Open Fractures

Pathophysiology

• Open fractures can either occur due to a spike of fractured bone puncturing the skin ('inside-out' injury) or due to laceration of the skin from tearing or penetrating injury ('outside-in' injury)

• The higher the energy of the injury, the amount of contamination, any delay in appropriate treatment and problems with wound closure increases the risk of infection

• The presence of a concomitant vascular injury raises the risk of amputation

• The Gustilo classification describes the degree of contamination, the size of the wound, whether the would would be able to be closed or require plastic surgery cover, and the presence of an associated vascular injury

Gustilo–Anderson Classification

• Type I: Clean wound <1 cm

• Type II: Wound 1–10 cm without extensive soft-tissue damage

• Type III: Extensive soft-tissue damage, high contamination
• IIIA: adequate soft tissue remains
• IIIB: periosteal stripping, flap required
• IIIC: arterial injury requiring repair

Investigations

• X-ray - AP and lateral views

Management

• Open fractures should be managed expediently to prevent infection at the fracture site

Immediate management

• Direct pressure if bleeding

• Reduce dislocation

• Remove macroscopic debris

• Photograph and cover with sterile or antiseptic-soaked dressing to prevent further contamination

• Stabilise

• Assess neurovascular status before and after reduction

Prophylaxis

• Broad-spectrum antibiotics within 3 hours of injury
• IV flucloxacillin for gram-positive cover
• IV gentamicin for gram-negative cover
• IV metronidazole to cover anaerobes if there is soil contamination

• Tetanus vaccine/immunoglobin
• If history unknown and uncontaminated, vaccinated >10 years ago (clean injury) or vaccinated >5 years ago (contaminated injury) → vaccine only
• If contaminated and history unknown/ < 3 prior doses → vaccine and Ig

Further management

• Open fractures require fairly prompt surgery

• Surgical removal of all contamination and excision of non-viable soft tissue - debridement
• Dead/devitalized tissue can harbour infection as the immune system is unable to access the devascularised tissues

• Stabilization with internal/external fixation
• An unstable fracture may produce a haematoma - acts as a culture medium for bacteria and may cause additional necrosis
• Delayed union more common due to high energy mechanism
• Frequent wound inspections needed

• Wound closure
• If the wound is not grossly contaminated and all remaining skin and muscle is viable, and if the wound can be closed without undue tension on the skin edges, the wound can be closed primarily
• Any wound tension may result in skin necrosis and wound breakdown
• Any wound which cannot be closed primary requires either skin grafting, local flap coverage or even free flap coverage from plastic surgery

• If there is doubt over the viability of the soft tissues or the wound is heavily contaminated, the wound is left open for 48 hours and then patient returned to theatre for further debridement and closure (secondarily or with plastic surgical flap coverage and/or skin grafting)