High Yield Topics

Open Fractures

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Ovid: 5-Minute Orthopaedic Consult

Editors: Frassica, Frank J.; Sponseller, Paul D.; Wilckens, John H.
Title: 5-Minute Orthopaedic Consult, 2nd Edition
> Table of Contents > Open Fractures

Open Fractures
Theodore T. Manson MD
Basics
Description
  • Open fractures are defined as situations in which the fracture site communicates with the outside environment.
    • The bone does not need to protrude from the skin for the injury to be an open fracture.
    • Any full-thickness skin laceration in the zone of fracture injury is considered an open fracture.
  • Open fractures can be classified by the Gustilo-Anderson system (1).
    • Type I: Low-energy fracture with a clean wound <1 cm long
    • Type II: Low- to medium-energy fracture with a laceration >1 cm long but without extensive soft-tissue damage
    • Type III:
      • High-energy fracture
      • Segmental fractures, gunshot injuries
      • More extensive soft-tissue devitalization than in type II
      • Type IIIA: Adequate soft-tissue coverage of bone
      • Type IIIB: Inadequate soft-tissue coverage of bone, fractures that need rotational or free flap coverage
      • Type IIIC: Fracture with an arterial injury
Risk Factors
Bones with thin soft-tissue envelopes (such as the
tibia) are more likely to present with open fracture than bones
well-protected with soft tissue (such as the femur).
Pathophysiology
  • Treatment of open fractures is based on preventing infection and stabilizing the injured bone.
    • Infection is promoted by:
      • Bacterial contamination of wound
      • Devitalized muscle and bone
      • Dead space
      • Foreign material
Associated Conditions
  • Many open injuries occur in the setting of multitrauma.
    • Follow ATLS protocol (2):
    • Palpate and examine every joint and the spine to assess for additional injury.
Diagnosis
Signs and Symptoms
  • Patients often are involved in high-energy trauma, although open fractures can occur via low-energy mechanisms.
  • Follow ATLS protocols.
History
  • When did the injury occur?
  • What was the mechanism (i.e., high or low energy)?
  • Was the limb exposed to:
    • Barnyard contamination?
    • Marine or freshwater contamination?
    • Oil or grease?
Physical Exam
  • The physician must 1) diagnose the open fracture and then 2) follow a general fracture physical examination.
  • Diagnosing an open fracture:
    • Bone protruding from skin (not required)
    • Fat or blood oozing from a laceration
    • Laceration in the zone of injury, which can be large in high-energy fractures
  • General examination for fractures:
    • Palpate joint above and below injury as well as every other joint in body.
    • Assess vascular viability of limb and damaged soft tissues.
      • Pulses or arterial brachial indices
      • Color and capillary refill of contused skin and muscle
    • Presence or absence of:
      • Periosteal stripping
      • Gross contamination with foreign material
      • Compartment syndrome
    • Neurologic motor and sensory examinations
Tests
Lab
Most patients with open fractures require operative treatment and should have a full set of preoperative labs.
Imaging
  • Imaging should be appropriate for the fracture site.
    • Usually AP and lateral radiographs of the bone in question and of the joints proximal and distal to the injury
    • CT scan is indicated for some fracture patterns but should not delay surgical débridement and stabilization.
Diagnostic Procedures/Surgery
If the limb is swollen or if the neurologic examination is not intact, compartment pressures should be monitored.
Differential Diagnosis
  • Sometimes a laceration is present on a fractured extremity that does not communicate with the fracture.
  • However, it is always prudent to assume that a laceration in the zone of fracture injury indicates an open fracture.
Treatment
Initial Stabilization
  • After being stabilized according to ATLS guidelines, patients should have:
    • The wound covered with a sterile dressing
    • The extremity splinted
    • Antibiotics administered (see “Medication” section)
    • Tetanus prophylaxis as indicated
  • The clinician should ensure that exposures of the wound to viewing are kept to a minimum.
General Measures
  • The goals of treatment are to prevent infection and restore musculoskeletal function.
  • Antibiotic therapy and prompt débridement and stabilization are the hallmarks of open fracture treatment.
    • Antibiotics as prophylaxis to infection is indicated in all cases.
    • Operative débridement is indicated in almost all cases.
    • Stabilization by fracture-specific implants is indicated in most cases.
Activity
Patient activity levels are governed by the fracture type.
Nursing
Fractured extremities should be elevated on pillows.
Special Therapy
Physical Therapy
Physical therapy after fracture repair is individualized to attain joint ROM and muscular strength.
Medication
  • Parenteral and oral narcotics are used for pain control.
  • Parenteral antibiotics are essential on presentation to the emergency room (3).
First Line
  • Antibiotics should be used to limit infection.
    • In general, antibiotics are continued 24–72 hours after the last surgical procedure, depending on the severity of the fracture.
    • Parenteral 1st-generation cephalosporin or clindamycin for all open fractures
    • Add aminoglycosides for type III fractures.
    • Ampicillin or penicillin should be used when anaerobes may be present.
      • Farm injuries
      • Vascular injuries
      • Extensive muscle necrosis
Second Line
  • Other antibiotics are used on a situational basis:
    • Quinolones, aztreonam, or 3rd-generation
      cephalosporins can be used as substitutes for aminoglycosides for type
      III fractures, but they are not as effective.
    • Culture-specific antibiotics are used for documented postoperative infections.

