Introduction
Open fractures are a common presentation to A&E, and require urgent assessment and management by the orthopaedic team.
Whilst most of these injuries can be safely managed on next day emergency lists, there are instances where emergency out-of-hours treatment is required. Left untreated, open fractures are associated with high rates of morbidity and mortality.
In this article, we look at the classification, investigations and management of open fractures.
Pathophysiology
A fracture is ‘open’ when there is a direct communication between the fracture site and the external environment. This is most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum.
Fracture may become open by either an “in-to-out” injury, whereby the sharp bone ends penetrate the skin from beneath, or an “out-to-in” injury, whereby a high energy injury (e.g. ballistic injury or a direct blow) penetrates the skin, traumatising the subtending soft tissues and bone.
Whilst any fracture can become open, the most common fractures are tibial, phalangeal, forearm, ankle, and metacarpal.
The outcomes of an open fracture can be considered in the following way:
- Skin – this can range from a very small wound to significant tissue loss, whereby coverage will not be achieved without the aid of plastics surgery (i.e. skin grafting or a local/free flap)
- Soft tissues – this can also range from very little tissue devitalisation to significant muscle/tendon/ligament loss requiring reconstructive surgery
- Neurovascular injury – nerves and vessels may be compressed due to limb deformity, go in to arteriospasm, develop and intimal dissection or be transected altogether
- Infection – the rate of infection is very high following open fracture, due to direct contamination, reduced vascularity, systemic compromise (such as following major trauma) and need for insertion of metalwork for fracture stabilisation
Figure 1 – A Gustilo-Anderson Type 2 Fracture
Clinical Features
Initial resuscitation and suitable management is essential, especially in cases of major trauma.
Patients will present with pain, swelling, and deformity, with an overlying wound or punctum (in severe cases, the bone end may be visible protruding from the wound).
On examination, ensure to check neurovascular status and overlying skin for any skin or tissue loss (Fig. 1). Any evidence of contamination should be assessed for and documented – marine, agricultural, and sewage contamination is of the highest importance.
The need for plastic surgery input should be identified early, to allow both specialties to be present at the first operation and therefore avoid multiple procedures.
Classification of Open Fractures
The Gustilo-Anderson classification can be used to classify open fractures
- Type 1: <1cm wound and clean
- Type 2: 1-10cm wound and clean
- Type 3A: >10cm wound and high-energy, but with adequate soft tissue coverage
- Type 3B: >10cm wound and high-energy, but with inadequate soft tissue coverage
- Type 3C: All injuries with vascular injury
A simple summary in how this can help to guide management is: 3A can be managed by orthopaedics alone, 3B requires plastics input, and 3C requires vascular input
Investigation
All patients with suspected open fractures require basic blood tests, including a clotting screen and a Group & Save.
A plain film radiograph of the affected area(s) will be required (Fig. 2). For very comminuted or complex fracture patterns, a CT-scan can often aid management.
Figure 2 – A radiograph of an Open Galeazzi Fracture
Management
Following suitable resuscitation and stabilisation, urgent realignment and splinting of the limb is warranted. Ensure to re-assess and document the neurovascular status following any realignment or reduction.
Broad-spectrum antibiotic cover should be administered, as per local guidelines, and a tetanus vaccination is required if the patient is not fully up-to-date with their vaccination.
Photograph the wound (Fig. 3) and remove any gross debris. However, an out-of-theatre washout is not indicated, instead the wound should then be dressed with a saline-soaked gauze.
Figure 3 – Ensure to photograph any open fracture, to avoid repeated uncovering of dressings for inspection
Definitive Management
Definitive surgical management requires debridement of the wound and the fracture site, removing all devitalised tissue present. This should happen either immediately if contaminated with marine, agricultural, or sewage material, or <12-24 hours in all other cases
Ensure the wound is washed out with copious volumes of saline. Ensure definitive skeletal stabilisation; if soft tissue coverage is required, this should happen within 72 hours, or as guided by plastic surgeon advice.
If there is vascular compromise, this needs immediate surgical exploration by vascular surgery.
Key Points
- Open fractures are associated with high rates of morbidity and mortality
- The most common fractures that are open are tibial, phalangeal, forearm, ankle, and metacarpal
- Check the overlying area for skin breakdown or tissue loss
- All patients with open fractures need antibiotic cover and up-to-date tetanus vaccination
- Timely surgical management, with input from plastic and vascular surgery as required, will ensure optimal outcomes
