Open Fractures- Features, Classification and Management

Last Updated on January 24, 2025

What are Open Fractures- Understanding Closed and Open Fractures

Open fractures are fractures where fracture hematoma is in communication with the external environment. A simple or closed fracture by is the one where the fracture hematoma does not communicate with the surroundings.

It means that the blood that is collected after the fracture is in the closed space formed by tissues around the bone and does not communicate with an external environment. But if the same fracture is accompanied by an external wound that is continuous with the fracture hematoma (which means the fracture hematoma is no longer closed, it can communicate to the exterior now because the tissues surrounding have also been injured and allow a passage to be formed where blood can trickle to the outside.

The mere presence of a wound does not make a fracture an open fracture. There should be some continuity between this wound and the fracture inside. 

For all practical purposes, all fractures with a wound over the skin should be treated as open fractures, unless proved otherwise.

Open fractures are associated with a higher risk of infection,  bone loss, neurovascular injury, and union problems.

Previously, open fractures were called compound fractures.

The terms open and closed are also used in dislocations of the joint and impart similar meanings like open fractures and closed fractures.

Similarly, a fracture may also communicate with the internal cavity, such as the abdomen. These are also called open fractures. It commonly happens in fractures of pelvic bones.

There are two ways in which a fracture might become an open fracture. Either the trauma may damage the external tissue surrounding the bone and lay a path for communication. This commonly happens in missile injuries or high-velocity trauma.

In the other case, the spikes of the broken bone may pierce the skin and other tissues from the inside and lay a communication path.

Why is it Important to Recognize Open Fractures?

All open injuries, whether a prick or bigger wound, by all means, are surgical emergencies in contrast to closed where only a few are surgical emergencies and can be managed for some time just by splinting.

It is noteworthy that unless there is severe soft tissue loss, most open fractures have a fate almost equivalent to their closed counterparts. However, because they are open, there are increased chances of contamination and infection.

Open fractures are serious injuries to deal with despite the advances made in fracture care and the prevention of and management of infection.

Open fractures occur in 30 per 100,000 people per year. The tibia and finger phalanx are the most commonly affected bones.

These are generally caused by high-energy trauma and are often associated with associated injuries.

An open fracture can also result from a lower-energy incident, such as a fall at home or sports injury.

Classification of Open Fractures

Classification of open fractures aims to put them into increasing grades of severity.

Gustilo classification modified by Anderson (Gustilo Anderson)

It is the most commonly used classification for open fractures. This classification is as follows

Type I

• Wound less than 1 cm with minimal soft tissue injury
• Wound bed is clean
• Fracture is usually a simple transverse, short oblique fracture, with minimal comminution

Type II

• The wound is greater than 1 cm with moderate soft tissue injury
• Fracture is usually a simple transverse, short oblique fracture, with minimal comminution

Type III

• Extensive damage to the soft tissues, including muscle, skin, and neurovascular structures.
• Often accompanied by a high-velocity injury or a severe crushing component.
• Special patterns classified as Type III:
  • Segmental Open fracture, irrespective of the size of the wound
  • Gunshot wounds high velocity and short-range shotgun injuries
  • Open fracture with neurovascular injury
  • Farm injuries, with soil contamination, irrespective of the size of the wound.
  • Traumatic amputations
  • Open fractures over 8 hours old
  • Mass casualties, e.g. war and tornado victims

Type III open fractures are further classified into 3 subtypes

• IIIA
  • Adequate soft tissue coverage despite soft tissue laceration or flaps or high energy trauma irrespective of the size of the wound.
  • This includes segmental fractures or severely comminuted fractures.
• Subtype IIIB
  • Extensive soft tissue lost with periosteal stripping and bony exposure.
  • This is usually associated with massive contamination.
• Subtype IIIC
  • Fracture in which there is a major arterial injury requiring repair for limb salvage
  • A fracture classification helps to plan the treatment and indicates the severity of injury without much description

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 and modified as required.

Oestern and Tscherne classification

Grade 0

• Minimal soft tissue damage
• Indirect injury to limb (torsion)
• Simple fracture pattern

Grade 1

• Superficial abrasion or contusion
• Mild fracture pattern

Grade 2

• Deep abrasion
• Skin or muscle contusion
• Severe fracture pattern
• Direct trauma to limb

Grade 3

• Extensive skin contusion or crush injury
• Severe damage to the underlying muscle
• Compartment syndrome
• Subcutaneous avulsion

Pathophysiology of  Open Fractures

The risk of a fracture being open is related to the amount of soft-tissue coverage present in the affected region. In other words, more superficial bones ar more likely to result in open fractures than deep bones. That is the reason we see more open tibial fractures than femoral fractures.

