Open Fractures

Ovid: Handbook of Fractures

Authors: Koval, Kenneth J.; Zuckerman, Joseph D.
Title: Handbook of Fractures, 3rd Edition
> Table of Contents > I – General Considerations > 3 – Open Fractures

Open Fractures
  • An open fracture
    refers to osseous disruption in which a break in the skin and
    underlying soft tissue communicates directly with the fracture and its
    hematoma. A compound fracture refers to the same injury, but this term is archaic.
  • One-third of patients with open fractures are multiply injured.
  • Any wound occurring on the same limb
    segment as a fracture must be suspected to be a consequence of an open
    fracture until proven otherwise.
  • Soft tissue injuries in an open fracture may have three important consequences:
    • Contamination of the wound and fracture by exposure to the external environment.
    • Crushing, stripping, and devascularization that results in soft tissue compromise and increased susceptibility to infection.
    • Destruction or loss of the soft tissue
      envelope may affect the method of fracture immobilization, compromise
      the contribution of the overlying soft tissues to fracture healing
      (e.g., contribution of osteoprogenitor cells), and result in loss of
      function from muscle, tendon, nerve, vascular, ligament, or skin damage.
  • Open fractures result from the application of a violent force. The applied kinetic energy (.5 mv2) is dissipated by the soft tissue and osseous structures (Table 3.1)
  • The amount of osseous displacement and
    comminution is suggestive of the degree of soft issue injury and is
    proportional to the applied force.
  • Patient assessment involves ABCDE: airway, breathing, circulation, disability, and exposure.
  • Initiate resuscitation and address life-threatening injuries.
  • Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
  • Identify all injuries to the extremities.
  • Assess the neurovascular status of injured limb(s).
  • Assess skin and soft tissue damage:
    exploration of the wound in the emergency setting is not indicated if
    operative intervention is planned because it risks further
    contamination with limited capacity to provide useful information and
    may precipitate further hemorrhage.
    • Obvious foreign bodies that are easily accessible may be removed in the emergency room under sterile conditions.
    • Irrigation of wounds with sterile normal saline may be performed in the emergency room if a surgical delay is expected.
    • P.21

    • Sterile injection of joints with saline may be undertaken to determine egress from wound sites to evaluate possible continuity.
      Table 3.1. Energy transmitted by injury mechanism
      Injury Energy (Foot-Pounds)
      Fall from curb 100
      Skiing injury 300–500
      High-velocity gunshot wound (single missile) 2,000
      20-mph bumper injury (assumes bumper strikes fixed target) 100,000
      From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
  • Identify skeletal injury; obtain necessary radiographs.
  • Open fractures are not immune to the
    potentially disastrous consequences of compartment syndrome,
    particularly with severe blunt trauma or crush injuries.
  • Severe pain, decreased sensation, pain to
    passive stretch of fingers or toes, and a tense extremity are all clues
    to the diagnosis. A strong suspicion or an unconscious patient in the
    appropriate clinical setting warrants monitoring of compartment
  • Compartment pressures >30 mm Hg raise
    concern and within 30 mm Hg of the diastolic blood pressure indicate
    compartment syndrome; immediate fasciotomies should be performed.
  • Distal pulses may remain present long after muscle and nerve ischemia and damage are irreversible.
  • An angiogram should be obtained if a vascular injury is suspected.
  • Indications for angiogram include the following:
    • Knee dislocation with ankle-brachial index (ABI) <0.9
    • Cool, pale foot with poor distal capillary refill
    • High-energy injury in an area of compromise (e.g., trifurcation of the popliteal artery)
    • Documented ABI <0.9 associated with a
      lower extremity injury (note: preexisting peripheral vascular disease
      may result in abnormal ABIs; comparison with the contralateral
      extremity may reveal underlying vascular disease)
  • Trauma survey includes a lateral cervical spine film and AP views of the chest, abdomen, and pelvis.
  • Extremity radiographs are obtained as
    indicated by clinical setting, injury pattern, and patient complaints.
    It is important to include the joint above and below an apparent limb
  • P.22

  • Additional studies include CT with or
    without intravenous or oral contrast, cystograms, urethrograms,
    intravenous pyelograms, angiography, and others as indicated clinically.
Gustilo and Anderson (Open Fractures) (Tables 3.2 and 3.3)
Table 3.2. Classification of open fractures
Type Wound Level of Contamination Soft Tissue Injury Bone Injury
I <1 cm long Clean Minimal Simple, minimal comminution
II >1 cm long Moderate Moderate, some muscle damage Moderate comminution
A Usually >10 cm long High Severe with crushing Usually comminuted; soft tissue coverage of bone possible
B Usually >10 cm long High Very severe loss of coverage; usually requires soft tissue reconstructive surgery Bone coverage poor; variable, may be moderate to severe comminution
C Usually >10 cm long High Very severe loss of coverage plus vascular injury requiring repair; may require soft tissue reconstructive surgery Bone coverage poor; variable, may be moderate to severe comminution
fractures, farmyard injuries, fractures occurring in a highly
contaminated environment, shotgun wounds, or high-velocity gunshot
wounds automatically result in classification as type III open
From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.


