Practice Essentials

The procedure for evaluation and management of open fractures is best described as a set of principles that has evolved over time, often in relation to advances in wartime care of military personnel. These principles involve both initial management and subsequent surgical intervention.^{[1, 2, 3, 4]}

The first step is accurate diagnosis and documentation of the mechanism of injury. Appropriate coverage of the wound and splinting of the fracture are performed in conjunction with initiation of appropriate antibiotic therapy and tetanus prophylaxis. Broad coverage for gram-positive organisms with the addition of gram-negative coverage for higher-grade injuries has become the most common choice for initiation of antibiotic therapy after an open fracture.

Urgent surgical intervention typically follows and involves both soft-tissue and bone management. Adjuncts to the care of open fractures have evolved and often involve delivery of antibiotics or metabolically important substances to the local fracture environment.

These principles are generally well established and accepted across the orthopedic community, but in some respects, controversy still exists regarding the details.

For more information, see the following topics:

Pathophysiology

The risk of a fracture being open is related to the amount of soft-tissue coverage in that region of the body and to the amount of energy imparted to that region. For example, the tibia has a long medial aspect that is subcutaneous, and therefore, it is “easier” for trauma to the lower leg to expose the bone and fracture site. Conversely, the femur is surrounded by thick muscle layers circumferentially and, therefore, is less likely to be exposed after a similar amount of force to the thigh.

Open fractures pose some unique risks beyond those encountered with similar closed fractures that may occur with similar amounts of force. The greatest problem is the risk of infection. Diaphyseal bone loss in excess of 3 cm presents a complex set of problems as well. If the open fracture was caused by penetrating trauma, direct injury to major neurovascular structures may be more likely, thereby affecting the prognosis for limb function.

Direct inoculation of the tissue is a basic issue in the pathophysiology of open fracture management. Furthermore, bacteria can colonize wounds at later stages of care, being introduced into the wound at subsequent dressing changes or repeat debridements prior to definitive wound closure. Gustilo and Anderson reported that 50.7% of their 158 patients had a positive wound culture upon initial evaluation.^[5] Another 31 patients that were initially culture-negative had a subsequent positive culture at the time of their definitive closure.

Devitalized tissue results from the energy imparted to the body. A crushing injury can impair the local immune response, with local ischemia playing a large role in this process. Ischemia may also occur by direct trauma to the large vessels and/or microcirculation. Important indirect causes of ischemia include increased myofascial compartment pressures, increased vascular permeability, and the use of vasoconstrictive medications during resuscitation.

