Open fractures

by Maritz Laubscher, Michael Held & Marc Nortje

Learning objectives

  1. Recognise and grade an open fracture.
  2. Understand the basic (non-surgical) management of an open fracture.


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.

Open tib/fib fracture
Open tib/fib fracture (Image source: Dr K Laubscher)

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.

  3. 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

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


  6. 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.
  7. Neurovascular check: Reassess the neurovascular status.
  8. Reduce and immbolise (with repeat neurovascular exam): Reduce and immobilise with a splint to reduce pain and limit further soft tissue injury.
  9. 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).


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.


  1. Walters J, editor. Orthopaedics: A guide for practitioners. Cape Town: UCT; 2010.
  2. Chang Y, Bhandari M, Zhu KL, et al. Antibiotic Prophylaxis in the Management of Open Fractures. JBJS Rev. 2019;7(2):e1. doi:10.2106/JBJS. RVW.17.00197

Modified images:

  1. Open fracture. Aavailable from: File:Open_fracture_01.JPG