The unique risks posed by open injuries are mainly infection and a higher rate of nonunion. Infection often occurs due to direct inoculation at the time of the injury. Dirt, grass, mud, and clothing can often result in contamination. Nonunion may result from infection or bone loss due to injury.

There are higher chances of injury to nerves and vessels because of the penetrating nature of the injury.

The soft tissue may get devitalized due to the high energy associated with injury resulting in a compromise of the healing process.

Clinical Presentation

An open fracture may involve a very small wound caused by a sharp bone spike to extensive injuries caused by high-velocity gunshot wounds or vehicular trauma. Industrial accidents can result in crushing injuries.

A detailed history needs to be obtained about the mechanism and extent of injury. The visible wound should be assessed for size and nature but the wound size is often not guide to the possible internal injuries.

Neurovascular should be ruled out by examination and if present appropriate confirmatory studies should be conducted. If the injury is very near to the joint, a CT scan should be considered to rule out joint involvement.

Recent studies have suggested preexisting depression is an independent predictor of complications. Therefore, a detailed psychiatric evaluation should be performed and documented.

Lab Tests

Typically lab tests are not needed.

Imaging

Routine X-rays suffice in most cases. In children,  comparison views of the contralateral extremity or joint may be taken.

Computed tomography and magnetic resonance imaging provide further detail of bone and soft tissue injury and are most useful in the management of complex periarticular (near joint) injuries.

Treatment of Open Fractures

Many open fractures are associated with motor vehicle accidents, gunshot wounds, falls and other major trauma. Consequently, an examination that includes neurologic status, head, spine, abdomen, and pelvis is completed before starting open fracture treatment. A dry sterile dressing covers the wound and the extremity is splinted. Tetanus immunization is indicated as dictated by the wound and immunity status.

Antibiotics are started as the primary goals of the treatment are to prevent infection of the wound and fracture site while allowing soft tissue healing, fracture union, and the eventual return of optimal function. Infection contributes to scarring and to loss of function of the soft tissue envelope, to the stiffness of joints, to deformity, and to delayed union and nonunion.

Treatment of  open fractures is influenced by

• Age and general condition
• Presence of other injuries
• The severity of  the  injury
• Severity of the contamination
• Time elapsed between injury and definitive treatment
• Vascular injuries.
• Approach Considerations

Operative treatment should be considered for almost all open fractures to minimize the complication rate and improve the outcome if the patient’s condition allows.

In elderly patients, concomitant issues like diabetes, obesity, smoking status, bone density, etc. may affect the outcome.

General Patient Management

General management aims to stabilize the patient and include

• Managing the critical injuries
• Splinting the injured parts
• IV fluids
• Blood transfusion
• Initial wound cleaning and covering with betadine dressing, and preliminary alignment, and splinting of the fracture
• Antibiotics
• Tetanus immunization

In the emergency room wound is thoroughly inspected. Tetanus prophylaxis is provided, and the initial dose of intravenous antibiotics is given.

Open fracture wounds can then be dressed with sterile, moist gauze, and clinical realignment of the limb can be accomplished with a temporary splint or traction. Patients who are appropriate for operative management should be urgently brought to the operating room.

Parenteral Antibiotics

Tetanus Immunization

Tetanus is caused by  Clostridium tetani,  an anaerobic bacterium commonly found in soil. It could be a life-threatening disease but immunization is very effective in preventing the infection. The tetanus immunization is given to each case with open fracture. The schedule is determined by the previous immunization status of the patient and the wound type. Tetanus immunoglobulins [Human tetanus immunoglobulins or HTIG] are added for highly contaminated wounds when needed.

• Tetanus booster within last 5 years–  No further treatment
• More than 5 years since booster or has not completed immunization series-  Tetanus toxoid (if wound tetanus prone, give HTIG)
• More than 10 years since booster or immunocompromised – Tetanus toxoid and HTIG

250–500 IU ofHTIG is added especially if [these are more prone to tetanus infection due to contamination]

• The wound contaminated by dirt, saliva, or feces
• Puncture wounds
• Missile injuries
• Burns
• Frostbite;
• Crush injuries

Note: Primary tetanus immunization via tetanus toxoids is done at  2, 4, and 6 months, 1-1.5 years, 5 years, 11–12 years, and then at 10-year intervals for maintenance immunization.

The dose for the tetanus toxoid should be combined with 250–500 IU of human tetanus immune globulin (HTIG). Furthermore, if more than 10 years has elapsed since the last tetanus booster or the patient’s immune system is compromised, both the tetanus toxoid and HTIG should be given.33 The HTIG will offer most patients 3 weeks of protection [Table 4].

