Open fracture

Background

• Fractures that have communication with the outside environment are considered open
• The fractured portion does not have to be overtly exposed
• True orthopedic emergency

Clinical Features

• Suspect open fracture with overlying wound regardless of how small
• Free air on x-ray may suggest open fracture in more equivocal cases

Differential Diagnosis

Extremity trauma

• Peripheral nerve injury
• Vascular injury
• Tendon injury
• Laceration
• Fracture
  • Open fracture
• Open joint injury
• Crush syndrome
• Compartment syndrome
• Rhabdomyolysis
• Contusion
• Myositis ossificans

Evaluation

• ATLS
• X-ray
• Trauma labs

Gustillo-Anderson grading scale

• Open fractures can be classified using the Gustillo-Anderson grading scale
  • As the grade increase, so does the risk of infection
  • Grading is based on wound size, neurovascular injury, and contamination

Grade I

• Wound <1cm
• Little soft tissue injury or crush injury
• Moderately clean puncture site
• Infection risk 0-12%

Grade II

• Laceration >1cm
• No extensive soft tissue damage, but slight or moderate crush injury
• Moderate contamination
• Infection risk 2-12%

Grade III

• Extensive damage to soft tissue, including neurovascular structures and muscle
• High degree of contamination
• Infection risk 5-50%
• Further subcategorized:
  • III A: Fracture covered by soft tissue (Infection risk 5-10%)
  • III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%)
  • III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%)

Additional Considerations

• Fracture with non-communicating overlying wound
• Additional sites of injury found in 40-80% of cases
• Nerve, vascular, muscular, and/or ligamentous injury

Management

Pain control

• Fentanyl
• Morphine

Prophylactic Antibiotics

• NNT 12.5 to prevent early fracture site infection

Grade I Fracture Options

• Cefazolin (Ancef) 2g IV three times daily
• Ciprofloxacin 400mg IV BID (avoid in pediatrics)

Grade II/III Fracture Options

• Add Gentamicin 300 mg (1-1.7mg/kg) IV to any of the Grade I regemins
• If concern for Clostridium then consider single drug regimen of Pipericillin/Tazobactam 4.5g (80mg/kg) IV three times daily

Wound Managment

• Surgical debridement and washout
  • Irrigation may be started in the ED for grossly contaminated wounds
• Tetanus prophylaxis

Disposition

Admission to ortho or trauma surgery

See Also

• Fracture (Main)

References

Authors

Neil Young