Clinical Presentation

Rajasekaran S, Devendra A, Ramesh P, Dheenadayalan J, Kamal CA. Initial management of open fractures. Tornetta P III, Ricci WM, Ostrum RF, McQueen MM, McKee MD, Court-Brown CM, eds. Rockwood and Green’s Fractures in Adults. 9th ed. Philadelphia: Wolters Kluwer; 2020. Vol 1: Chap 15.
Scherl SA, Kay RM. Management of the multiply injured child. Waters PM, Skaggs DL, Flynn JM, eds. Rockwood and Wilkins’ Fractures in Children. 9th ed. Philadelphia: Wolters Kluwer; 2020. Chap 4.
Mosheiff R. Open fractures. Buckley RE, Moran CG, Apivatthakakul T, eds. AO Principles of Fracture Management. 3rd ed. New York: Thieme; 2017. Chap 4.2.
Diwan A, Eberlin KR, Smith RM. The principles and practice of open fracture care, 2018. Chin J Traumatol. 2018 Aug. 21 (4):187-192. [QxMD MEDLINE Link].
Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun. 58 (4):453-8. [QxMD MEDLINE Link].
Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug. 24 (8):742-6. [QxMD MEDLINE Link].
Orthopaedic Trauma Association: Open Fracture Study Group. A new classification scheme for open fractures. J Orthop Trauma. 2010 Aug. 24 (8):457-64. [QxMD MEDLINE Link].
Hao J, Cuellar DO, Herbert B, Kim JW, Chadayammuri V, Casemyr N, et al. Does the OTA Open Fracture Classification Predict the Need for Limb Amputation? A Retrospective Observational Cohort Study on 512 Patients. J Orthop Trauma. 2016 Apr. 30 (4):194-8. [QxMD MEDLINE Link].
Ghoshal A, Enninghorst N, Sisak K, Balogh ZJ. An interobserver reliability comparison between the Orthopaedic Trauma Association's open fracture classification and the Gustilo and Anderson classification. Bone Joint J. 2018 Feb. 100-B (2):242-246. [QxMD MEDLINE Link].
American College of Surgeons Trauma Programs. Advanced Trauma Life Support. American College of Surgeons. Available at http://www.facs.org/trauma/atls/index.html. 2022; Accessed: April 28, 2022.
Okike K, Bhattacharyya T. Trends in the management of open fractures. A critical analysis. J Bone Joint Surg Am. 2006 Dec. 88 (12):2739-48. [QxMD MEDLINE Link].
Johnson EN, Burns TC, Hayda RA, Hospenthal DR, Murray CK. Infectious complications of open type III tibial fractures among combat casualties. Clin Infect Dis. 2007 Aug 15. 45 (4):409-15. [QxMD MEDLINE Link].
Neubauer T, Bayer GS, Wagner M. Open fractures and infection. Acta Chir Orthop Traumatol Cech. 2006 Oct. 73 (5):301-12. [QxMD MEDLINE Link].
Stewart DG Jr, Kay RM, Skaggs DL. Open fractures in children. Principles of evaluation and management. J Bone Joint Surg Am. 2005 Dec. 87 (12):2784-98. [QxMD MEDLINE Link].
Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, et al. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg Am. 2005 Jan. 87 (1):8-12. [QxMD MEDLINE Link].
Hubbard EW, Riccio AI. Pediatric Orthopedic Trauma: An Evidence-Based Approach. Orthop Clin North Am. 2018 Apr. 49 (2):195-210. [QxMD MEDLINE Link].
Mooney JF 3rd, Argenta LC, Marks MW, Morykwas MJ, DeFranzo AJ. Treatment of soft tissue defects in pediatric patients using the V.A.C. system. Clin Orthop Relat Res. 2000 Jul. 26-31. [QxMD MEDLINE Link].
Court-Brown CM, Biant LC, Clement ND, Bugler KE, Duckworth AD, McQueen MM. Open fractures in the elderly. The importance of skin ageing. Injury. 2015 Feb. 46 (2):189-94. [QxMD MEDLINE Link].
Koval KJ, Lurie J, Zhou W, Sparks MB, Cantu RV, Sporer SM, et al. Ankle fractures in the elderly: what you get depends on where you live and who you see. J Orthop Trauma. 2005 Oct. 19 (9):635-9. [QxMD MEDLINE Link].
Clement ND, Beauchamp NJ, Duckworth AD, McQueen MM, Court-Brown CM. The outcome of tibial diaphyseal fractures in the elderly. Bone Joint J. 2013 Sep. 95-B (9):1255-62. [QxMD MEDLINE Link].
Tampe U, Widmer LW, Weiss RJ, Jansson KÅ. Mortality, risk factors and causes of death in Swedish patients with open tibial fractures - a nationwide study of 3, 777 patients. Scand J Trauma Resusc Emerg Med. 2018 Jul 25. 26 (1):62. [QxMD MEDLINE Link].
