Summary Open fractures are fractures with direct communication to the external environment. Diagnosis is made clinically by assessing the size and nature of the external wound as well as obtaining radiographs of the bone at the location of the soft tissue injury. Treatment depends on location of fracture but generally requires immediate IV antibiotics and urgent irrigation and debridement followed by surgical fixation as needed. Epidemiology Incidence common 30.7 per 100,000 persons per year Demographics average age is 45 years old Anatomic location tibia and finger phalanx are most common Etiology Pathophysiology mechanism of injury high-energy trauma "inside-out" open fractures Associated conditions often associated with additional injuries (30%) compartment syndrome the presence of an open wound does not preclude the occurrence of compartment syndrome in the injured limb Classification Gustilo classification Tscherne classification Presentation History obtain information regarding mechanism, location, and timing of injury obtain history regarding preexisting psychiatric disorders preexisting depression is an independent predictor of complications patients with preexisting psychiatric disorders experience less improvement in physical and emotional function following skeletal trauma depression and substance abuse are the most common psychiatric disorders in polytraumatized patients Physical exam inspection assess soft-tissue damage login to view 1 more bullet neurovascular if concern for vascular insult, ankle brachial index (ABI) should be obtained login to view 2 more bullets provocative tests consider saline load test or CT scan if concern for traumatic arthrotomy login to view 1 more bullet Imaging Radiographs indications obtain radiographs including joint above and below fracture CT indications peri-articular injuries evaluation for traumatic arthrotomy of the knee Treatment Operative urgent IV antibiotics, irrigation & debridement, provisional vs. definitive fixation indications login to view 3 more bullets timing login to view 2 more bullets techniques login to view 5 more bullets outcomes login to view 3 more bullets definitive soft tissue reconstruction and fracture fixation indications login to view 1 more bullet outcomes login to view 1 more bullet Technique Urgent IV antibiotics, tetanus prophylaxis, extremity stabilization and dressings in the emergency room antibiotics timing login to view 4 more bullets types login to view 14 more bullets tetanus prophylaxis timing login to view 1 more bullet two forms of prophylaxis login to view 7 more bullets guidelines for tetanus prophylaxis depend on 3 factors login to view 3 more bullets extremity stabilization & dressing stabilization login to view 2 more bullets dressing login to view 3 more bullets Irrigation & debridement, provisional vs. definitive fixation in operating room irrigation and debridement debridement can be within 24 hours unless the wound is grossly contaminated or significantly large login to view 4 more bullets technique login to view 11 more bullets temporary fracture stabilization technique login to view 2 more bullets local antibiotic administration indications login to view 2 more bullets technique login to view 2 more bullets soft tissue coverage timing login to view 6 more bullets technique login to view 2 more bullets Definitive soft tissue reconstruction and fracture fixation no critical bone defect open reduction and internal fixation or intramedullary treatment depending on fracture location and morphology critical bone defect technique login to view 7 more bullets Complications Surgical site infection incidence fracture-related infection ranges from <1% in type I open fractures to 30% in type III fractures Osteomyelitis incidence ranges between 1.8% to 27% depending on the bone involved and fracture characteristics. the tibia is the most common site of post-surgical osteomyelitis following surgical treatment of open fractures risk factors include: login to view 4 more bullets Depression Increased risk of developing depression after open tibia fracture Pre-existing depression may worsen outcomes after fracture Neurovascular injury Compartment syndrome Prognosis To minimize risk of infection, debridement recommended to be performed within 24 hours for all type III fractures and within 12 hours for type IIIB open tibia fractures Contamination with dirt and debris and devitalization of the soft tissues increase the risk of infection and other complications Gross contamination will need operatively debrided in a much shorter time period, generally 6-12 hours Infection rates higher in open injuries due to blunt trauma compared to penetrating trauma Blunt force open fractures and ballistic fractures are associated with increased deep infection rates when they involve the tibia