An open fracture is one that has an associated wound over it and that wound communicates with fracture hematoma. Open fractures are always a special situation because they demand prompt and aggressive approach.
Presentation
The presentation is with pain, swelling and an associated bleeding wound. In severe cases the fracture fragments may be jutting out. Because, often the skin has been breached, there are higher chances of neurovascular injuries. Therefore all the nerves and vessels should be carefully examined.
The patient should be thoroughly examined to find and rule out other possible injuries. This is especially true for high velocity traumas.
The wound should be inspected for severity and any bleeding vessel should be ligated. The fracture should be splinted in a coaptation splint or U splint after wound has been cleaned and dressed.
The extent of injury determines the number of investigations. A plain anteroposterior and lateral radiograph would serve the purpose in most of the cases.
If there is associated injury in any part of the body, it should be xrayed.
If there is an arterial injury, a doppler ultrasound would be required to confirm and know the level of injury.
The fracture Treatment
The surgeon must perform a thorough debridement of the bone and soft tissues on an emergent basis to decrease the risk of deep infection. Prophylactic antibiotics should be administered.
If the wound is small and clean the fracture can be managed with closed fracture treatment after debridement.
However moderate clean wounds would require fixation external or internal, depending on the condition of wound after debridement.
External fixation usually is reserved for fractures with such severe injury to the soft tissues and profound contamination that complete debridement is not achieved at the initial procedure. Wound care after the initial debridement of any open fracture consists of additional debridements or healing by secondary intention as dictated by the severity of soft tissue damage.
Gunshot fractures
Gunshot fractures constitute a unique type of open fracture. The injuries vary considerably depending on the type of firearm involved. These fractures, especially if caused by high-velocity bullets, result in more frequent and more severe nerve and vessel injury and a more comminuted fracture.
For wounds from low-velocity missiles, minimal debridement of the wound, to include excision of skin edges and removal of superficial fragments of clothing and debris, followed by superficial irrigation, is sufficient to prevent most infections and can be considered for closed fracture treatment or internal fixation.
Shotgun injuries and high-velocity missile wounds, usually result in severe damage to the soft tissue and formal debridement in the operating room followed by fixation, often with an external fixator, is necessary.
Join Discussions