Synonym: compound fracture

An open fracture can be defined as a broken bone that is in communication through the skin with the environment. The amount of communication can vary from a small puncture wound in the skin to a large avulsion of soft tissue that leaves the bone exposed.

Presentation

The diagnosis is usually obvious but may be missed, especially if the puncture wound is very small, or a fracture of the terminal phalanx which is technically open.

Staging

Open fractures have been classified by Gustilo and Anderson.^1,2 The classification of open fractures is based on the size of the wound and the amount of soft-tissue injury, and correlates with both infection and amputation rates as shown below.

Gustilo and Anderson classification of open fractures

• Type I: clean wound smaller than 1 cm in diameter, appears clean, simple fracture pattern, no skin crushing.
• Type II: a laceration larger than 1 cm but without significant soft-tissue crushing, including no flaps, degloving, or contusion. Fracture pattern may be more complex.
• Type III: an open segmental fracture or a single fracture with extensive soft-tissue injury. Also included are injuries older than 8 hours. Type III injuries are subdivided into three types:
  • Type IIIA: adequate soft-tissue coverage of the fracture despite high-energy trauma or extensive laceration or skin flaps.
  • Type IIIB: inadequate soft-tissue coverage with periosteal stripping. Soft-tissue reconstruction is necessary.
  • Type IIIC: any open fracture that is associated with vascular injury that requires repair.

Management

The aims of management are to prevent infection, ensure healing of the fracture and promote the restoration of function.

• The treatment of open fractures should be considered as an emergency. Adequate fluid/blood replacement, analgesia, splinting, antibiotics and tetanus prophylaxis are required before surgical treatment.³ Start broad spectrum antibiotics (e.g. IV co-amoxiclav) as soon as possible after injury (certainly within 3 hours).
• Wounds are handled only to remove gross contaminants (or to obtain a photographic record and to seal from the environment). They are no longer "provisionally cleaned" or routinely irrigated. Immediate surgical exploration is only indicated if there is gross contamination, a compartment syndrome developing, a devascularised limb or if the patient has multiple injuries.³
• Debridement is then performed by orthopaedic and plastic surgeons working together on a scheduled trauma list in normal working hours (within 24 hours of the injury) unless there is marine, agricultural or sewage contamination.³
• Associated injuries may be severe and also require urgent treatment.

Surgical

• The most important surgical aspect of care in open fractures includes early and complete debridement of non-viable tissue and stabilisation of the fracture.
• Even as little as a 5-hour delay in debridement is associated with increased infection rates.
• Early wound management generally includes the use of antibiotic-impregnated beads and definitive wound closure within 1 week of injury.

Complications

• Patients with open fractures are at risk of complications of acute wound infection and osteomyelitis. Infection can result in non-union of the fracture, chronic osteomyelitis and can possibly result in the need for amputation.
• There is also a risk of tetanus infection.
• Infection rates vary but remain as high as 20% in severe cases. This risk depends on the degree of associated soft-tissue injury and the initial management of the patient. Infections may be caused by bacteria that contaminate the wound at the time of injury or by hospital-acquired pathogens.
• Complications other than infection, failure of skeletal fixation and non-union of fracture will depend on the location and extent of soft-tissue damage.
• Both neurovascular injury and compartment syndrome can occur.

Document references

1. Gustilo RB, Anderson JT; Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8. [abstract]
2. Gustilo RB, Mendoza RM, Williams DN; Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug;24(8):742-6. [abstract]
3. Standards for the Management of Open Fractures of the Lower Limb, The British Orthopaedic Association and the British Association of Plastic Reconstructive and Aesthetic Surgeons, October 2009

Internet and further reading

• Open Fractures, Wheeless' Textbook of Orthopaedics

Acknowledgements