Open fractures

by Maritz Laubscher, Michael Held & Marc Nortje

---

Introduction

Open fractures, also known as compound fractures, are fractures with a direct communication to the external environment. A wound in the proximity of a fracture should be managed as an open fracture until proven otherwise. Open fractures often occur through high energy mechanisms and are often associated with additional injuries. Common sites for open fractures are the tibia (most common open long bone fracture), ankle, phalanges, metacarpals and forearm.

Approach to open fractures

1. ATLS: Life before limb – ABCDEs, direct pressure on wound to limit bleeding (part of secondary survey).
2. Grading a fracture (Gustilo-Anderson classification): Extent of contamination, soft tissue coverage (need for flap) and presence of vascular injury are defining features when grading the fracture.



Grade	Wound Size (cm)	Soft tissue damage, fracture comminu- tion and contamination
I	<1	Minimal
II	1–10	Moderate
III	> 10	Severe
A		Adequate soft tissue cover
B		Soft tissue coverage requires a flap
C		Associated arterial inju- ry requiring surgery



3. Early antibiotics and analgesia:

Antibiotics Early antibiotics most important intervention to prevent infection. Studies shown delay more than 3h from injury increases infection rate.

• Grade 1 and 2: Narrow spectrum antibiotic covering skin commensals (gram positive organisms). Local preference – cefazolin (1st generation cephalosporin) for 48 hours.
• Grade 3 Broad spectrum cover required, including cover for gram negative organisms. Local preference
• early treatment with co-amoxiclav or cefazolin, gentamycin (and metronidazole in case of farmyard injury) for 5 days.
• Tetanus toxoid 0.5 ml subcutaneous.

Analgesia

4. Irrigation and dressing: As part of preparation for theatre, the wound should be cleaned with brief irrigation and sterile saline dressing should be applied. Dressing should be undisturbed until the patient is taken to theatre. Photographic documentation of the wound facilitates communication with other teams.
5. Neurovascular check: Reassess the neurovascular status.
6. Reduce and immbolise (with repeat neurovascular exam): Reduce and immobilise with a splint to reduce pain and limit further soft tissue injury.
7. Refer to orthopaedics: Patients must be referred to orthopaedic surgeon – obtain consent, keep NPO, X-rays etc.

During surgery

Increased time to debridement does not increase infection rates, providing initial treatment was adequate (early antibiotics and sterile dressing).

• Debridement: Removal of all foreign matter and excision of dead and devitalised tissue.
• No benefit shown to using other irrigation fluids like soap or antiseptic solutions. Any bony fragments which are not attached to soft tissue should be removed.
• External fixation allows maintenance of the fracture reduction while giving full and easy access to the soft tissue and wound care.
• In a hospital where the expertise or equipment is not available, open fractures can be debrided and a back slab applied. Select open fractures with clean wounds can be internally fixed in the first sitting, providing the expertise are available.
• Open fractures with clean, minor wounds can be closed primarily following initial debridement. If the wound is not closable or contaminated, it is better left open and a sterile vacuum assisted closure dressing applied.

Post-surgery

Patients should be reassessed in 24–48 hours for a change in dressing and assessment for further debridement. If the wound is clean, it may be closed by appropriate means. If not clean, further debridement is done and a pus swab is taken. The patient would be taken back to theatre as often as required until skin closure can be done.

Relook surgery

On relook surgery, the fracture is then treated on its merits. Options include:

1. Definitive external fixation.
2. Conversion of temporary external fixation to internal fixation.