Classifying open fractures

Synonym: compound fracture

What is an open fracture?

An open fracture can be defined as a broken bone that is in communication through the skin with the environment. The amount of communication can vary from a small puncture wound in the skin to a large avulsion of soft tissue that leaves the bone exposed.

Presentation

The diagnosis is usually obvious but may be missed, especially if the puncture wound is very small, or a fracture of the terminal phalanx which is technically open.

Staging

Open fractures were historically classified by Gustilo and Anderson.¹ The classification of open fractures is based on descriptors of the size of the wound and the amount of soft-tissue injury but subjectivity could lead to misclassification. There is also a lack of evidence that correlates classification with outcomes such as infection and amputation rates.

Gustilo and Anderson classification of open fractures

• Type I: clean wound smaller than 1 cm in diameter, appears clean, simple fracture pattern, no skin crushing.

• Type II: a laceration larger than 1 cm but without significant soft-tissue crushing, including no flaps, degloving or contusion. Fracture pattern may be more complex.

• Type III: an open segmental fracture or a single fracture with extensive soft-tissue injury. Also included are injuries older than eight hours. Type III injuries are subdivided into three types:

  • Type IIIA: adequate soft-tissue coverage of the fracture despite high-energy trauma or extensive laceration or skin flaps.

  • Type IIIB: inadequate soft-tissue coverage with periosteal stripping. Soft-tissue reconstruction is necessary.

  • Type IIIC: any open fracture that is associated with vascular injury that requires repair.

The Orthopaedic Trauma Society classification²

• This is based on objective descriptors which are measured after the first surgical excision (or debridement).

• Injuries are broadly classified into 'simple' or 'complex' based on the need for a reconstructive procedure to achieve wound closure.

• Simple fractures require no additional procedures to achieve wound closure.

• Complex fractures need either bone, vascular or soft tissue reconstruction to achieve closure and can be further subdivided into types A-C.

Open fracture treatment³

The aims of management are to prevent infection, ensure healing of the fracture and promote the restoration of function.

• The treatment of open fractures should be considered as an emergency. Adequate fluid/blood replacement, analgesia, splinting, antibiotics and tetanus prophylaxis are required before surgical treatment. Start broad-spectrum antibiotics (eg, IV co-amoxiclav) as soon as possible after injury (certainly within three hours).

• Wounds are handled only to remove gross contaminants (or to obtain a photographic record and to seal from the environment). They are no longer 'provisionally cleaned' or routinely irrigated. Immediate surgical exploration is only indicated if there is gross contamination, a compartment syndrome developing, a devascularised limb or if the patient has multiple injuries.

• Debridement is then performed by orthopaedic and plastic surgeons working together on a scheduled trauma list in normal working hours (within 24 hours of the injury) unless there is marine, agricultural or sewage contamination.

• Associated injuries may be severe and also require urgent treatment.

Surgical

• The most important surgical aspect of care in open fractures includes early and complete debridement of non-viable tissue and stabilisation of the fracture.

• Delayed debridement is associated with increased infection rates.

• Early wound management generally includes the use of antibiotic-impregnated beads and definitive wound closure within one week of injury.

Open fracture complications⁴

• Patients with open fractures are at risk of complications of acute wound infection and osteomyelitis. Infection can result in non-union of the fracture and chronic osteomyelitis. It can also possibly result in the need for amputation.

• There is also a risk of tetanus infection.

• Infection rates vary but remain as high as 20% in severe cases. This risk depends on the degree of associated soft-tissue injury and the initial management of the patient. Infections may be caused by bacteria that contaminate the wound at the time of injury or by hospital-acquired pathogens.

• Complications other than infection, failure of skeletal fixation and non-union of fracture will depend on the location and extent of soft-tissue damage.

• Both neurovascular injury and compartment syndrome can occur.