Primary Wound Care

The first cardinal rule is to avoid further soft tissue injury. This is achieved by

• Fractures reduction immediately to alleviate pressure on the injured ischemic soft tissues.
• Cleaning of the wound and sterile dressing
• Splinting the part and rapid transport to the hospital
• Limiting contamination by maintaining sterility
• IV antibiotics

Simple soap or savlon solution is used to clean the wound. The wound should be thoroughly irrigated with as much as 10 liters of saline solution or ringer lactate. Liters of normal saline is used to clean fractures of long bones. All foreign material must be removed, including the wadding from gunshot wounds and pieces of clothing driven inward by the force of injury. Necrotic muscle and devitalized bone are excised from the wound.

Debridement involves the removal of all contamination and the meticulous excision of all devitalized tissue.

The severity of the wound would dictate the extent of the debridement.

Any tight compartments must be decompressed and the muscle viability assessed by bleeding, contractility, and color.

Anything that appears not viable should be debrided.

Multiple debridements may be required to ensure that no nonviable tissue is left behind as a focus of infection. Low-velocity wounds may require only local irrigation, debridement of the entry and exit wounds, and supportive oral antibiotic treatment.

The closure may be accomplished if no necrotic tissue or contamination is present. Local muscle flaps or vascularized free-tissue transfers may be required for larger soft-tissue defects. The flap may provide the additional benefit of improved circulation on the area, which assists healing of the fracture site and protects against infection with increased oxygen tension.

Bony fragments which are not attached to soft tissue need to be removed. A large fragment, especially articular should be preserved though if possible.

A stabilized fracture offers better healing due to the following advantages.

• Decreases dead space [created by fragment mobility]
• Controls bleeding
• Decreases local irritation
• Improves the blood supply to the tissues,
• Facilitates wound care
• Facilitates soft tissue envelope reconstruction
• Decreases infection
• Encourages faster rehabilitation and leads to better function.

Immobilization in open fractures is done by external fixation or less commonly, internal fixation in selected cases. For example, in open epiphyseal injuries and intra-articular injuries, internal fixation is preferred.

Plaster immobilization had been done in the past but is considered inferior method.

There are various external fixation devices available for fracture fixation. They usually serve as temporary fixation. Definitive fixation is done after the wound has healed.

Internal fixation devices also vary with the type of fracture and site of the fracture.

After the initial debridement and stabilization, the wound of the injury must always be left open. Part of the surgical incision that was made as an extension of the wound to permit thorough debridement can be closed as long as the edges can be brought together without any tension.

The wound is then dressed with sterile gauze packs. Some authors prefer using antibiotic-impregnated methyl methacrylate beads and then covering the wound with an adherent plastic drape.  This technique captures the oozing exudates and turns into a concentrated antibiotic solution.

With either technique, serial debridements are undertaken as part of wound care till all dead tissue is removed.

Any skin and soft tissue procedure required for coverage is undertaken now. This could be simple secondary closure, simple skin grafting or free flap reconstruction.

Follow-up Fracture Care

After wound healing, the further course depends on the choice of implant.

If external fixator is to be continued, the fracture site is bone grafted now.

In fractures treated by plating or nailing, the indications for bone grafting depend on the severity of the soft tissue wound and the fracture morphology.

If the wound was such that either a rotation myofascial flap or a free muscle flap was necessary, the bone graft is carried out after 5–7 weeks, once a stable soft tissue envelope is secure.

Open Joint Injuries

Anatomic reduction, and stable fixation of the articular fracture and its metaphyseal component is the mainstay of treatment of joint injuries. Therefore open reduction and stable internal fixation is the treatment of choice, even in the open joint injuries.

The initial care and other principles remain the same.

At the time of the initial surgery, anatomical reduction of the articular surfaces and their stabilization with the minimum of internal fixation should be done, possibly with lag screws.

The lag screws are supplemented by an external fixation.

The metaphyseal component is not treated at this time to avoid the quantum of the implant due to the risk of sepsis.

The definitive reconstruction of the metaphyseal defect is undertaken 4-6 weeks later when a stable and healthy soft cover has been achieved.

A buttress or a bridge plate is used for this fixation and any defect if present is packed with autogenous cancellous bone.

If plating cannot be carried out, the external fixation is left on and the metaphysis is bone-grafted.

References

• Zalavras CG, Patzakis MJ. Open fractures: Evaluation and management. J Am Acad Orthop Surg. 2003;11:212–9.
• 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.
• Diwan A, Eberlin KR, Smith RM. The principles and practice of open fracture care, 2018. Chin J Traumatol. 2018 Aug. 21 (4):187-192. [Link]

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