Open Fractures Clinical Presentation

Updated: May 30, 2018
  • Author: Thomas M Schaller, MD; Chief Editor: Murali Poduval, MBBS, MS, DNB  more...
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Presentation

History and Physical Examination

Open fractures occur in many ways, and the location and severity of the injury are directly related to the location and magnitude of the force applied to the body. Clearly, this involves a broad spectrum of clinical scenarios.

In the most benign form, an open fracture may involve a very small wound caused by a sharp bone spike, creating a small, minimally contaminated hole in the overlying skin. The opposite end of the spectrum may involve high-velocity gunshot wounds, vehicular trauma, or industrial accidents with associated tissue crushing and devitalization.

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Classification

Gustilo-Anderson classification

Internationally, for adults and pediatric patients, the modified Gustilo-Anderson classification is widely used. [5]  Their initial description was published in 1976, as follows:

  • Type I - Open fracture with a wound less than 1 cm in length, and clean
  • Type II - Open fracture with a laceration more than 1 cm in length, without extensive soft-tissue damage, flaps, or avulsions
  • Type III - Either an open segmental fracture, an open fracture with extensive soft-tissue damage, or a traumatic amputation

The description of type III fractures was subsequently further refined and described by Gustilo et al in 1984, [6]  as follows:

  • Type IIIa - Severe comminution or segmental fractures, but with adequate coverage of bone and a wound that is closeable by simple means
  • Type IIIb - Extensive soft-tissue damage in association with the open fracture, with significant bone exposure and periosteal stripping, typically requiring tissue rotation or free tissue transfer for closure
  • Type IIIc - Any open fracture with an arterial injury that requires repair

It is important to note that the severity of the injury may not be fully appreciated at the time of initial evaluation, and therefore, classification should be based on the intraoperative findings.

Orthopaedic Trauma Association classification

The Orthopaedic Trauma Association (OTA) published a fracture and dislocation classification compendium, according to which open fractures are categorized on the basis of five main variables: skin injury, muscle injury, arterial injury, contamination, and bone loss. [7]

Skin injury is quantified as follows:

  1. Laceration with edges that approximate
  2. Laceration with edges that do not approximate
  3. Laceration associated with extensive degloving

Muscle injury is quantified as follows:

  1. No appreciable muscle necrosis, some muscle injury with intact muscle function
  2. Loss of muscle but the muscle remains functional, some localized necrosis in the zone of injury that requires excision, intact muscle-tendon unit
  3. Dead muscle, loss of muscle function, partial or complete compartment excision, complete disruption of a muscle-tendon unit, muscle defect does not reapproximate

Arterial injury is quantified as follows:

  1. No major vessel disruption
  2. Vessel injury without distal ischemia
  3. Vessel injury with distal ischemia

Contamination is quantified as follows:

  1. None or minimal contamination
  2. Surface contamination (not ground in)
  3. Contaminant embedded in bone or deep soft tissues or high risk environmental conditions (barnyard, fecal, dirty water, etc)

Bone loss is quantified as follows:

  1. None
  2. Bone missing or devascularized bone fragments, but still some contact between proximal and distal fragments
  3. Segmental bone loss

To date, relatively few studies have been done comparing the Gustilo-Anderson and OTA classification systems with regard to prediction of treatment outcomes (eg, infection, limb amputation, need for soft-tissue coverage, or limb salvage). In a retrospective study aimed at examining this question, Hao et al found the OTA system to be better than the Gustilo-Anderson system at predicting postoperative complications and treatment outcomes in patients with open long-bone fractures. [8]  Interobserver reliability appears to be comparable for the two systems. [9]

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