Open Fractures

Background

An open fracture is a fracture that communicates with an overlying disruption of the skin and soft tissues. They are also called compound fractures. Open fractures are potentially limb-threatening injuries.

Mechanism

Open fractures are usually caused by high energy mechanisms such as:

• falls from height
• motor vehicle crashes
• motor vehicle versus pedistrian
• bicycle crashes
• crush injuries, e.g. structural collapse

Assessment

History

Focus on

• impact energy, e.g. fall from a great height versus tripped over the curb.
• likelihood of contamination, e.g. tractor roll-over on a farm = very dirty!

Examination

• examine the wound, the surrounding tissues, and look for contamination.
• exploration of wounds that overly fractures is usually not very informative and disruption may increase the risk of infection. However, a blunt sterile probe may be safely used to determine if bone can be contacted and is in communication with the wound.
• assess neurovascular status.
• perform a secondary survey identify any other associated injuries (is the patient’s head still attached?)

Consider taking a photograph of the wound so that different doctors don’t keep coming along and pulling down the dressings, which will add to the risk of infection.

Investigations

• x-ray of relevant body part pre- and post-reduction (do not wait for an x-ray if it cannot be obtained immediately and there is evidence of neurovascular compromise)
• wound swabs for culture rarely change management (they indicate colonisation rather than infection; even in established infection the organism cultured is not always the causative organism)

Imaging

• plain films confirm the presence of a fracture
• Visible tracking of air from the wound to the fracture on x-ray is also highly suggestive of an open fracture if the wound is distant from the fracture site

Grading systems

The Gustillo-Anderson classification describes open fractures and their risk of infection according to degree of soft tissue injury and contamination:

• Class I —
  <1 cm wound — no evidence of contamination (0-2% infection risk)

• Class II —
  >1 cm wound — moderate contamination (2-5%)

• Class IIIA —
  severe soft tissue injury but adequate bone coverage, highly contaminated (5-10%)

• Class IIIB —
  severe soft tissue injury, massive contamination, bone is exposed and there is periosteal stripping (10-50%)

• Class IIIC —
  same as IIIB but with an  arterial injury requiring repair (25-50%)

The Mangled Extremity Severity Score (MESS) takes into account other factors:

• extent of skeletal and soft-tissue damage
• extent and severity of limb ischemia
• associated shock
• age

Management

Resuscitation

• attend to coexistent life-threatening injuries
• control hemorrhage and correct coagulopathy
  • e.g. direct pressure, tourniquets if in extremis
  • fluid resuscitation, transfusion of packed cells and other blood products as required

Specific treatment

• Assess the limb and seek/treat complications
  • e.g. neurovascular compromise, compartment syndrome, crush injury and rhabomyolysis
• Give antibiotics early (infection increases if delayed >3 hours from time of injury)
• Remove gross contaminants from the wound
• if there will be more than a 1 to 2 hour delay in going to the operating theatre for washout and debridement then clean by profusely irrigating with saline and cover the wound with a sterile dressing (e.g. saline soaked pads; avoid iodine)
• reduce gross deformities using gentle traction and splint the injured limb — this is a top priority if there is neurovascular compromise
• immobilise the limb with a POP backslab and elevate the limb

Antibiotics

• choice depends on local guidelines based on local infection patterns, sensitivities and practicalities.
• Australian Therapeutic Guidelines recommendation for first-line prophylaxis for open fractures is flucloxacillin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly as S. aureus is the most common cause of secondary infection.
• However, most sources suggest broad spectrum antibiotics that cover both gram-positives and gram-negatives, depending on the severity of the injury and degree of contamination. For example:

Grade I/ II

• 1st generation cephalosporin
• e.g. cephazolin 1 g (child: 25 mg/kg up to 1 g) IV, 8-hourly
• e.g. cephalothin 2 g (child: 50 mg/kg up to 2 g) IV, 6-hourly

Grade II/ III

• add an aminoglycoside (e.g. gentamicin)

If heavily contaminated

• add penicillin or metronidazole due to the risk of infection with Clostridum and other anaerobes.
• consider adding doxycycline, or changing to ciprofloxacin, if the wound is heavily contaminated with sea water to cover for Vibrio species.

Supportive care and monitoring

• Give analgesia early; e.g. morphine or fentanyl +/- ketamine for analgesia
• Procedural seadation may be required
• Give tetanus toxoid/ tetanus immunoglobulin if indicated

Disposition

• Consult orthopedics
• Most open fractures can be safely taken to the operating theatre the next day for washout and further management. Previously prevailing dogma, known as the ‘Six Hour Golden Rule’, held that open fractures require operative repair within 6 hours of injury to decrease the risk of osteomyelitis

References and links

LITFL

• Bone and Joint Bamboozler 002 — Broken Open

Journal articles and textbooks

• Lee CK, Hansen SL. Management of acute wounds. Surg Clin North Am. 2009 Jun;89(3):659-76. PMID: 19465203.
• Newton EJ, Love J. Acute complications of extremity trauma. Emerg Med Clin North Am. 2007 Aug;25(3):751-61, iv. PMID: 17826216.