Open Fractures: Classification, Emergency Management, and Surgical Treatment

Open Fractures: A Critical Orthopedic Emergency

Open fractures represent some of the most challenging injuries in orthopedic trauma, characterized by a broken bone that communicates with the external environment through a breach in the skin. These injuries demand immediate, systematic management due to their high risk of infection, delayed healing, and potential limb-threatening complications. The Gustilo-Anderson classification system serves as the gold standard for assessing injury severity and guiding treatment decisions.

The Gustilo-Anderson Classification System

This widely adopted classification system categorizes open fractures based on wound size, contamination level, and soft tissue damage:

1. Grade I

• Wound Characteristics: Clean wound <1 cm in length
• Tissue Damage: Minimal soft tissue injury
• Contamination: Little to no contamination
• Clinical Significance: Lowest infection risk (0-2%)

2. Grade II

• Wound Characteristics: Laceration 1-10 cm in length
• Tissue Damage: Moderate soft tissue damage
• Contamination: Moderate contamination
• Clinical Significance: Infection risk 2-7%

3. Grade III (Subdivided into IIIA, IIIB, IIIC)

• Wound Characteristics: >10 cm wound or any size with:
  • High-energy trauma
  • Extensive contamination (farmyard/marine)
  • Segmental fractures
  • Traumatic amputations

Subclassifications:

• IIIA: Adequate soft tissue coverage possible
• IIIB: Requires flap coverage due to extensive soft tissue loss
• IIIC: Vascular injury requiring repair (highest amputation risk)

Emergency Department Management Protocol

Primary Survey (ATLS Protocol)

1. Airway with cervical spine protection
2. Breathing and ventilation assessment
3. Circulation with hemorrhage control
4. Disability (neurological status)
5. Exposure (complete trauma survey)

Fracture AssessmentSecondary Survey: Focused Orthopedic Assessment

• History Taking:
  • Mechanism of injury (high vs. low energy)
  • Environmental exposure (soil, water, farmyard)
  • Tetanus immunization status
  • Time since injury
• Physical Examination:
  • Visual Inspection:
    • Photograph wound before dressing
    • Cover with sterile saline-soaked dressing
    • Note any skin tenting or degloving
  • Palpation:
    • Assess for crepitus
    • Evaluate soft tissue integrity
  • Neurovascular Assessment:
    • Document distal pulses (Doppler if needed)
    • Motor/sensory examination

Immediate Interventions

• Antibiotic Therapy:
  • First-line: Cefuroxime 1.5g IV q8h
  • Penicillin allergy: Clindamycin 600mg IV q6h
  • Heavy contamination: Add Gentamicin 1.5mg/kg IV q8h
• Tetanus Prophylaxis:
  • Tetanus toxoid if immunization status uncertain
• Wound Management:
  • Remove gross contaminants only
  • Avoid aggressive irrigation in ED
  • Maintain moist sterile dressing
• Fracture Stabilization:
  • Anatomic reduction if neurovascular compromise
  • Splint application (plaster or prefabricated)

Definitive Surgical Management

Surgical Timing Guidelines

• Emergency (<6 hours):
  • Vascular compromise
  • Gross contamination (marine/farmyard)
  • Compartment syndrome
• Urgent (<24 hours):
  • All other open fractures
  • Tibial fractures (higher complication risk)

Surgical Principles: The 7 Critical Steps

1. Preoperative Preparation
   • General anesthesia
   • Tourniquet application (deflatable)
   • “Pre-scrub” with warm saline/chlorhexidine
   • Nailbrush for embedded debris
2. Radical Debridement
   • Extend wound to visualize entire “zone of injury”
   • Sequential tissue layer assessment:
     • Skin: Excise 1-2mm of wound edges
     • Fat/Fascia: Remove non-viable tissue
     • Muscle: Judge by “4 Cs”:
       1. Color (pink/red viable)
       2. Contractility (pinch test)
       3. Consistency (firm vs. mushy)
       4. Capacity to bleed
     • Bone: Perform “tug test” for fragments
   • Irrigation: 6L warmed saline (low pressure)
3. Fracture Stabilization
   • Internal Fixation Options:
     • Intramedullary nailing (diaphyseal fractures)
     • Plate fixation (periarticular fractures)
   • External Fixation Indications:
     • Severe contamination
     • Polytrauma patients
     • Planned staged reconstruction
4. Wound Closure Decision Making
   • Primary Closure Criteria:
     1. Healthy patient (no comorbidities)
     2. Complete debridement
     3. No farmyard/marine exposure
     4. Tension-free approximation
   • Delayed Closure:
     • Vacuum-assisted closure (VAC) dressing
     • Gentamicin bead pouch for contaminated cases
5. Second-Look Procedures
   • 48-hour re-exploration for:
     • Questionable tissue viability
     • High-grade injuries
     • Heavy initial contamination
6. Soft Tissue Reconstruction (Reconstructive Ladder)
   • Options in Ascending Complexity:
     1. Secondary intention healing
     2. Primary closure
     3. Skin grafting (split-thickness)
     4. Local flaps (e.g., gastrocnemius flap)
     5. Regional flaps
     6. Free tissue transfer (e.g., latissimus dorsi)
7. Bone Defect Management
   • Acute Options:
     • Cement spacer with antibiotics
     • Acute shortening (especially upper limb)
   • Staged Reconstruction:
     • Masquelet technique
     • Bone transport (Ilizarov method)

Complications and Their Prevention

Early Complications

• Infection:
  • Superficial (5-15%)
  • Deep (3-10%)
  • Osteomyelitis (1-5%)
• Compartment Syndrome
• Acute Vascular Compromise

Late Complications

• Nonunion (5-20%)
• Malunion
• Chronic Osteomyelitis
• Post-traumatic Arthritis

Preventive Strategies

• Strict adherence to antibiotic protocols
• Meticulous surgical technique
• Early soft tissue coverage (<7 days)
• Multidisciplinary approach (ortho/plastics)

Special Considerations

High-Risk Scenarios

• Farmyard Injuries:
  • Add penicillin for anaerobes
  • Consider hyperbaric oxygen
• Marine Injuries:
  • Add doxycycline for Vibrio coverage
  • More aggressive debridement
• Ballistic Injuries:
  • Different debridement philosophy
  • Often require external fixation

Pediatric Open Fractures

• Higher healing potential
• More conservative debridement
• Earlier weight-bearing

Rehabilitation and Follow-up

Postoperative Care

• IV antibiotics for 24-72 hours
• VAC dressing changes q48-72h
• Early physical therapy (non-weight bearing)

Monitoring Schedule

• Weekly for first month
• Monthly until union
• Annual long-term follow-up for infection surveillance

Conclusion: Keys to Successful Management

1. Time is Tissue: Expedite debridement (<24h)
2. Team Approach: Orthopedic + plastic surgery
3. Aggressive Debridement: The foundation of success
4. Stable Fixation: Enables soft tissue healing
5. Early Coverage: <7 days reduces infection

For Further Reference:

• AAOS Clinical Practice Guidelines
• Gustilo Classification (Wikipedia)
• Journal of Orthopedic Trauma