Toole WP, Elliott M, Hankins D, Rosenbaum C, Harris A, Perkins C. Are low-energy open ankle fractures in the elderly the new geriatric hip fracture?. J Foot Ankle Surg. 2015 Mar-Apr. 54 (2):203-6. [QxMD MEDLINE Link].
Patzakis MJ, Harvey JP Jr, Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am. 1974 Apr. 56 (3):532-41. [QxMD MEDLINE Link].
Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthop Surg. 2003 May-Jun. 11 (3):212-9. [QxMD MEDLINE Link].
Samai K, Vilella A. Update in Therapeutics: Prophylactic Antibiotics in Open Fractures. J Trauma Nurs. 2018 Mar/Apr. 25 (2):83-86. [QxMD MEDLINE Link].
Takahara S, Tokura T, Nishida R, Uefuji A, Ichimura K, Nishihara H, et al. Ampicillin/sulbactam versus cefazolin plus aminoglycosides for antimicrobial prophylaxis in management of Gustilo type IIIA open fractures: A retrospective cohort study. Injury. 2022 Apr. 53 (4):1517-1522. [QxMD MEDLINE Link].
Sudduth JD, Moss JA, Spitler CA, Pham VH, Jones LC, Brown JT, et al. Open Fractures: Are We Still Treating the Same Types of Infections?. Surg Infect (Larchmt). 2020 Nov. 21 (9):766-772. [QxMD MEDLINE Link].
Chang Y, Bhandari M, Zhu KL, Mirza RD, Ren M, Kennedy SA, et al. Antibiotic Prophylaxis in the Management of Open Fractures: A Systematic Survey of Current Practice and Recommendations. JBJS Rev. 2019 Feb. 7 (2):e1. [QxMD MEDLINE Link].
Messner J, Papakostidis C, Giannoudis PV, Kanakaris NK. Duration of Administration of Antibiotic Agents for Open Fractures: Meta-Analysis of the Existing Evidence. Surg Infect (Larchmt). 2017 Nov/Dec. 18 (8):854-867. [QxMD MEDLINE Link].
Stennett CA, OʼHara NN, Sprague S, Petrisor B, Jeray KJ, Leekha S, et al. Effect of Extended Prophylactic Antibiotic Duration in the Treatment of Open Fracture Wounds Differs by Level of Contamination. J Orthop Trauma. 2020 Mar. 34 (3):113-120. [QxMD MEDLINE Link].
Garner MR, Sethuraman SA, Schade MA, Boateng H. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. J Am Acad Orthop Surg. 2020 Apr 15. 28 (8):309-315. [QxMD MEDLINE Link].
Vanvelk N, Chen B, Van Lieshout EMM, Zalavras C, Moriarty TF, Obremskey WT, et al. Duration of Perioperative Antibiotic Prophylaxis in Open Fractures: A Systematic Review and Critical Appraisal. Antibiotics (Basel). 2022 Feb 23. 11 (3):[QxMD MEDLINE Link]. [Full Text].
Rhee P, Nunley MK, Demetriades D, Velmahos G, Doucet JJ. Tetanus and trauma: a review and recommendations. J Trauma. 2005 May. 58 (5):1082-8. [QxMD MEDLINE Link].
Govender S, Csimma C, Genant HK, Valentin-Opran A, Amit Y, Arbel R, et al. Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg Am. 2002 Dec. 84 (12):2123-34. [QxMD MEDLINE Link].
Jones AL. Recombinant human bone morphogenic protein-2 in fracture care. J Orthop Trauma. 2005 Nov-Dec. 19 (10 Suppl):S23-5. [QxMD MEDLINE Link].
Trueta J. Reflections on the past and present treatment of war wounds and fractures. Mil Med. 1976 Apr. 141 (4):255-8. [QxMD MEDLINE Link].
Lin DL, Kirk KL, Murphy KP, McHale KA, Doukas WC. Evaluation of orthopaedic injuries in Operation Enduring Freedom. J Orthop Trauma. 2004 May-Jun. 18 (5):300-5. [QxMD MEDLINE Link].
Radotra I, Azimi DY, Maamoun W. The use of smartphone-application based medical photography for open fractures: A national survey of orthoplastic affiliated Major Trauma Centres in England. Injury. 2022 Mar 5. [QxMD MEDLINE Link].
Anglen JO, Apostoles S, Christensen G, Gainor B. The efficacy of various irrigation solutions in removing slime-producing Staphylococcus. J Orthop Trauma. 1994 Oct. 8 (5):390-6. [QxMD MEDLINE Link].
Petrisor B, Jeray K, Schemitsch E, Hanson B, Sprague S, Sanders D, et al. Fluid lavage in patients with open fracture wounds (FLOW): an international survey of 984 surgeons. BMC Musculoskelet Disord. 2008 Jan 23. 9:7. [QxMD MEDLINE Link].
Crowley DJ, Kanakaris NK, Giannoudis PV. Debridement and wound closure of open fractures: the impact of the time factor on infection rates. Injury. 2007 Aug. 38 (8):879-89. [QxMD MEDLINE Link].