  • This was originally designed to classify
    soft tissue injuries associated with open tibial shaft fractures and
    was later extended to all open fractures.
  • It is useful for communicative purposes despite variability in interobserver reproducibility.

Grade I: Clean skin opening of <1
cm, usually from inside to outside; minimal muscle contusion; simple
transverse or short oblique fractures
Grade II: Laceration >1 cm long, with
extensive soft tissue damage; minimal to moderate crushing component;
simple transverse or short oblique fractures with minimal comminution
Grade III: Extensive soft tissue damage,
including muscles, skin, and neurovascular structures; often a
high-energy injury with a severe crushing component
IIIA: Extensive soft tissue laceration, adequate bone coverage; segmental fractures, gunshot injuries, minimal periosteal stripping
IIIB: Extensive soft tissue injury
with periosteal stripping and bone exposure requiring soft tissue flap
closure; usually associated with massive contamination
IIIC: Vascular injury requiring repair
Tscherne Classification of Open Fractures
  • This takes into account wound size, level of contamination, and fracture mechanism.

Grade I: Small puncture wound without associated contusion, negligible bacterial contamination, low-energy mechanism of fracture
Grade II: Small laceration, skin and soft tissue contusions, moderate bacterial contamination, variable mechanisms of injury
Grade III: Large laceration with heavy
bacterial contamination, extensive soft tissue damage, with frequent
associated arterial or neural injury
Grade IV: Incomplete or complete
amputation with variable prognosis based on location of and nature of
injury (e.g., cleanly amputated middle phalanx versus crushed leg at
the proximal femoral level)
Tscherne Classification of Closed Fractures
  • This classifies soft tissue injury in closed fractures and takes into account indirect versus direct injury mechanisms.

Grade 0: Injury from indirect forces with negligible soft tissue damage
Grade I: Closed fracture caused by low
to moderate energy mechanisms, with superficial abrasions or contusions
of soft tissues overlying the fracture
Grade II: Closed fracture with
significant muscle contusion, with possible deep, contaminated skin
abrasions associated with moderate to severe energy mechanisms and
skeletal injury; high risk for compartment syndrome
Grade III: Extensive crushing of soft
tissues, with subcutaneous degloving or avulsion, and arterial
disruption or established compartment syndrome


Emergency Room Management
Table 3.3. Factors that modify open fracture classification regardless of initial skin defect
  1. Exposure to soil
  2. Exposure to water (pools, lakes/streams)
  3. Exposure to fecal matter (barnyard)
  4. Exposure to oral flora (bite)
  5. Gross contamination on inspection
  6. Delay in treatment >12 hours
Signs of high-energy mechanism
  1. Segmental fracture
  2. Bone loss
  3. Compartment syndrome
  4. Crush mechanism
  5. Extensive degloving of subcutaneous fat and skin
  6. Requires flap coverage (any size defect)
From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
After initial trauma survey and resuscitation for life-threatening injuries (see Chapter 2):
  • Perform a careful clinical and radiographic evaluation as outlined earlier.
  • Wound hemorrhage should be addressed with direct pressure rather than limb tourniquets or blind clamping.
  • Initiate parenteral antibiosis (see later).
  • Assess skin and soft tissue damage; place a saline-soaked sterile dressing on the wound.
  • Perform provisional reduction of fracture and place a splint.
  • Operative intervention: open fractures
    constitute orthopaedic emergencies, because intervention less than 8
    hours after injury has been reported to result in a lower incidence of
    wound infection and osteomyelitis. In certain centers, there has been a
    move to delay operating on lower-energy open fractures in the middle of
    the night and to treat the injury as the first case of the morning. The
    patient should undergo formal wound exploration, irrigation, and
    debridement before definitive


    fracture fixation, with the understanding that the wound may require multiple debridements.

