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 the size and nature of the external wound may not reflect the damage to the deeper structures neurovascular if concern for vascular insult, ankle brachial index (ABI) should be obtained normal ratio is > 0.9 vascular surgery consult and angiogram is warranted if ABI < 0.9 provocative tests consider saline load test or CT scan if concern for traumatic arthrotomy some studies now show CT scan more sensitive than saline load test for the knee 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 I&D should be performed in vast majority of open fractures only exception is low-energy small puncture wound open fracture in children a soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise timing consider I&D as soon as possible ideal time of soft tissue coverage controversial, but most centers perform within 5-7 days techniques emergency room urgent IV antibiotics, tetanus prophylaxis, and extremity stabilization and dressing immediate emergency room care fractures should be stabilized and dressed antibiotics are given with type indicated by injury pattern and location tetanus administration outcomes infection rates of open fracture depend on zone of injury, periosteal stripping and delay in treatment incidence of fracture-related infection range from <1% in type I open fractures to 30% in type III fractures mutlidisciplinary training of open fracture management has been associated with decreased timing to antibiotic administration definitive soft tissue reconstruction and fracture fixation indications once soft tissue coverage is obtained and an adequate sterility is achieved outcomes definitive treatment with internal fixation leads to significantly decreased time to union, improved functional outcomes, and decreased time in the hospital compared to those definitively fixed with external fixation Technique Urgent IV antibiotics, tetanus prophylaxis, extremity stabilization and dressings in the emergency room antibiotics timing 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 for 24 hours after final closure if wound is not closed during initial surgical debridement (48 hours for type III wounds) types Gustilo type I and II 1st generation cephalosporin clindamycin or vancomycin can also be used if allergies exist Gustilo type III 1st generation cephalosporin + aminoglycoside 3rd generation cephalosporin alone used an alternative in recent literature some institutions use vancomycin + cefepime farm injuries, heavy contamination, or possible bowel contamination add high dose penicillin for anaerobic coverage (clostridium) special considerations fresh water wounds fluoroquinolones or 3rd or 4th generation cephalosporin saltwater wounds doxycycline + ceftazidime or a fluoroquinolone tetanus prophylaxis timing initiate in emergency room or trauma bay two forms of prophylaxis toxoid 0.5 mL, regardless of age immunoglobulin < 5 years old receive 75 U 5-10 years old receive 125 U >10 years old receive 250 U toxoid and immunoglobulin should be given intramuscularly with two different syringes in two different locations guidelines for tetanus prophylaxis depend on 3 factors complete or incomplete vaccination history (3 doses) date of most recent vaccination severity of wound extremity stabilization & dressing stabilization splint, brace, or traction for temporary stabilization decreases pain, minimizes soft tissue trauma, and prevents disruption of clots dressing remove gross debris from wound, do not remove any bone fragments place sterile saline-soaked dressing on wound little evidence to support aggressive irrigation or irrigation with antiseptic solution in the ED, as this can push debris further into wound Irrigation & debridement, provisional vs. definitive fixation in operating room irrigation and debridement timing recent meta-analysis (GOLIATH study) have recommended debridement within 24 hours to minimize risk of infection for type III fractures within 12 hours for type IIIB open tibia fractures staged debridement and irrigation perform every 24 to 48 hours as needed technique incision extend wound proximally and distally in line with extremity to adequate expose open fracture irrigation low-pressure bulb irrigation vs. high-pressure pulse lavage studies have shown that low pressure bulb irrigation is less expensive than high pressure pulse lavage and has no difference in infection rates or union rates saline vs. saline with castile soap vs. antibiotic solution studies have shown that saline with castile soap had decreased primary wound healing problems when compared to antibiotic solutions on average, 3L of saline are used for each successive Gustilo type (i.e 9L for type III) debridement thorough debridement of devitalized tissue is critical to prevent deep infection bony fragments without soft tissue attachments should be removed temporary fracture stabilization technique performed at the time of initial debridement external fixation is temporary initial treatment of choice for majority of high energy open fractures of the lower extremity local antibiotic administration indications significantly contaminated wounds with large soft tissue defects large bony defects technique beads made by mixing methylmethacrylate with heat-stable antibiotic powder vancomycin and tobramycin most commonly used soft tissue coverage timing early soft tissue coverage or wound closure is ideal timing of flap coverage for open tibial fractures remains controversial, < 7 days is desired increased risk of infection beyond 7 days odds of infection increase by 16% for each day beyond day 7 early studies demonstrated increased infection with delay beyond 72 hours, however recent studies do not support this finding (LEAP study) studies have not shown any statistical difference between rate of infection when ORIF is performed before fasciotomy closure, at fasciotomy closure, or after fasciotomy closure technique can proceed with bone grafting after wound is clean and closed negative-pressure wound therapy may be utilized during debridement until definitive coverage can be achieved (increased risk of infection if open >7 days) 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 Masquelet technique ("induced-membrane" technique) 2 stage technique 1st stage: I&D, cement spacer and temporizing fixation 2nd stage: placement of bone graft into "induced membrane" and definitive fixation Studies show optimal time frame for bone grafting to be 4-6 weeks after placement of cement spacer distraction osteogenesis vascularized bone flap/transfer 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: blast mechanism of injury acute surgical amputation delay in defintive soft tissue coverage greater than 7 days more severe Gustillo-Anderson classification. 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 Infection rates higher in open injuries due to blunt trauma compared to penetrating trauma