Open fracture

Background

• Fractures that have communication with the outside environment are considered "open".
  • The fractured portion does not have to be overtly exposed.
  • Infection can lead to serious complications including nonunion and osteomyelitis.
• True orthopedic emergency due to increased risk of infection from exposure of bone.
  • Early initial antimicrobial prophylaxis has been shown to reduce the risk of infection (ARR 6.5%, NNT = 16).
  • Antibiotic prophylaxis for >24 hours duration has not been demonstrated to improve outcomes, including for type III open fractures.

Clinical Features

Open fracture of finger wound

Gustilo Type 2 open fracture.

Open fracture grade IIIb, with lateral condyle tibia fracture site exposed.

Type IIIb open fracture of mid leg.

• Fracture with overlying wound suspected of reaching bone (i.e. "communicating"), regardless of how narrow wound may be

Differential Diagnosis

Extremity trauma

• Compartment syndrome
• Contusion
• Crush syndrome
• Degloving injury
  • Morel-Lavallée lesion
  • Ring avulsion injury
• Fracture
  • Open fracture
• Laceration
• Myositis ossificans
• Open joint injury
• Peripheral nerve injury
• Rhabdomyolysis
• Tendon injury
• Vascular injury

Evaluation

• ATLS
• X-ray
  • Shows fracture type
  • Free air on x-ray may suggest open fracture in more equivocal cases (not sensitive)
• Trauma labs

Additional Considerations

• Additional sites of injury found in 40-80% of cases
• Nerve, vascular, muscular, and/or ligamentous injury

Gustilo-Anderson grading scale

As the grade increases, so does the risk of infection

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%)

Management

Pain control

• Typically opioid pain control
  • Fentanyl (preferred initially for trauma patients with concern for possible hemorrhagic shock) or morphine (for longer-acting control)

Prophylactic Antibiotics for Open fractures

Initiate as soon as possible; increased infection rate when delayed

Grade I & II Fractures Options

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

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)
• 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)

Special Considerations

• Concern for clostridium (soil contamination, farm injuries, possible bowel contamination): additionally add penicillin
• Fresh water wounds: fluoroquinolones OR 3rd/4th generation cephalosporin
• Saltwater wounds (vibrio): doxycycline + ceftazidime OR fluoroquinolone

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
• Discharge may be considered for select fractures (e.g. metacarpal, phalanx without excessive contamination), typically after bedside washout by consulting service (e.g. orthopedics)

See Also

• Fracture (Main)