Open fracture


  • 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).[1]
    • Antibiotic prophylaxis for >24 hours duration has not been demonstrated to improve outcomes, including for type III open fractures.[2]

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


  • 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%)


Pain control

Prophylactic Antibiotics for Open fractures

Initiate as soon as possible; increased infection rate when delayed[3]

Grade I & II Fractures Options

  • Cefazolin (Ancef) 2 g IV (immediately and q8 hours x 3 total doses)[4]
  • Cephalosporin allergy: clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)[4]

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)[4]
  • 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)[4]

Special Considerations

Wound Managment [6]

  • 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


  • 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

External Links


  1. The NNT. Accessed 4/23/2022.
  2. Dunkel N, Pittet D, Tovmirzaeva L, et al: Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection. Bone Joint J 2013;95-B:831-837.
  3. Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
  4. 4.0 4.1 4.2 4.3 4.4 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
  5. 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.
  6. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y). 2017;12(2):119-126.