Open Fractures

Question 1

Define open fracture

Answer 1

Direct communication between fracture site and the external environment.

Often through the skin, but can also be to vagina or rectum e.g. in pelvic fracture.

Question 2

How can fractures become open?

Answer 2

In-to-out injury where sharp bone ends penetrate skin from beneath.

Out-to-in whereby high-energy injury penetrates skin.

Question 3

Most common fractures to be open.

Answer 3

Tibial

Phalangeal

Forearm

Ankle

Metacarpal

Question 4

Complications

Answer 4

Skin defect needing skin graft

Soft tissue injury of muscle, tendon or ligament

Neurovascular injury

Infection

Question 5

Clinical features

Answer 5

Initial resuscitation and suitable management is essential.

Pain, swelling and deformity with an overlying wound or punctum.

Question 6

Examination findings

Answer 6

Check neurovascular status and overlying skin for any skin or tissue loss.

Check for contamination like marine, agricultural or sewage contaminations.

Question 7

Classification system for open fractures

Answer 7

Gustilo-Anderson classification

Question 8

Explain Gustilo-Anderson classification

Answer 8

Type 1 - <1cm wound and clean

Type 2 - 1-10 cm wound and clean

Type 3A - >10 cm wound and high-energy but with adequate soft tissue coverage

Type 3B - >10 cm wound and high-energy but with inadequate soft tissue coverage

Type 3C - All injuries with vascular injury

Question 9

Ix

Answer 9

Blood test + coag and G&S

Plain x-ray of affected areas

If very comminuted or complex a CT-scan may be warranted

Question 10

Initial management

Answer 10

Resus and stabilisation

Urgent realignment and splinting of the limb

Re-assess and document the neurovascular status following realignment or reduction.

Broad-spectrum abx + tetanus vaccination

Photograph the wound and remove any gross debris.

Question 11

Definitive management

Answer 11

Debridement of the wound
This should happen within 12-24 hours or immediately if there is marine, agricultural or sewage contamination.

Ensure wound is washed out with saline.

Ensure definitive skelatal stabilisation.

If soft tissue coverage is required this should happen within 72 hours or as guided by plastic surgeon advice.

If there is vascular compromise this needs immediate surgical exploration by vascular surgeon.