Open Fracture

An open fracture is a fracture in which the fracture haematoma and bone communicate with the external environment through a traumatic wound.

The wound does not need to lie directly over the fracture. A small puncture several centimetres away can still represent an open fracture if the wound tract communicates with the fracture.

The major threats are:

Deep fracture related infection
Osteomyelitis
Soft tissue necrosis
Nonunion
Vascular injury
Compartment syndrome
Limb loss

Open fracture management is therefore not simply fracture fixation. It requires coordinated treatment of bone, soft tissue, contamination and vascular injury.

Gustilo Anderson classification

Final classification is most accurate during operative debridement, after the true extent of contamination and tissue injury is visible.

Type I

Wound 1 cm or smaller
Usually low energy
Minimal contamination
Minimal muscle damage
Minimal periosteal stripping

Type II

Wound greater than 1 cm and up to approximately 10 cm
Moderate soft tissue injury
No extensive crushing, flaps or major tissue loss
No severe periosteal stripping

Type III

High energy injury, gross contamination, extensive soft tissue injury or major fracture comminution regardless of wound length.

Type IIIA

Extensive injury but adequate viable soft tissue remains to cover the bone after debridement

Type IIIB

Extensive periosteal stripping and exposed bone
Significant soft tissue loss
Requires rotational or free flap coverage

Type IIIC

Associated arterial injury requiring repair to maintain limb viability

Farm injuries and heavily contaminated high energy injuries should be treated as at least severe type III injuries.

Soft tissue severity

The fracture line alone does not predict outcome. Prognosis depends heavily on:

Muscle viability
Periosteal stripping
Skin loss
Neurovascular injury
Degree and type of contamination
Compartment syndrome
Time to effective antimicrobial treatment and source control

Perform standard major trauma assessment before focusing on the limb.

Inspect for:

Any wound near the fracture
Visible bone
Gross contamination
Degloving
Crush injury
Muscle loss
Active haemorrhage
Distal ischaemia
Compartment tension

Do not repeatedly probe the wound in the emergency department.

Document neurovascular status before and after reduction or splinting:

Dorsalis pedis or posterior tibial pulse where relevant
Capillary refill
Skin temperature and colour
Motor function
Sensory examination

A palpable pulse does not completely exclude significant arterial injury.

Hard signs such as active pulsatile bleeding, expanding haematoma, absent distal perfusion or obvious limb ischaemia require immediate vascular and orthopaedic escalation.

Evaluate repeatedly for compartment syndrome. Open fractures can still develop compartment syndrome because the skin wound does not reliably decompress all fascial compartments.

Plain radiographs: AP and lateral views of the entire fractured bone, including the joint above and below where appropriate.

CT is useful for complex periarticular fractures but should not delay emergency management.

CT angiography: obtain when arterial injury is suspected in a stable patient.

Do not delay restoration of blood flow to a critically ischaemic limb solely to obtain sophisticated imaging when the vascular injury is clinically obvious.

Immediate management

Priorities are:

Resuscitate the patient
Control haemorrhage
Administer IV antibiotics immediately
Cover the wound
Restore gross limb alignment
Splint the fracture
Assess tetanus status
Plan formal operative debridement

Give antibiotics as soon as possible, ideally within 1 hour of injury.

A practical adult antimicrobial strategy is:

Gustilo I or II

Cefazolin 2 g IV every 8 hours

Use 3 g IV every 8 hours in adults weighing at least 120 kg.

With severe immediate beta lactam allergy:

Clindamycin 900 mg IV every 8 hours, where local susceptibility supports its use.

Gustilo III

Additional Gram negative activity is required.

One contemporary strategy is:

Ceftriaxone 2 g IV every 24 hours.

An alternative is cefazolin plus an aminoglycoside according to local trauma antimicrobial protocols.

Do not continue prophylactic antibiotics unnecessarily for several days after adequate surgical source control. Contemporary trauma practice generally limits routine prophylaxis to approximately 24 hours, with modification for unusual contamination or ongoing established infection.

Contamination specific therapy

Modify antibiotics when the environment changes the organism spectrum.

Farm or faecal contamination requires additional anaerobic and clostridial consideration.

Fresh water and marine contamination require additional coverage against water associated organisms according to local microbiology.

These exposures should be explicitly recorded rather than treating every open fracture with the same antibiotic regimen.

Tetanus

For a contaminated traumatic wound, give a tetanus containing booster when vaccination is incomplete, uncertain or sufficiently remote.

