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
- 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
Workup
- ATLS
- X-ray
- Trauma labs
Management
Pain control
- Fentanyl
- Morphine
Antibiotics
- Prompt antibiotics (NNT 16)
- Grade I
- Cefazolin (Ancef) 2g IV
- Grade II or III
- Cefazolin (Ancef) 2g IV AND Gentamicin 300 mg (1-1.7mg/kg) IV
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
External Links
Sources
Uptodate Gustilo, RB et al. Prevention of infection in the treatment of 1,025 open fractures of long bones: retrospective and prospectivel. JBJS. 1976;58A(4)453-458. http://www.ncbi.nlm.nih.gov/pubmed/14974035