Management of Open Fractures

Introduction to Classification

• The Gustilo-Anderson classification is a fundamental system for categorizing open fractures, dividing injuries into three main types (I, II, and III), with type III subdivided into A, B, and C based on the severity of soft tissue damage, contamination, and vascular compromise, as stated by the American College of Surgeons 1

Characteristics of Each Type

• Type I open fractures are characterized by a wound less than 1 cm, minimal soft tissue damage, minimal contamination, and a simple fracture, typically transverse or short oblique 1
• Type II open fractures have a wound greater than 1 cm, moderate soft tissue damage, no extensive flaps or avulsions, and moderate contamination 1
• Type III open fractures are characterized by extensive soft tissue damage, including periosteal stripping and bone exposure, and are subdivided into:
• The following table summarizes the Gustilo-Anderson classification:

Initial Management

• Apply direct pressure to control active bleeding, and for severe bleeding unresponsive to direct compression, consider tourniquet application if in an extremity, according to the American Society of Anesthesiologists 1
• Re-evaluate tourniquet necessity as soon as possible to minimize ischemia time, as suggested by the American Society of Anesthesiologists 1
• Thoroughly irrigate the wound with warm saline solution, as recommended by the American Heart Association 2
• Assess for severity of soft tissue damage, check for visible bone fragments, and evaluate neurovascular status (color, temperature, capillary refill) 3
• Obtain 3-view radiographs of the affected area (PA, lateral, and oblique) for diagnostic evaluation, with an internally rotated oblique projection increasing diagnostic yield for certain fractures 4
• Splinting can reduce pain and prevent further injury, and is a recommended initial treatment for open fractures 3

Pain Management

• Provide appropriate pain relief using NSAIDs, opioid analgesics as needed for severe pain, and consider regional nerve blocks for extremity injuries, as recommended by the British Association of Dermatologists 5

Surgical Management

• Surgical exploration is necessary to assess the extent of injury, remove foreign bodies and contaminants, evaluate tissue viability, and plan for definitive coverage, as recommended by the American Urological Association 6
• Consider primary closure for small, clean degloving injuries with good vascularity, defatting and reapplication for larger injuries, delayed skin grafting after adequate wound bed preparation with VAC therapy, and flap reconstruction for complex cases with significant tissue loss 6
• Administer antibiotics as soon as possible to lower the risk of deep infection, with cefazolin plus additional gram-negative coverage recommended for type III open fractures (strong recommendation) 7
• Bring the patient to the operating room for debridement and irrigation ideally within 24 hours of injury, with irrigation using saline without additives (strong recommendation) 7
• Temporizing external fixation is a viable initial option for type III open fractures, and definitive fixation at initial debridement may be considered in selected patients 7
• Achieve wound coverage within 7 days from injury (moderate recommendation) 7

Infection Prevention and Management

• Higher risk of infection is found in patients who smoke, have diabetes, are obese, or consume significant alcohol (>14 units/week) 7
• Established infections with retained hardware require at least 3 months of suppressive antibiotics to improve outcomes, although the exact duration may vary based on individual patient factors and clinical guidelines 8
• Staphylococcal infections can be treated with cefazolin for methicillin-sensitive strains and vancomycin or daptomycin for methicillin-resistant strains, with consideration of combination therapy with rifampin for biofilm-producing strains 8
• Gram-negative infections require targeted therapy based on susceptibility testing due to lower success rates with standard treatments 9
• Local antibiotic delivery may be beneficial for open grade 3 fractures 7
• Negative pressure wound therapy (NPWT) may not be justified after open fractures due to associated costs, as stated by the AAOS 7

Prophylaxis and Rehabilitation

• Tetanus prophylaxis should be considered as part of the treatment protocol for open wounds, with Tdap preferred if not previously given, and administration to patients without vaccination within 10 years, as suggested by 10, 11
• Prophylaxis should be limited to the operative period, with a maximum duration of 24 hours [8, @9@, 10]
• For patients with beta-lactam allergies, clindamycin 900mg IV slow or vancomycin 30mg/kg/120min can be used as alternative first-line options 8
• Consider adding vancomycin 30 mg/kg IV (maximum 2g) if MRSA risk factors are present, as Staphylococcus aureus is responsible for 35-75% of post-traumatic infections 10
• Regular wound assessments are necessary to monitor healing, watch for signs of infection or tissue necrosis, and consider rehabilitation needs based on location and extent of injury 6
• Avoid overly aggressive debridement, as it may preserve marginally viable tissue that may survive due to collateral blood flow, as recommended by the American Urological Association 6
• Control bleeding using direct pressure if severe, cover the open wound with a clean dressing to prevent further contamination, immobilize the affected limb in the position found unless straightening is necessary for safe transport, and activate emergency response immediately if the extremity appears blue, purple, or pale, as recommended by the American Academy of Orthopaedic Surgeons 3