Open fracture

An open fracture is a fracture in which the fracture haematoma communicates with the outside environment through a wound, or with a contaminated body cavity such as the mouth or vagina. It is an emergency because of the high risk of infection, soft tissue loss, limb ischaemia and associated life threatening injury. The priorities are life saving resuscitation, early antibiotics, tetanus cover, wound care and urgent surgical debridement and stabilisation.

Clinical relevance. Infection rates range from under 2% in type I wounds to 10 to 50% in type III wounds. Delays in antibiotics beyond 1 hour, in debridement and in soft tissue coverage increase infection and nonunion.

Mechanisms. High energy trauma (road traffic collisions, falls, gunshot, blast) causes extensive soft tissue injury and contamination. Low energy injuries cause inside-out wounds with less contamination. Farm, soil, water and faecal exposure increase the risk of anaerobic and Gram negative infection. Classification (Gustilo and Anderson).

• Type I: wound under 1 cm, clean, minimal soft tissue damage.
• Type II: wound 1 to 10 cm, without extensive soft tissue damage, flaps or avulsion.
• Type IIIA: extensive soft tissue laceration but adequate coverage of bone, regardless of wound size (high energy, segmental fractures, farm injuries).
• Type IIIB: extensive soft tissue loss with periosteal stripping and bone exposure, usually needing flap coverage.
• Type IIIC: any open fracture with arterial injury requiring repair.

Key distinctions. Classification is made finally in theatre after debridement. Gunshot wounds, farm injuries and severely contaminated wounds are classed as type III. A wound near a fracture is open until proved otherwise.

History.

• Mechanism, time of injury, energy and place (farm, soil, water, road), prehospital treatment and antibiotics given.
• Time of last oral intake, allergies, tetanus status, medicines (anticoagulants), comorbidities (diabetes, peripheral vascular disease, immunosuppression, smoking), and age.
• Limb function before injury and handedness.

Examination.

• Primary survey first: airway with cervical spine protection, breathing, circulation (control bleeding), disability, and exposure. Exclude head, chest, abdominal and pelvic injuries.
• Limb: inspect the wound (size, contamination, bone exposed, muscle viability), deformity, swelling and skin. Take a photograph and then cover. Do not probe or irrigate repeatedly in the emergency department.
• Neurovascular: pulses (dorsalis pedis, posterior tibial, radial, ulnar), capillary refill, temperature, sensation and motor function. Doppler and ankle brachial index (under 0.9 suggests arterial injury).
• Compartments: tense swelling, pain on passive stretch.
• Proximal and distal joints, and other limbs.

Red flags.

• Hypotension, tachycardia or signs of shock (life threatening bleeding or associated injuries).
• Pulseless, cold, pale limb (arterial injury, 6 hour warm ischaemia limit), expanding haematoma or pulsatile bleeding.
• Tense compartments, pain on passive stretch or paraesthesia (compartment syndrome).
• Gross contamination, bone loss, crush or degloving injury, or a wound over a joint.
• Fever, spreading erythema, pus or foul odour (infection).
• Open pelvic fracture, open femoral fracture, or fractures with rectal, vaginal or perineal wounds (high mortality).
• Neurological deficit.
• Gas in tissue on radiograph (clostridial infection).

Special groups. Children need weight based doses and growth plate assessment. Older adults and patients with diabetes, vascular disease or immunosuppression have higher infection risk. Pregnancy needs shielded imaging and obstetric input.

Open fracture patterns by site. Open tibial shaft fracture (commonest), open forearm, hand and finger fracture, open femoral fracture, open ankle fracture and dislocation, open humeral and elbow fracture, open pelvic fracture, open joint injury without fracture.

Wounds near a fracture. Closed fracture with abrasion, blister, or skin tenting that may become full thickness; stab or gunshot with bone injury; pathological fracture through a necrotic tumour; traumatic amputation; joint penetration (traumatic arthrotomy) without fracture; tendon or neurovascular injury alone.

Complicating or competing conditions.

• Vascular: arterial transection, intimal injury, pseudoaneurysm, compartment syndrome.
• Infective: wound infection, gas gangrene (clostridial myonecrosis), necrotising soft tissue infection, tetanus, osteomyelitis.
• Systemic: haemorrhagic shock, fat embolism syndrome, traumatic coagulopathy, rhabdomyolysis, acute kidney injury, thromboembolism.
• Associated injuries: head, spine, chest, abdominal, pelvic and other limb injuries.

Step 1. Life saving priorities and primary survey first. A catastrophic limb haemorrhage needs direct pressure, tourniquet (note the time) and early surgery.

Step 2. Assess the limb neurovascularly, document before and after any splinting or reduction, and measure ankle brachial index when pulses are abnormal or the injury is near the knee. Pressure under 0.9 or absent pulses need CT angiography or formal angiography.

Step 3. Imaging. Two plane radiographs of the entire bone with the proximal and distal joints, and radiographs of other injured regions. CT for intra-articular or complex fractures and for associated trauma (whole body CT in major trauma). Radiograph of the chest and pelvis in major trauma.

Step 4. Laboratory tests: full blood count, urea, creatinine, electrolytes, glucose, coagulation, lactate and blood gas, creatine kinase when crush or prolonged limb ischaemia, group and crossmatch, and pregnancy test where relevant.

Step 5. Classify the wound size and contamination, record the time of injury, and photograph. Do not swab the wound in the emergency department.

Interpretation. Ankle brachial index over 0.9 with normal pulses makes major arterial injury unlikely. A mangled extremity severity score is a limited aid for amputation decisions, and experienced surgical judgement decides.

Limitations. Initial radiographs may under represent bone injury. Pulses may be present despite intimal injury. Compartment syndrome may develop after hours.