FLOW Investigators, Bhandari M, Jeray KJ, Petrisor BA, et al. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. N Engl J Med. 2015 Dec 31. 373 (27):2629-41. [QxMD MEDLINE Link].
Cross WW 3rd, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop. 2008 Oct. 42 (4):377-86. [QxMD MEDLINE Link]. [Full Text].
Pollak AN. Timing of débridement of open fractures. J Am Acad Orthop Surg. 2006. 14 (10 Spec No.):S48-51. [QxMD MEDLINE Link].
Schenker ML, Yannascoli S, Baldwin KD, Ahn J, Mehta S. Does timing to operative debridement affect infectious complications in open long-bone fractures? A systematic review. J Bone Joint Surg Am. 2012 Jun 20. 94 (12):1057-64. [QxMD MEDLINE Link].
Mener A, Staley CA, Lunati MP, Pflederer J, Reisman WM, Schenker ML. Is Operative Debridement Greater Than 24 Hours Post-admission Associated With Increased Likelihood of Post-operative Infection?. J Surg Res. 2020 Mar. 247:461-468. [QxMD MEDLINE Link].
Zalavras CG, Patzakis MJ, Holtom P. Local antibiotic therapy in the treatment of open fractures and osteomyelitis. Clin Orthop Relat Res. 2004 Oct. (427):86-93. [QxMD MEDLINE Link].
Pelissier P, Masquelet AC, Bareille R, Pelissier SM, Amedee J. Induced membranes secrete growth factors including vascular and osteoinductive factors and could stimulate bone regeneration. J Orthop Res. 2004 Jan. 22 (1):73-9. [QxMD MEDLINE Link].
Wenke JC, Owens BD, Svoboda SJ, Brooks DE. Effectiveness of commercially-available antibiotic-impregnated implants. J Bone Joint Surg Br. 2006 Aug. 88 (8):1102-4. [QxMD MEDLINE Link].
Morgenstern M, Vallejo A, McNally MA, Moriarty TF, Ferguson JY, Nijs S, et al. The effect of local antibiotic prophylaxis when treating open limb fractures: A systematic review and meta-analysis. Bone Joint Res. 2018 Jul. 7 (7):447-456. [QxMD MEDLINE Link].
Dedmond BT, Kortesis B, Punger K, Simpson J, Argenta J, Kulp B, et al. The use of negative-pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma. 2007 Jan. 21 (1):11-7. [QxMD MEDLINE Link].
Herscovici D Jr, Sanders RW, Scaduto JM, Infante A, DiPasquale T. Vacuum-assisted wound closure (VAC therapy) for the management of patients with high-energy soft tissue injuries. J Orthop Trauma. 2003 Nov-Dec. 17 (10):683-8. [QxMD MEDLINE Link].
Liu X, Zhang H, Cen S, Huang F. Negative pressure wound therapy versus conventional wound dressings in treatment of open fractures: A systematic review and meta-analysis. Int J Surg. 2018 May. 53:72-79. [QxMD MEDLINE Link].
Grant-Freemantle MC, Ryan ÉJ, Flynn SO, Moloney DP, Kelly MA, Coveney EI, et al. The Effectiveness of Negative Pressure Wound Therapy Versus Conventional Dressing in the Treatment of Open Fractures: A Systematic Review and Meta-Analysis. J Orthop Trauma. 2020 May. 34 (5):223-230. [QxMD MEDLINE Link].
Qian H, Lei T, Hu Y. Negative pressure wound therapy versus gauze dressings in managing open fracture wound of lower limbs: A meta-analysis of randomized controlled trials. Foot Ankle Surg. 2022 Apr 6. [QxMD MEDLINE Link].
Jenkinson RJ, Kiss A, Johnson S, Stephen DJ, Kreder HJ. Delayed wound closure increases deep-infection rate associated with lower-grade open fractures: a propensity-matched cohort study. J Bone Joint Surg Am. 2014 Mar 5. 96 (5):380-6. [QxMD MEDLINE Link].
Scharfenberger AV, Alabassi K, Smith S, Weber D, Dulai SK, Bergman JW, et al. Primary Wound Closure After Open Fracture: A Prospective Cohort Study Examining Nonunion and Deep Infection. J Orthop Trauma. 2017 Mar. 31 (3):121-126. [QxMD MEDLINE Link].
Weitz-Marshall AD, Bosse MJ. Timing of closure of open fractures. J Am Acad Orthop Surg. 2002 Nov-Dec. 10 (6):379-84. [QxMD MEDLINE Link].
[Guideline] Hauser CJ, Adams CA Jr, Eachempati SR, Council of the Surgical Infection Society. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt). 2006 Aug. 7 (4):379-405. [QxMD MEDLINE Link].
Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am. 1991 Oct. 73 (9):1316-22. [QxMD MEDLINE Link].