Patients with an unknown or incomplete primary immunisation series and a dirty major wound should also receive tetanus immune globulin, commonly 250 IU IM, in addition to active vaccination.

Wound care before theatre

Remove only obvious loose gross contamination.

Cover the wound with saline moistened sterile gauze and an occlusive dressing.

Avoid repeated emergency department washouts and repeated opening of the dressing.

Realign gross deformity and apply a well padded splint.

Operative debridement

The goal is complete excision of contamination and devitalised tissue, not simply irrigation.

Proceed immediately when there is:

Arterial compromise
Compartment syndrome
Gross agricultural, sewage or similar contamination

Otherwise, high energy open fractures require prompt debridement, commonly within approximately 12 hours, and lower energy injuries should undergo formal debridement within approximately 24 hours.

At surgery:

Extend the wound along safe reconstructive or fasciotomy lines
Excise devitalised skin
Remove nonviable fat
Debride necrotic muscle
Remove grossly contaminated free cortical fragments without meaningful soft tissue attachment when appropriate
Irrigate with large volumes of normal saline

Muscle viability is assessed using colour, consistency, contractility and capacity to bleed, but these findings must be interpreted together rather than using one criterion alone.

Repeat debridement when tissue viability remains uncertain.

Skeletal stabilisation

Stabilisation reduces additional soft tissue trauma, restores length and alignment and facilitates soft tissue reconstruction.

Options include:

Intramedullary nail
Plate fixation
External fixation

Temporary external fixation is useful in unstable polytrauma, severe contamination, vascular reconstruction or when definitive soft tissue management is not immediately possible.

Definitive internal fixation can be performed at initial debridement when the wound has been adequately excised and definitive soft tissue closure or coverage can be achieved safely.

Soft tissue closure

Aim for definitive closure or flap coverage as early as possible.

When immediate definitive closure is impossible, definitive coverage should ideally occur within approximately 72 hours.

Do not close contaminated devitalised tissue under tension merely to obtain primary skin closure.

Type IIIB fractures require early orthoplastic planning for rotational or free tissue transfer.

Vascular injury

A type IIIC fracture is a limb threatening vascular emergency.

Restore perfusion urgently.

In a severely unstable fracture, temporary vascular shunting followed by rapid skeletal stabilisation and definitive vascular repair may reduce total ischaemia time.

The decision between reconstruction and amputation must consider:

Warm ischaemia time
Extent of muscle destruction
Nerve injury
Bone loss
Contamination
Physiological condition
Reconstructive burden

Scoring systems should not substitute for multidisciplinary clinical judgement.

Clinical toolsCalculators

BMI GCS EDD Parkland Formula

Corrected Sodium Corrected Calcium Anion Gap Creatinine Clearance Insulin Calculations qSOFA Wells PE Wells DVT CHA₂DS₂-VASc HAS-BLED CURB-65 Centor/McIsaac

Calcaneal Fracture

The calcaneus is the largest tarsal bone and forms the posterior subtalar articulation.

Calcaneal fractures are divided into:

Extraarticular fractures
Intra articular fractures involving the posterior subtalar facet

Most major intra articular fractures result from axial loading, commonly after a fall from height.

The force drives the talus downward into the calcaneus, producing:

Posterior facet depression
Heel shortening
Heel widening
Varus deformity
Lateral wall blowout
Subfibular impingement

Associated lumbar spine fractures must be considered after axial load injuries.

Essex Lopresti classification

Based on the secondary fracture line.

Tongue type

The secondary fracture line exits posteriorly, producing a large posterior tuberosity fragment attached to the Achilles tendon.

The Achilles can pull the fragment superiorly, threatening the posterior heel skin.

Joint depression type

The secondary fracture line exits superiorly behind the posterior facet, leaving a separate depressed articular fragment.

These patterns require different reduction strategies.

Sanders CT classification

Based on the number and location of fracture lines through the posterior facet on coronal CT.

Type I

Nondisplaced or minimally displaced fracture, generally less than approximately 2 mm displacement, regardless of the number of fracture lines.

Type II

One primary fracture line divides the posterior facet into two articular fragments.

Subgroups A, B and C reflect the position of the fracture line from lateral to medial.

Type III

Two fracture lines divide the posterior facet into three articular fragments.

Subgroups AB, AC and BC reflect fracture line location.

A central depressed fragment is frequently present.

Type IV

Three or more fracture lines produce four or more articular fragments.