Immediate priorities. Resuscitate, control haemorrhage (direct pressure, then tourniquet applied 5 to 7.5 cm over a limb wound with the time recorded and left in place until surgery, safe for up to 2 hours), and give analgesia. Notify orthopaedic and plastic surgery teams early.

Tranexamic acid 1 g IV over 10 minutes then 1 g over 8 hours when significant bleeding is present or likely and within 3 hours of injury.

Antibiotics (give within 1 hour of injury, ideally as soon as possible).

• Type I and II: cefazolin 2 g IV every 8 hours (3 g for weight over 120 kg; maximum 6 g daily; for CrCl 10 to 34 mL/min give half the dose every 12 hours; monitor creatinine and rash); continue until 24 hours after wound closure.
• Type III: cefazolin 2 g IV every 8 hours (3 g for weight over 120 kg; maximum 6 g daily; half the dose every 12 hours for CrCl 10 to 34 mL/min).
• Add gentamicin 5 mg/kg IV once daily to cefazolin in type III. Use ideal or adjusted body weight in obesity; reduce or avoid with CrCl under 60 mL/min; monitor creatinine and levels; limit to 72 hours or until soft tissue coverage, whichever comes first.
• Alternatively, in type III give piperacillin with tazobactam 4.5 g IV every 6 hours as a single agent (maximum 18 g piperacillin daily; every 8 hours for CrCl 20 to 40 mL/min and every 12 hours under 20 mL/min).
• Continue type III antibiotics for 24 hours after definitive soft tissue coverage or up to 72 hours, whichever is shorter.
• Faecal, farm, soil or water contamination: add metronidazole 500 mg IV every 8 hours (maximum 1.5 g daily), and consider benzylpenicillin for clostridial cover on specialist advice.
• Penicillin allergy: clindamycin 600 to 900 mg IV every 8 hours (maximum 2.7 g daily; monitor for diarrhoea) plus gentamicin 5 mg/kg IV once daily for type III.
• In penicillin allergy, vancomycin 25 mg/kg IV loading dose (maximum 3 g) then maintenance dosed by kidney function and levels is an alternative.
• Children: cefazolin 30 mg/kg IV every 8 hours (maximum 2 g for each dose), with weight based gentamicin for type III under specialist advice.

Tetanus. Tetanus vaccine if more than 5 years since the last dose or if immunisation is incomplete.

Give human tetanus immunoglobulin 250 units IM at a separate site when immunisation is incomplete or unknown or the wound is high risk, and 500 units if the wound is over 24 hours old or heavily contaminated.

Wound and limb care.

• Remove gross contamination, photograph the wound, cover with a saline soaked sterile dressing and an occlusive layer, and do not close or pack the wound.
• Realign the limb gently, apply a splint including the proximal and distal joints, and recheck neurovascular status after splinting.
• Do not re-expose the wound repeatedly. Do not push exposed bone back into the wound.
• Remove rings and tight objects. Nil by mouth.

Surgical management.

• Urgent surgical debridement within 12 hours for type III or grossly contaminated wounds, and within 24 hours for type I and II, with earlier surgery for vascular injury, compartment syndrome and severe contamination.
• Extension of the wound, excision of non-viable tissue, low pressure irrigation with 3 to 9 L of warm isotonic saline (no antiseptic or antibiotic additives), and skeletal stabilisation (intramedullary nail, plate, or temporary external fixator).
• Soft tissue coverage with a plastic surgeon: primary closure of clean type I and II wounds when tension free, delayed closure or negative pressure dressing for type III, and definitive flap coverage within 72 hours to 7 days for type IIIB.
• Vascular repair or shunting within 6 hours of warm ischaemia for type IIIC. Fasciotomy when compartment syndrome is present or likely (prolonged ischaemia, crush, reperfusion).
• Amputation for non-viable limb, life threatening infection or irreparable injury, decided by senior surgeons after counselling where possible.

Analgesia. Paracetamol 1 g IV every 6 hours (maximum 4 g daily; 3 g daily if weight under 50 kg, malnutrition, alcohol excess or liver disease) and morphine 2 mg IV boluses every 5 minutes titrated to pain (maximum 10 mg before reassessment; reduce in older adults and kidney impairment; monitor sedation and respiratory rate). Regional anaesthesia is avoided until compartment syndrome has been considered.

Venous thromboembolism prophylaxis. Enoxaparin 40 mg subcutaneously once daily (20 mg daily if CrCl 15 to 30 mL/min; unfractionated heparin 5000 units subcutaneously every 8 to 12 hours if CrCl under 15 mL/min) from 12 to 24 hours after surgery or when bleeding is controlled; monitor platelets from day 4 and creatinine.

Monitoring. Neurovascular and compartment checks every hour for 24 hours then every 4 hours, temperature, wound review at dressing change, CRP trend, creatinine and creatine kinase after crush or ischaemia, and aminoglycoside levels.

Referral and escalation. Orthopaedic trauma surgeon and plastic surgeon (orthoplastic care) at a centre able to give both. Vascular surgery for vascular injury. Trauma team for polytrauma. Critical care for shock or sepsis. Rehabilitation and psychology after limb threatening injury.

Admission criteria. All open fractures need admission for debridement and stabilisation, intravenous antibiotics, and neurovascular observation. Minor open phalangeal fractures (type I, distal, clean) may be managed in an outpatient setting after debridement and oral antibiotics under specialist direction. Discharge and safety netting.

Discharge after fixation and wound cover with antibiotics completed, analgesia, thromboprophylaxis plan, a weight bearing plan and early review at 5 to 7 days. Patients return for fever, wound redness, discharge, increasing pain, swelling, numbness, pale or cold limb, or cast tightness.