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Management of open Fracture
Prepared By :
Dr: Bader Abu Hadi
Definition
 Break in the skin and underlying soft tissue leading

directly into or communicating with the fracture and its
hematoma.
 Any wound occurring on the same limb segment as a
fracture must be suspected to be aconsequence of an
open fracture until proven otherwise.
Epidemiology
 3% of all limb fractures
 21.3 per 100,000 per year
Open fracture classification
 Allows comparison of results

 Provides guidelines on prognosis and treatment
 Fracture healing, infection and amputation rate correlate
with the degree of soft tissue injury
 Gustilo upgraded to Gustilo and Anderson
 AO open fracture classification
Gustilo and Anderson Classification
Model is tibia, however

applied to all types of open
fractures
Emphasis on wound size
Crush injury assoc with small wounds
Sharp injury assoc with large wounds
Better to emphasize
Degree of soft tissue injury
Degree of contamination
Type 1 Open Fractures
 Wound less than 1 cm

 Inside-out injury
 Clean wound
 Minimal soft tissue damage
 No significant periosteal stripping
Type 2 Open Fractures
Moderate soft tissue damage

Outside-in
wound 1cm -10cm
Higher energy
Some necrotic muscle
Some periosteal stripping
Type 3a Open Fractures
 High energy
 Outside-in
 wound size more 10 cm
 Extensive muscle devitalization
 Bone coverage with existing soft tissue
Type 3b Open Fractures
 High energy
 Outside in
 Extensive muscle devitalization
 Requires a flap for bone coverage and
soft tissue closure
 Periosteal stripping
Type 3c Open Fractures
 High energy
 Increased risk of amputation and
infection
 Any grade 3 with
major vascular injury requiring repair
Why use this classification?
Grades of soft tissue injury correlates with

infection and fracture healing
Grade 1 2 3A 3B 3C
Infection
0-2% 2-7% 10-25% 10-50% 25-50%
Rates
Fracture
Healing 21-28 28-28 30-35 30-35
(weeks)
Amputation
50%
Rate
 Fractureclassification should most reliably
done in the operation room at the
completion of primary wound care and
debridement.
CLINICAL EVALUATION
1. Patient assessment involves ABCDE: airway, breathing, circulation, disability, and

exposure.
2. Initiate resuscitation and address life-threatening injuries.
3. Evaluate injuries to the head, chest, abdomen, pelvis, and spine.
4. Identify all injuries to the extremities.
5. Assess the neurovascular status of injured limb(s).
6. Assess skin and soft tissue damage: Exploration of the wound in the emergency
setting is not
indicated if operative intervention is planned because it risks further contamination
with limited
capacity to provide useful information and may precipitate further hemorrhage.
■ Obvious foreign bodies that are easily accessible may be removed in the emergency
room under
sterile conditions.
■ Irrigation of wounds with sterile normal saline may be performed in the emergency
room if asignificant surgical delay is expected.
■ Computed tomography (CT) scan has been shown to be an effective method to
assess traumatic
arthrotomy. Air on CT in the presence of an open wound is diagnostic for traumatic
Radiological Examination
 MRI and CT scans are rarely required in the acute

situation but may be helpful in open pelvic, intra-
articular, carpal, and tarsal fractures.
 Angiography may be required in Gustilo IIIb or IIIc
fractures.
 In the polytraumatized patient, the surgeon must
decide if a delay for further imaging is appropriate.
Goals of treatment
 1. preserve life
 2. preserve limb
 3. preserve function
Also….
 Prevent infection
 Fracture stabilization
 Soft tissue coverage

Management in the Emergency Room
Fracture management begins after initial trauma survey

and resuscitation is complete
o initiate early IV antibiotics and update tetanus prophylaxis as indicated
o direct pressure will control active bleeding
o do not blindly clamp or place tourniquets on damaged extremities
Assessment
o soft-tissue damage
o neurovascular exam
Dressing
o remove gross debris from wound
o place sterile saline-soaked dressing on the wound
Stabilize
o splint fracture for temporary stabilization decreases pain, further injury
from bone ends, and disruption of clots
Management in the operative Room
 Aggressive debridement and irrigation
 saline shown to be most effective irrigating agent
 on average, 3L of saline are used for each successive Gustilo type
• Type I: 3L
• Type II: 6L
• Type III: 9L
bony fragments without soft tissue attachment can be removed
Management in the operative Room
Fracture stabilization
can be with internal or external fixation, as indicated
Staged debridement and irrigation
perform every 24 to 48 hours as needed
Early soft
tissue coverage or wound closure is idial
Antibiotic Treatment
 Gustilo Type I and II

