sustainment and antibiotic administration. there is an increased risk of infection in patients who smoke or have diabetes. the most common pathogen implicated in infected open fractures is staphylococcus aureus. epidemiology crush injuries are the most common form of injuries, followed by falls from standing height, and road traffic accidents. open fractures tend to occur more often in males than females at the ratio of 7 to 3 and the age of onset of 40.8 and 56 years respectively. in terms of anatomy location, fractures of finger phalanges are the most common one at the rate of 14 per 100,000 people per year in the general population, followed by fracture of tibia at 3.4 per 100,000 population per year, and distal radius fracture at 2.4 per 100,000 population per year. infection rates for gustilo grade i fractures is 1.4%, followed by 3.6% for grade ii fractures, 22.7% for grade iiia fractures, and 10 to 50% of grade iiib and iiic fractures. history in ancient egypt, physicians were diagnosing and treating open fractures. treatment consisted of manual reduction, where the broken bone is made to be straight again with physical maneuvers, and then application of splints and topical ointments. splints were constructed using linen and sticks or tree bark. a topical ointment consisting of honey, grease, and lint made from vegetable fiber were then applied daily to the open fracture. however, the ancient egyptians noted open fractures to have a poor prognosis, and fifth dynasty graves have been discovered containing people who passed away from open fractures. during the 19th century crimean war, the use of plaster-of-paris for the stabilization of open and closed fractures was pioneered. it has been reported that the pioneering russian surgeon who introduced the novel technique had been inspired by watching sculptors creating works of art. before the 1850s, surgeons usually amputated the limbs for those with open fractures, as it was associated with severe sepsis and gangrene which can be life-threatening. it was only until the 20th century, when joseph lister adopted the aseptic technique in surgeries, that the rate of death from open fractures reduced from 50% to 9%.