  • Do not irrigate, debride, or probe the
    wound in the emergency room if immediate operative intervention is
    planned: this may further contaminate the tissues and force debris
    deeper into the wound. If a surgical delay is anticipated, gentle
    irrigation with normal saline may be performed. Only obvious foreign
    bodies that are easily accessible should be removed.
  • Bone fragments should not be removed in the emergency room, no matter how seemingly nonviable they may be.
Antibiotic Coverage for Open Fractures (Table 3.4)
Table 3.4. Intravenous antibiotic therapy for open fracturesa
  Type I Type II Type III Organic Contamination
Cefazolin, 1 g every 8 hours X X X  
Aminoglycoside, 3–5 mg/kg/dayb     X  
Penicillin, 2,000,000 units every 4 hours (or metronidazole, 500 mg every 6 hours)       X
aAntibiotic doses for adult patients.
bVaries with renal function of patient.
From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.

Grade I, II: First-generation cephalosporin
Grade III: Add an aminoglycoside
Farm injuries: Add penicillin and an aminoglycoside
Tetanus prophylaxis should also be given in the
emergency room (see later). The current dose of toxoid is 0.5 mL
regardless of age; for immune globulin, the dose is 75 U for patients
<5 years of age, 125 U for those 5 to 10 years old, and 250 U for
those >10 years old. Both shots are administered intramuscularly,
each from a different syringe and into a different site.
Requirements for Tetanus Prophylaxis

Immunization history dT TIG dT TIG
Incomplete (<3 doses) or not known + + +
Complete/>10 years since last dose + +
Complete/<10 years since last dose –a
Key: +, prophylaxis required;
-, prophylaxis not required; dT, diphtheria and tetanus toxoids; TIG,
tetanus immune globulin; a, required if >5 years since last dose.


Operative Treatment
Irrigation and Debridement
Adequate irrigation and debridement are the most important steps in open fracture treatment:
  • The wound should be extended proximally and distally to examine the zone of injury.
  • The clinical utility of intraoperative cultures has been highly debated and remains controversial.
  • Meticulous debridement should be performed, starting with the skin and subcutaneous fat (Table 3.5).
    Table 3.5. Factors of muscle viability
    Color Normally beefy red; rarely, carbon monoxide exposure can be deceiving
    Consistency Normally firm, not easily disrupted
    Capacity to bleed Can be deceiving because arterioles in necrotic muscle can bleed
    Typically reliable
    Contractility Responsive to forceps pinch or low cautery setting
    Typically reliable
    From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.


