Basics
Description
- Continuity between skin violation and fracture site, ranging from a puncture wound to grossly exposed bone
- Surgical urgency, as delays in care increase risk of infection and rate of complications
- Predisposition to complications in certain patients:
- Massive soft tissue damage
- Severe wound contamination
- Compromised vascularity
- Fracture instability
- Compromised host (diabetes, vascular disease)
Etiology
Open fractures typically result from significant blunt force or penetrating trauma.
Diagnosis
Signs and Symptoms
- Deformity with nearby violation in skin integrity
- Neurovascular compromise may occur.
- Additional traumatic injuries are frequently present.
History
Significant trauma
Physical Exam
- Complete neurologic and vascular exam
- Examine thoroughly for other traumatic injuries.
Essential Workup
- Plain radiographs including joints above and below the affected area
- Guided workup based on mechanism and evidence of other traumatic injuries
Diagnosis Tests & Interpretation
Lab
- CBC, chemistry panel, coagulation studies for large-bone (femur, pelvis) fractures or multiple-trauma victims
- Type and screen or type and cross-match for potential of significant blood loss.
- Pred ©bridement and postd ©bridement cultures have limited value and are not recommended.
Imaging
Doppler or angiography if vascular damage is suspected:
- Posterior knee dislocation
- Ischemic extremity
- Massive soft tissue injury in high-risk areas
Diagnostic Procedures/Surgery
- Measurement of compartment pressures if concern for compartment syndrome
- Consider arthrogram by intra-articular injection of saline or methylene blue if joint involvement is suspected.
- Angiography if noninvasive techniques are inadequate for ruling out vascular compromise
Differential Diagnosis
Noncontiguous laceration/abrasion
Treatment
Pre-Hospital
- Moist, sterile dressings over open wounds
- Immobilize joints above and below fracture.
- Control bleeding with local compression.
- Consider tourniquet for traumatic amputations or uncontrollable hemorrhage.
- Longitudinal traction of involved extremity if distal pulses absent
Initial Stabilization/Therapy
- Management of ABCs.
- Gentle reduction and immobilization of fracture
Ed Treatment/Procedures
- Intravenous access
- Keep patient NPO
- Tetanus vaccination, if needed
- Antibiotics reduce the incidence of early infection in open fractures and should be given early in the ED course.
- Minimize number of times dressing is removed to avoid secondary contamination.
- Examine limb regularly for compartment syndrome and neurovascular status.
- Certain large joint open fracture/dislocations should be reduced emergently in the ED (ankle, elbow, knee)
- Urgent orthopedic consultation for formal irrigation, d ©bridement, and possible operative fixation.
- Vascular surgery consultation for injuries with potential vascular damage
Medication
- Cefazolin: 1-2 g (peds: 20 mg/kg IM/IV)
- Add gentamicin: 1.5-2 mg/kg IV for more extensive injuries and highly contaminated wounds (peds: 2-2.5 mg/kg IV)
- Add penicillin G: 4-5 million U IV in farmyard injuries, vascular injuries, and in wounds at risk of contamination with Clostridium (peds: 50,000 U/kg IV)
- Tetanus booster: 0.5 mL IM
- Tetanus immunoglobulin: 250 IU IM if not previously immunized against tetanus
- Morphine sulfate: 2-10 mg (peds: 0.05-0.1 mg/kg per dose IV or equivalent analgesic)
DTaP booster for children <7 yr of age
Follow-Up
Disposition
Admission Criteria
Most patients will be admitted for irrigation, d ©bridement, IV antibiotics, and possibly operative fixation.
Discharge Criteria
Simple open fractures may be washed out and immobilized in the ED after consultation with an orthopedic surgeon. The patient should be discharged with oral antibiotics.
Issues for Referral
Most open fractures will require emergent orthopedic consultation and may require trauma team evaluation for other injuries.
Followup Recommendations
Patients discharged from the emergency department should be followed up with an orthopedic surgeon in 1-2 days.
Pearls and Pitfalls
- Open fractures are surgical urgencies requiring prompt orthopedic consultation.
- 40-70% of patients with open fractures have other traumatic injuries.
- Prompt and thorough ED assessment and treatment can significantly decrease morbidity in patients with open fractures.
Additional Reading
- Bucholz RW, Heckman JD, Court-Brown CM, Tornetta P. Rockwood and Greens Fractures in Adults, 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2010.
- Hauser CJ, Adams CA Jr,Eachempati SR, etal. Surgical Infection Society guideline:Prophylactic antibiotic use in open fractures: An evidence-basedguideline. Surg Infect(Larchmt). 2006;7(4):379-405.
- Okike K, Bhattacharyya T. Trends in the management of openfractures. A critical analysis. J Bone Joint Surg Am. 2006;88(12):2739-2748.
- Schenker ML, Yannascoli S, Baldwin KD, et al. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012;94(12):1057-1064.
Codes
ICD9
- 818.1 Ill-defined open fractures of upper limb
- 827.1 Other, multiple and ill-defined fractures of lower limb, open
- 829.1 Fracture of unspecified bone, open
- 828.1 Open multiple fractures involving both lower limbs, lower with upper limb, and lower limb(s) with rib(s) and sternum
ICD10
- S52.90XB Unsp fracture of unsp forearm, init for opn fx type I/2
- S82.90XB Unsp fracture of unsp lower leg, init for opn fx type I/2
- T14.8 Other injury of unspecified body region
SNOMED
- 439987009 Open fracture of bone (disorder)
- 50531009 Open fracture of lower limb (disorder)
- 18336000 Open fracture of upper limb (disorder)