Open fracture

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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

NNT 12.5 to prevent early fracture site infection[1]

Grade I Fracture Options

Grade II/III Fracture Options

  • Add Gentamicin 300 mg (1-1.7mg/kg) IV to any of the Grade I regemins
    • Once daily dosing has been shown to be safe and effective
  • If concern for Clostridium (soil contamination, farm injuries) then consider single drug regimen of Pipericillin/Tazobactam 4.5g (80mg/kg) IV TID

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

External Links

References

  1. Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.