    • Large skin flaps should not be developed
      because this further devitalizes tissues that receive vascular
      contributions from vessels arising vertically from fascial attachments.
    • A traumatic skin flap with a
      base-to-length ratio of 1:2 will frequently have a devitalized tip,
      particularly if it is distally based.
    • Tendons, unless severely damaged or contaminated, should be preserved.
    • Osseous fragments devoid of soft tissue may be discarded.
    • Extension into adjacent joints mandates exploration, irrigation, and debridement.
  • The fracture surfaces should be exposed, with recreation of the injury mechanism.
  • Pulsatile lavage irrigation, with or
    without antibiotic solution, should be performed. Some authors have
    demonstrated decreased infection rates with >10 L of irrigation
    under pulsatile lavage.
  • Meticulous hemostasis should be
    maintained, because blood loss may already be significant and the
    generation of clot may contribute to dead space and nonviable tissue.
  • Fasciotomy should be considered, especially in the forearm or leg.
  • Historically, it has been advocated that
    traumatic wounds should not be closed. One should close the surgically
    extended part of the wound only. More recently, certain centers have
    been closing the open wound after debridement with close observation
    for signs or symptoms of sepsis.
  • The wound, if left open, should be
    dressed with saline-soaked gauze, synthetic dressing, a vacuum assisted
    closure (VAC) sponge, or an antibiotic bead pouch.
  • Serial debridement(s) should be performed
    every 24 to 48 hours as necessary until there is no evidence of
    necrotic soft tissue or bone.
Foreign Bodies
Foreign bodies, especially organic ones, must be sought
and removed because they can lead to significant morbidity if they are
left in the wound. (Note: Gunshot injuries are discussed separately.)
  • Wood may become blood soaked and difficult to differentiate from muscle.
  • Cloth and leather are usually found between tissue planes and may be remote from the site of injury.
  • The foreign material itself usually
    incites an inflammatory response, whereas intrinsic crevices may harbor
    pathogenic organisms or spores.
Fracture Stabilization
In open fractures with extensive soft tissue injury,
fracture stabilization (internal or external fixation) provides
protection from additional soft tissue injury, maximum access for wound
management, and maximum limb and patient mobilization. (See individual
chapters for specific fracture management) (Table 3.6).
Table 3.6. Relative indications for type of skeletal fixation in open fractures
External fixation
  1. Severe contamination: any site
  2. Periarticular fractures
    1. Definitive
      • Distal radius
      • Elbow dislocation
      • Selected other sites
    2. Temporizing
      • Knee
      • Ankle
      • Elbow
      • Wrist
      • Pelvis
  3. Distraction osteogenesis
  4. In combination with screw fixation for severe soft tissue injury
Internal fixation
  1. Periarticular fractures
    1. Distal/proximal tibia
    2. Distal/proximal femur
    3. Distal/proximal humerus
    4. Proximal ulnar radius
    5. Selected distal radius/ulna
    6. Acetabulum/pelvis
  2. Diaphyseal fractures
    1. Femur
    2. Tibia
    3. Humerus
    4. Radius/ulna
From Bucholz RW, Heckman JD, Court-Brown C, et al., eds. Rockwood and Green’s Fractures in Adults, 6th ed. Philadelphia: Lippincott Williams & Wilkins, 2006.
Soft Tissue Coverage and Bone Grafting
  • Wound coverage is performed once there is no further evidence of necrosis.
  • The type of coverage—delayed primary
    closure, split-thickness skin graft, rotational or free muscle flaps—is
    dependent on the severity and location of the soft tissue injury.
  • Bone grafting can be performed when the
    wound is clean, closed, and dry. The timing of bone grafting after free
    flap coverage is controversial. Some advocate bone grafting at the time
    of coverage; others wait until the flap has healed (normally 6 weeks).
Limb Salvage
Choice of limb salvage versus amputation in Gustilo
Grade III injuries is controversial. Immediate or early amputation may
be indicated if:
  • The limb is nonviable: irreparable
    vascular injury, warm ischemia time >8 hours, or severe crush with
    minimal remaining viable tissue.
  • Even after revascularization the limb
    remains so severely damaged that function will be less satisfactory
    than that afforded by a prosthesis.
  • The severely damaged limb may constitute
    a threat to the patient’s life, especially in patients with severe,
    debilitating, chronic disease.
  • P.28

  • The severity of the injury would demand
    multiple operative procedures and prolonged reconstruction time that is
    incompatible with the personal, sociologic, and economic consequences
    the patient is willing to withstand.
  • The patient presents with an injury severity score (ISS; see Chapter 2)
    of >20 in whom salvage of a marginal extremity may result in a high
    metabolic cost or large necrotic/ inflammatory load that could
    precipitate pulmonary or multiple organ failure.
  • The expected postsalvage function does not justify limb salvage.
The Mangled Extremity Severity Score (MESS) was designed to predict the likelihood of amputation based on four criteria. A


score of >7 has been reported to predict amputation accurately in both retrospective and prospective studies (Table 3.7).

Table 3.7. Mangled extremity severity score (MESS) for prediction of amputation
A. Skeletal/soft tissue injury Pointsa
1. Low energy (stab, simple fracture, low-velocity gunshot wound) 1
2. Medium energy (open/multiple fractures or dislocations) 2
3. High energy (close-range shotgun, high-velocity gunshot, crush) 3
4. Very high energy (above plus gross contamination, soft tissue avulsion) 4
B. Limb ischemia  
1. Pulse reduced or absent but perfusion normal 1b
2. Pulseless, paresthesias, diminished capillary refill 2b
3. Cool, paralyzed, insensate, numb 3b
C. Shock  
1. Systolic blood pressure always >90 mm Hg 0
2. Hypotensive transiently 1
3. Persistent hypotension 2
D. Age (Years)  
1. <30 0
2. 30–50 1
3. >50 2
aMESS = total points.
bScore doubles for ischemia >6 hours.
  • Infection: Open fractures may result in
    cellulitis or osteomyelitis, despite aggressive, serial debridements,
    copious lavage, appropriate antibiosis, and meticulous wound care.
    Gross contamination at the time of injury is causative, although
    retained foreign bodies, soft tissue compromise, and multisystem injury
    are risk factors for infection.
  • Compartment syndrome: This devastating
    complication results in severe loss of function, especially in tight
    fascial compartments including the forearm and leg. It may be avoided
    by a high index of suspicion with serial neurovascular examinations
    accompanied by compartment pressure monitoring, prompt recognition of
    impending compartment syndrome, and fascial release at the time of

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