Pathophysiology
- Open fractures can either occur due to a spike of fractured bone puncturing the skin ('inside-out' injury) or due to laceration of the skin from tearing or penetrating injury ('outside-in' injury)
|
Penetrating |
Secondary |
| Mechanism |
Out > in |
In > out |
| Energy |
High |
Moderate |
| Wound |
Variable |
Usually small |
| Contamination |
Variable |
Minimal |
- The higher the energy of the injury, the amount of contamination, any delay in appropriate treatment and problems with wound closure increases the risk of infection
- The presence of a concomitant vascular injury raises the risk of amputation
- The Gustilo classification describes the degree of contamination, the size of the wound, whether the would would be able to be closed or require plastic surgery cover, and the presence of an associated vascular injury
Investigations
- X-ray: AP and lateral views
Management
- Open fractures should be managed expediently to prevent infection at the fracture site
Immediate management
- Direct pressure if bleeding
- Reduce dislocation
- Remove macroscopic debris
- Photograph and cover with sterile or antiseptic-soaked dressing to prevent further contamination
- Stabilise
- Assess neurovascular status before and after reduction
Prophylaxis
- Broad-spectrum antibiotics within 3 hours of injury
- IV flucloxacillin for gram-positive cover
- IV gentamicin for gram-negative cover
- IV metronidazole to cover anaerobes if there is soil contamination
- Tetanus vaccine/immunoglobin
- If history unknown and uncontaminated, vaccinated >10 years ago (clean injury) or vaccinated >5 years ago (contaminated injury) → vaccine only
- If contaminated and history unknown/ < 3 prior doses → vaccine and Ig