Media Gallery

An open tibia fracture with bone loss. A tibial nail was placed and the wound was managed with negative pressure wound therapy, eventually covered with split-thickness skin graft.
Eight weeks later, the defect was approached from a lateral incision to avoid the previous medial open fracture wound. A central bone grafting technique was performed.
The central aspect of the leg was filled with bone graft, and internal fixation of the fibula was performed.
The appearance of the mature synostosis 8 months after the patient's original injury.
An open midfoot fracture with bone loss at the base of the first metatarsal, including approximately 66% of the joint surface.
The foot was cared for with serial debridement and temporary pinning of the midfoot to preserve alignment with minimal additional surgical trauma.
An antibiotic-impregnated cement spacer was placed in the bone void, and 12 weeks later, after the pins had already been removed, a midfoot fusion was performed.
Intraoperative image of the midfoot fusion. The cement spacer has been replaced by autologous bone graft from the iliac crest.

of 8

Author

Erin Pichiotino, MD Resident Physician, Department of Orthopedic Surgery, Prisma Health-Upstate

Erin Pichiotino, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, American Public Health Association, Arthroscopy Association of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Thomas M Schaller, MD Orthopedic Trauma Surgeon, Steadman Hawkins Clinic of the Carolinas

Thomas M Schaller, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Orthopaedic Surgeons, AO Foundation, Orthopaedic Trauma Association

Disclosure: Serve(d) as a speaker or a member of a speakers bureau for: Smith-Nephew<br/>Received income in an amount equal to or greater than $250 from: smith nephew.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Samuel Agnew, MD, FACS Associate Professor, Departments of Orthopedic Surgery and Surgery, Chief of Orthopedic Trauma, University of Florida at Jacksonville College of Medicine; Consulting Surgeon, Department of Orthopedic Surgery, McLeod Regional Medical Center

Samuel Agnew, MD, FACS is a member of the following medical societies: American Association for the Surgery of Trauma, American College of Surgeons, Orthopaedic Trauma Association, Southern Orthopaedic Association

Disclosure: Nothing to disclose.

Chief Editor

Murali Poduval, MBBS, MS, DNB Orthopaedic Surgeon, Senior Consultant, and Subject Matter Expert, Tata Consultancy Services, Mumbai, India

Murali Poduval, MBBS, MS, DNB is a member of the following medical societies: Association of Medical Consultants of Mumbai, Bombay Orthopedic Society, Indian Orthopedic Association, Indian Society of Hip and Knee Surgeons

Disclosure: Nothing to disclose.

Additional Contributors

Steven I Rabin, MD, FAAOS Clinical Associate Professor, Department of Orthopedic Surgery and Rehabilitation, Loyola University, Chicago Stritch School of Medicine; Medical Director, Musculoskeletal Services, Dreyer Medical Clinic

Steven I Rabin, MD, FAAOS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American College of Surgeons, American Fracture Association, American Orthopaedic Association, AO Foundation, Chicago Metropolitan Trauma Society, Illinois Association of Orthopaedic Surgeons, Limb Lengthening and Reconstruction Society, Mid-America Orthopaedic Association, Orthopaedic Trauma Association

Disclosure: Nothing to disclose.

Open Fractures

Practice Essentials

Pathophysiology

References

Tables

Contributor Information and Disclosures

What would you like to print?