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.