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

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

Prophylactic Antibiotics

Prophylactic Antibiotics for Open fractures

Initiate as soon as possible; increased infection rate when delayed[1]

Grade I & II Fractures Options

  • Cefazolin (Ancef) 2 g IV (immediately and q8 hours x 3 total doses)[2]
  • Cephalosporin allergy: clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[2]

Grade III Fracture Options

  • Ceftriaxone 2 g IV (immediately x 1 total dose) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]
  • Cephalosporin allergy: aztreonam 2 g IV (immediately and q8 hours x 3) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)[2]

Special Considerations

Wound Managment

  • Surgical debridement and washout within 24 hours.
    • Thorough ED irrigation and debridement appears safe for hand (metacarpal, phalanx) fractures without excessive contamination
  • Irrigation may be started in the ED for grossly contaminated wounds
    • Place a sterile dressing over wound to decrease continued contamination
  • Tetanus prophylaxis

Disposition

Admission to ortho or trauma surgery

See Also

External Links

References

  1. Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
  2. 2.0 2.1 2.2 2.3 2.4 Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. Journal of the American Academy of Orthopaedic Surgeons. April 15, 2020. 28(8):309-315
  3. HoffWS, Bonadies JA, Cachecho R, Dorlac WC: East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70:751-754.