These are severely comminuted injuries with poor reconstructive prognosis and high risk of post traumatic subtalar arthritis. Increasing Sanders grade correlates with increasing reconstructive difficulty.

Patients have severe hindfoot pain, swelling and inability to bear weight.

Ecchymosis extending to the plantar heel is strongly suggestive.

Inspect posterior heel skin carefully.

A displaced tongue type fracture can create a prominent posterior tuberosity beneath thin skin.

Blanching, tenting or threatened posterior skin is an orthopaedic emergency because skin necrosis can occur rapidly.

Assess:

Sural nerve sensation
Tibial nerve function
Distal perfusion
Foot compartment tension

High energy calcaneal fractures may be open medially.

Evaluate the spine, pelvis and contralateral hindfoot after a major fall.

Obtain:

Lateral foot or hindfoot radiograph
Axial Harris view where useful
AP foot

Böhler angle

Measured on lateral radiograph.

Normal is approximately 20° to 40°.

Loss or reversal suggests posterior facet collapse.

Critical angle of Gissane

Normally approximately 120° to 145°.

Distortion reflects disruption around the posterior facet.

CT hindfoot: essential for most displaced intra articular fractures and provides Sanders classification.

Immediate care

Elevate aggressively.

Apply a well padded splint.

Avoid constrictive circumferential casting during major swelling.

Treat open fractures immediately.

Urgent posterior skin threat

A displaced tongue type or tuberosity avulsion threatening the posterior heel skin requires urgent reduction and fixation, even if the rest of the definitive reconstruction must wait.

Do not delay until routine swelling has subsided if the posterior skin is blanching.

Nonoperative treatment

Appropriate for:

Sanders I fracture
Nondisplaced extraarticular fracture
Minimally displaced intra articular injury with preserved heel anatomy
Patients with prohibitive surgical risk
Selected patients with very high wound complication risk

Non weight bearing is commonly required for approximately 8 to 12 weeks, with early subtalar and ankle range of motion once swelling permits. Sanders I fractures and fractures retaining near normal Böhler angle can often be treated without surgery.

Operative indications

Consider fixation for:

Displaced intra articular fracture with posterior facet incongruity
Significant heel widening
Varus deformity
Loss of calcaneal height
Displaced tuberosity fracture
Open fracture
Tongue type fracture threatening skin
Anterior process fracture with major calcaneocuboid articular involvement

The decision must also account for:

Smoking
Diabetes
Peripheral vascular disease
Soft tissue condition
Functional demand

These factors substantially influence wound complication risk.

Timing

Except for urgent skin threatening patterns and open fractures, delay large surgical approaches until swelling has subsided and skin wrinkling has returned.

This often takes approximately 10 to 14 days.

Do not perform an extensile lateral exposure through tense oedematous skin.

Reduction objectives

Restore:

Posterior facet congruity
Calcaneal height
Heel length
Heel width
Hindfoot valgus relationship, avoiding residual varus
Calcaneocuboid alignment

A perfectly reduced posterior facet with a severely widened varus heel is not an adequate reconstruction.

Fixation techniques

Options include:

Percutaneous reduction and screws
Sinus tarsi approach
Extensile lateral ORIF
Plate fixation

The sinus tarsi approach provides direct access to the posterior facet with less soft tissue disruption than a traditional extensile lateral flap in selected fractures.

Sanders II and III

Reconstruction is generally feasible in appropriate surgical candidates.

Elevate and anatomically reduce the posterior facet, restore the tuberosity and support with screws or plate fixation.

Sanders IV

The posterior facet may be too fragmented for durable reconstruction.

Options include:

ORIF when reconstructable
ORIF combined with primary subtalar arthrodesis
Primary subtalar arthrodesis in selected severely comminuted injuries

The decision depends on cartilage destruction, patient age and reconstructability.

Postoperative care

Maintain non weight bearing until sufficient fracture healing, generally approximately 8 to 12 weeks.

Begin ankle and subtalar movement when soft tissues permit.

Major complications include:

Wound necrosis
Deep infection
Sural nerve injury
Heel widening
Varus malunion
Subfibular impingement
Peroneal tendon irritation
Chronic heel pain
Subtalar stiffness
Post traumatic subtalar arthritis

Late painful subtalar arthritis with preserved ankle function can be treated with subtalar arthrodesis.

Open Fracture

Overview

Clinical Features

Diagnosis

Management

Overview

Clinical Features

Diagnosis

Management