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Open fractures

  • Open fracture – a fracture with direct communication to the external environment

Epidemiology

  • More common in middle aged people
  • Tibia and phalanx are most common open fractures

Etiology/pathophysiology

  • ‘Out-to-in’ injury – due to a high energy trauma (direct blow)
    • Penetrates the skin and traumatises the soft tissues and bone
  • ‘In-to-out’ injury – when a sharp bone end penetrates the skin from beneath

Associated conditions

  • Early problems – multisystem injury, compartment syndrome, neurovascular injury
  • Late – infection, non-union

Classification –  Gustilo-Anderson Classification

  • Type I – wound <1cm, minimal contamination or muscle damage
  • Type II – wound 1-10cm, moderate soft tissue injury
  • Type IIIA – wound >10cm, high energy trauma, comminuted fracture, extensive soft tissue damage
  • Type IIIB – extensive periosteal stripping, required soft tissue coverage
  • Type IIIC – vascular injury, requires vascular repair

Treatment

BOA Guidelines

  • Initial assessment and ATLS if required
  • Assessment of limb neurovascular status
  • Remove gross contamination from the wound and cover with saline-soaked gauze and cling film
  • Restore alignment if fracture is grossly displaced
  • Antibiotics and tetanus prophylaxis (see below)
  • Obtain X-rays
  • Assess for presence of compartment syndrome
  • Wound debridement in theatre
  • Consider primary amputation if limb has been avascular for >6 hours
  • Refer to specialist centre – for definitive reconstruction

Antibiotics and tetanus prophylaxis

  • Gustilo type I + II – 1st gen cephalosporin (cefazolin/cephalexin)
  • Gustilo type III – 1st gen cephalosporin + aminoglycoside (gentamicin)
    • Others – vancomycin, high dose penicillin (for anaerobic coverage)

Tetanus prophylaxis

  • Initiate in emergency room
  • 0.5ml toxoid vaccine – intramuscular
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