Introduction

Clinical Definition

An open fracture is when the broken bone breaks through the skin or any other body cavity that is open to the outside, including those through the rectum or vagina. 

Classification 

Gustilo and Anderson Classification^1,2

Involve the orthopaedic team and consider including the plastics or vascular team. This is especially vital when addressing the issue of a fracture, adequate soft tissue coverage or blood vessel injury.

Initial Assessment of Open Fracture

ATLS Primary Survey

For all patients with trauma, the initial step should be an ATLS primary survey. The primary survey aims to identify life-threatening injuries in a rapid and systematic manner. This protocol is as follows: 

Location

• According to the BOAST guidelines, “patients with open fractures of long bones, hind foot or midfoot should be taken directly or transferred to a specialist centre that can provide Orthoplastic care.”³
• Assessment and management should follow a specific chronological order, as listed below, to ensure optimal care. 

History 

A focused history should be taken to understand the sequence and mechanism of injury. The most common theme used is the acronym (S)AMPLE.

Antibiotics

• Obtain IV access and give prophylactic IV antibiotics as soon as possible, ideally within 1 hour of injury
• The type of antibiotic depends on local hospital/trust protocol
• Tetanus prophylaxis should also be provided 

Pre-Reduction Examination

• Assess neurological and vascular status at repeated intervals
• A PR or PV exam is mandatory in assessing significant pelvic fractures to ascertain whether these are occult open injuries that may require transfer to a specialist centre
• Maintain a low threshold for suspecting compartment syndrome if clinical signs present

Trauma CT

• NICE guidance suggests that for patients with multiple injuries and blunt major trauma, a whole-body CT +/- angiogram should considered⁴
• If this does not apply, then at minimum, x-rays with anteroposterior and lateral views should be taken of the fracture site, the joint above and the joint below
• CT scan can aid orientation and reduction maneuver used

Removal of Gross Contamination

• Gross contaminants (debris) should be removed as possible but do not perform a “mini washout” of the affected area prior to debridement outside of theatre due to risk of further dissemination of infected debris into the wound⁴

Photographic Evidence

• Medical photographs should be taken on an approved device on key stages during assessment and management e.g. on admission and after reduction

Reduction of the Limb

• Reduce and realign the limb and document post-reduction neurovascular status
• After doing so, splint the limb for stabilisation and bandage with a saline soaked dressing with an occlusive layer to prevent desiccation of wound
• Post-reduction radiographs should also be taken

Secondary Skeletal Survey

A secondary survey should be done once all major threats have been ruled out and the patient has been stabilised. This survey involves a head to perineum/genitalia investigation to investigate for any further significant injuries once life-threatening injuries have been ruled out or managed.

Definitive Management of Open Fractures

Main Complications

The complications of open fractures are very similar to the complications of fractures in general. However, there are a few key complications to note when handling an open fracture. These can be separated into early and late complications⁵:

• Early Complications
  • Surgical site infection
  • Blood loss
  • Compartment syndrome
• Late Complications
  • Osteomyelitis
  • Delayed union, mal-union or non-union

Summary of Open Fracture Assessment and Management

1. ATLS primary survey
2. SAMPLE history (Symptoms, Allergies, Medications, Past medical history, Last meal, Events)
3. IV antibiotics and tetanus prophylaxis
4. Pre-reduction neurovascular examination (if compartment syndrome suspected then follow protocol)
5. Pre-reduction imaging (radiographs + CT)
6. Removal of gross contaminants (do not perform a “washout”)
7. Photographs (required pre-reduction, post-reduction and other key stages)
8. Reduction of limb + splinting 
9. Post-reduction checklist
   1. Bandage with saline soaked dressing with occlusive layer
   1. Neurovascular status 
   1. Imaging of reduced limb
10. Secondary survey 
11. Definitive management 
    1. Pre-operative preparation
    1. Initial debridement with definitive soft tissue coverage

Written by Dr Hiu Ching Kelvin Gao (FY1) & reviewed by Mr Jack Clark (Orthopaedic Registrar)