1st generation cephalosporin
clindamycin or vancomycin can also be used if allergies exist
 Gustilo Type III
1st generation cephalsporin and aminoglycoside
 Farm injuries or possible bowel contamination
add penicillin for anaerobic coverage (clostridium)
Antibiotic Treatment
 Duration
initiate as soon as possible
 studies show increased infection rate when antibiotics are delayed for more
than 3 hours from time of injury
 continue for 24 hours after initial injury if wound is able to be closed
primarily
 continue until 24 hours after final closure if wound is not closed during
initial surgical debridement
Tetanus Prophylaxis
 Initiate in emergency room

 Two forms of prophylaxis
toxoid dose 0.5 mL, regardless of age
immune globulin dosing
 <5-years-old receives 75U
 5-10-years-old receives 125U
 >10-years-old receives 250U
Tetanus Prophylaxis
toxoid and immunoglobulin should give intramuscularly

with two different syringes in two different locations
Guidelines for tetanus prophylaxis depend on
3 factors
o complete or incomplete vaccination
history (3 doses)
o date of most recent vaccination
o severity of wound
Contraindications to primary closure
 Inadequate debridement
 Gross contamination
 Farm related or freshwater immersion injuries
 Delay in treatment >12 hours
 Delay in giving abx
 Compromised host or tissue viability
Types of fracture stabilization
 Splint
 Good option if operative fixation not required
 Internal fixation
 Wound is clean and soft tissue coverage
available
 External fixation
 Dirty wounds or extensive soft tissue injury
How to decide, salvage or amputation of limb?
complications
 Infection
 delayed union
 nonunion,
 malunion
 loss of function
Gunshot injuries
 wounding capability of a bullet directly related to its kinetic

energy . damage
caused by
 passage of missile
 secondary shock wave
 Cavitation
fractures may be caused even without direct impact
Classification
 Low velocity <350 meters per second or < 2,000 feet

per second ( most handguns)
 Intermediate velocity highly variable depending on
distance from target 350-500 meters per second
(shotgun blasts )
 High velocity >600 meters per second or >2,000 feet
per second as military (assault) and hunting rifles
Classification
 Gunshut fracures comparable to Gustillo-Anderson

Type III regardless of size
 high risk of infection
 Bullets lodged in joints should be removed to avoid
lead arthropathy and systemic lead poisoning
Presentation
 Symptoms
pain, deformity , bleeding
 Physical exam
perform careful neurovascular exam
clinical suspicion for compartment syndrome
secondary to increased muscle edema from higher
velocity trauma
 examine and document all associated wounds
massive bone and soft tissue injuries occur even with

low velocity weapons
Evaluation
 Radiographs
identify bone involvement and fracture pattern
 CT scan
identify potential intra-articular missile
detect hollow viscus injury that may communicate with
fracture .
high index of suspicion for pelvis or spine fractures
 Ct angiography
Treatment
 Treatment in emergency as open
fracture
 Treat open fractures from low velocity
GSW as closed fractures
 ORIF/external fixation
unstable fracture pattern in low-velocity
gunshot injury
 external fixation
high-velocity gunshot wounds

Soft tissues and vascular injury
Treatment Joint gunshot
 arthrotomy
indications
intra-articular missile
may lead to local inflammation, arthritis and lead
intoxication (plumbism)
complications
 Infection
 delayed union, nonunion, malunion and loss of function
 Lead intoxication (plumbism)
may be caused by intra-articular missile

systemic effects include
neurotoxicity
anemia
emesis and abdominal colic
Thank you

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Management of open Fracture

 Break in the skin and underlying soft tissue leading

 Allows comparison of results

Model is tibia, however

 Wound less than 1 cm

Moderate soft tissue damage

Grades of soft tissue injury correlates with

1. Patient assessment involves ABCDE: airway, breathing, circulation, disability, and

 MRI and CT scans are rarely required in the acute

 Soft tissue coverage

Fracture management begins after initial trauma survey

 Gustilo Type I and II

 Initiate in emergency room

toxoid and immunoglobulin should give intramuscularly

 wounding capability of a bullet directly related to its kinetic

 Low velocity <350 meters per second or < 2,000 feet

 Gunshut fracures comparable to Gustillo-Anderson

massive bone and soft tissue injuries occur even with

high-velocity gunshot wounds

may be caused by intra-articular missile

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