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Open Fractures and Trauma
What is an open fracture?
Fractures where the broken bone protrudes through the skin or communicates with a wound are termed “open” or compound fractures. Exposure of the fracture to the external environment produces local contamination and increases the risk of significant infection. Open fractures are considered a surgical emergency.
Are all open fractures the same?
The severity of open fractures can vary significantly. The degree of injury and complexity of the treatment is influenced by a series of factors:
The severity of open fractures can vary significantly. The degree of injury and complexity of the treatment is influenced by a series of factors:
  • Energy level (height of a fall / speed of car accident / caliber of bullet)
  • Degree of contamination (soil, broken glass, stagnant water)
  • Degree soft tissue injury (crushed / avulsed)
  • Complexity of fracture pattern (number of bony pieces)
  • Vascular injury
You may hear a physician describe your fracture to other health care professionals according to the Gustilo classification. This rating system rapidly describes the degree of injury, risk for complications and need for plastic and vascular surgery intervention to save the extremity.
How are open fractures treated?
The initial evaluation and treatment of open fractures is best performed at a designated trauma center. These fractures are often associated with motor vehicle accidents, industrial accidents, falls and gun shot wounds. Up to one third of individuals will have other life threatening injuries in addition to the complicated fracture.
Following initial stabilization and a thorough search for additional injuries individuals with an open fracture will receive tetanus prophylaxis, IV antibiotics and a temporary splint.
Open fractures are considered a surgical emergency. Every effort is made to obtain formal surgical treatment in a timely fashion to reduce the risk of infection.
In the operating room the surgeon will remove debris, unhealthy soft tissue and unattached segments of bone (surgical debridement). The wound and fracture are washed with a large volume of sterile fluid often containing antibiotics. Medical grade water picks are often used to assist in the cleansing process (pulse lavage).
After decontaminating the wound the orthopedic surgeon will stabilize the fracture. This may be achieved with internal methods (plates / rods) or with an external frame made from a series of pins, wires and rings. If the associated wound is small it will be closed with sutures and the patient will receive a course of IV antibiotics prior to discharge.
What happens if large areas of skin and muscle are damaged or missing?
After thorough cleansing (debridement) and fracture stabilization the surgical team may be left with a large, complex wound that cannot be directly brought together with sutures. Plastic surgery techniques will ultimately be required to achieve a closed wound but will likely be performed at a later time. The patient is returned to the operating room every 48-72 hours and the cleansing process repeated until the wound is optimized. Antibiotic containing beads are frequently left in the wound between cleansings to fight bacteria and reduce the odds of developing a chronic bone infection (chronic osteomyelitis).
Generally the wound can be prepared for definitive reconstruction within a 5-7 day period. The plastic surgeon will utilize local skin or muscle (local flap) to cover the fracture with well-vascularized soft tissue and facilitate healing. Alternately, large or distally located wounds may require microsurgical reconstruction. An expendable muscle or region of skin can be harvested from a distant location (back/abdomen) and brought to the wounded leg. The artery and vein in the transplanted tissue are connected to local blood vessels in the leg. The vascular connection (microvascular anastomosis) is performed under a high-power microscope with stitches finer than a hair. The newly established circulation is carefully monitored until discharge with a microphone pen (Doppler). Tissue transplants are frequently referred to as a free tissue transfers or “free flaps”. Following reconstruction a course of antibiotics are provided under the guidance of an infectious disease expert.
What if there is an associated vascular injury?

Open fractures with associated vascular trauma (Gustilo Grade IIIc) are severe injuries and benefit from a multidisciplinary team evaluation (vascular surgery, orthopedic surgery and plastic surgery). After carefully analyzing the degree of soft tissue damage, complexity of the fracture, presence of nerve injury and possibility for vascular reconstruction the surgical team will make recommendations regarding the odds of successful limb salvage. Even in the best situation these severe injuries require amputation in approximately 50% of cases.