Open Fractures

Question 1

What is an open fracture?

Answer 1

Direct communication between the fracture site and the external environment
-Most often through the skin, however pelvic fractures may be internally open, having penetrated into the vagina or rectum

Question 2

How can a fracture become open?

Answer 2

In-to-out injury - sharp bone ends penetrate the skin from beneath
Out-to-in injury - high energy injury penetrates the skin, traumatising the subtending soft tissues and bone

Question 3

What are the most common open fractures?

Answer 3

Tibial, phalangeal, forearm, ankle and metacarpal

Question 4

What are the possible outcomes of skin in an open fracture?

Answer 4

Ranges from small wound to significant tissue loss, whereby coverage will not be achieved without the aid of plastics surgery - skin grafting or flap

Question 5

What are the possible outcomes for soft tissues in open fracture?

Answer 5

Very little tissue devitalisation to significant muscle/tendon/ligament loss requiring debridement and reconstructive surgery

Question 6

What are the outcomes for neurovasculature?

Answer 6

Nerves and vessels may be compressed due to deformity or transected completely

Question 7

What is the main concern following open fracture and why does this occur? How is it managed?

Answer 7

Infection due to direct contamination, reduced vascularity, systemic compromise (following major trauma), need for insertion of metalwork for fracture stabilisation
Managed with broad spectrum antibiotic cover and tetanus vaccination

Question 8

How do patients present with open fracture?

Answer 8

Pain, swelling, deformity with an overlying wound or puncture
If severe, bone end may be visible protruding from the wound

Question 9

What should be assessed in an open fracture?

Answer 9

Neurovascular status
Overlying skin/tissue loss
Evidence of contamination

Question 10

What classification system is used to classify open fractures?

Answer 10

Gustilo-Anderson

Question 11

Describe the Gustilo-Anderson classification

Answer 11

Type 1: <1cm wound and clean
Type 2: 1-10cm wound and clean
Type 3A: >10cm wound and high energy, but with adequate soft tissue overage
Type 3B: >10cm wound and high energy, but with inadequate soft tissue coverage
Type 3C: Vascular injury

Question 12

How are type 3 fractures managed?

Answer 12

3A: orthopaedics alone
3B: Plastics input
3C: Vascular input

Question 13

What investigations would you carry out for an open fracture

Answer 13

Bedside - temperature, BP
Bloods - FBC, clotting screen, group and save
Imaging - plain film radiograph, CT
Special

Question 14

What is the initial management of an open fracture?

Answer 14

Resuscitation and stabilisation
Realignment and splinting of the limb
Reassess NV status following realignment or reduction
Broad spectrum antibiotic cover
Tetanus vaccination is required if the patient is not up to date
Photograph the wound
Remove any gross debris
Dress with saline soaked gauze

Question 15

What is the definitive management of an open fracture

Answer 15

Debridement of the wound and the fracture site removing all devitalised tissue present
- immediately if contaminated with marine, agricultural or sewage or 12-24 hours in other cases
Wash out wound with saline
Definitive skeletal stabilisation
If soft tissue coverage is required, within 72 hours or as guided by plastics
If there is vascular compromise, this needs immediate surgical exploration by vascular surgery