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Surgery
  • The key to effective treatment is meticulous débridement.
  • The goal is a clean wound with viable tissues and no infection.
    • Irrigate the wound (usually 6–10 L of saline) to decrease bacterial load and remove foreign material.
    • Débride skin and subcutaneous tissues back to bleeding edges.
    • Débride nonviable muscle based on assessment of muscle color, circulation, contraction, and consistency.
    • Débride cortical bone fragments that are devoid of soft-tissue attachments.
    • Most open fracture wounds should not be closed initially (4).
    • The timing of the closure of open-fracture wounds is controversial.
      • Many type I and some type II wounds can be closed primarily after débridement.
      • A repeat débridement in 24–48 hours with delayed wound closure is in general a safe practice.
      • Larger, devitalized wounds may require
        the assistance of plastic surgeons for soft-tissue coverage, including
        rotational and free flaps.
    • Fracture stabilization helps minimize infection risk and maximizes functional recovery.
      • Implant choice depends on fracture location and severity.
      • Staged treatment with an initial external fixator may reduce tissue inflammation in the early injury phase (5).
      • Later, definitive fixation may involve intramedullary nailing or plate fixation (6).
Follow-up
  • Follow-up depends on the type of fracture and the severity of the wound.
  • Wounds should be assessed for advancing erythema and drainage.
Disposition
  • Most open fractures are treated operatively.
    • Adults: Typically within 6–24 hours of injury
    • Pediatric patients: Within 6–24 hours of injury (7)
Issues for Referral
All open fractures should be seen by an orthopaedic surgeon on presentation.
Complications
  • Complications and prognosis are related to fracture type and location but include (1):
    • Infection:
      • Type I: 2%
      • Type II: 2–10%
      • Type III: 10–50% depending on the subtype and location
    • Osteomyelitis
    • The occurrence of nonunion increases with the amount of periosteal stripping.
    • Malunion
    • Arthritis
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 analysis. J Bone Joint Surg 1976;58A: 453–458.
2. American
College of Surgeons Committee on Trauma. Advanced Trauma Life Support
Program for Doctors, 6th ed. Chicago: American College of Surgeons,
1997.
3. Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg 2003;11:212–219.
4. Weitz-Marshall AD, Bosse MJ. Timing of closure of open fractures. J Am Acad Orthop Surg 2002;10: 379–384.
5. Roberts
CS, Pape HC, Jones AL, et al. Damage control orthopaedics: evolving
concepts in the treatment of patients who have sustained orthopaedic
trauma. Instr Course Lect 2005;54: 447–462.
6. Nowotarski
PJ, Turen CH, Brumback RJ, et al. Conversion of external fixation to
intramedullary nailing for fractures of the shaft of the femur in
multiply injured patients. J Bone Joint Surg 2000;82A:781–788.
7. Skaggs DL, Friend L, Alman B, et al. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg 2005;87A:8–12.
Additional Reading
Castillo
RC, Bosse MJ, MacKenzie EJ, et al. Impact of smoking on fracture
healing and risk of complications in limb-threatening open tibia
fractures. J Orthop Trauma 2005;19:151–157.
Norris BL, Kellam JF. Soft-tissue injuries associated with high-energy extremity trauma: principles of management. J Am Acad Orthop Surg 1997;5: 37–46.
Miscellaneous
Codes
ICD9-CM
Depends on fracture location
Patient Teaching
  • Compared with closed fractures, open fractures:
    • Take longer to heal
    • Have higher rates of nonunion
    • Have higher rates of infection and osteomyelitis
  • Limbs with open fractures may develop compartment syndrome.
  • Treatment may require staged interventions.
  • Multiple surgeries may be needed to clean a dirty wound.
  • Wound closure may require rotational or free muscle flaps.
FAQ
Q: What is the risk of infection after open fracture?
A: The risk depends on the grade of injury. Patients who smoke or have chronic illnesses have higher infection rates.

Q: How long do open fractures take to heal?
A:
Although a closed long-bone fracture generally heals in 10–14 weeks,
time to healing for an open fracture can be much longer and depends on
the amount of soft-tissue damage and bone loss.

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