Open Fractures

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Open fractures imply communication of the fracture haematoma with an epithelial surface like skin, bowel mucosa, bladder mucosa etc. The main problem here is infection, and therefore, every effort should be made to prevent it. In some cases, the degree of bone loss may warrant amputation. Exclude a neurological deficit especially when the injury is extensive. It is prudent to take a photograph of the affected part(s) for documentation and medico-legal purposes.

Patients should never be sent for imaging unless haemodynamically stable. 

Cause

  • Road traffic accidents
  • Domestic violence
  • Assaults 
  • Work place injuries
  • Fall from a height

Symptoms

  • Localised pain
  • Swelling
  • Bleeding
  • Exposed bone, muscle and fascia
  • Inability to move the part

Signs

  • Swelling
  • Deformity 
  • Blood
  • Laceration over the fracture
  • Crepitus
  • Shock if there has been significant blood loss
  • Confusion or unconsciousness if there is shock or associated head injury

Investigations

  • Haemoglobin
  • Blood for grouping and cross matching
  • X-rays of suspected part to include joints above and below
  • Trauma series X-rays  (Cervical spine, Chest and Pelvis) if injury is deemed severe or if patient is confused or unconscious
  • CT scan (for fractures involving the following areas):
    • Head
    • Spine 
    • Pelvis
    • Fractures around joints
  • CT angiograms (if significant vascular injury is suspected)
  • MRI (to assess spinal cord and soft tissue injuries of the knee)
  • Abdominal USG (if intra-abdominal injury is suspected)

TreatmentTreatment Objectives

  • To resuscitate the patient (save a life first) - ATLS protocol (ABCDE)
  • To save the affected limb(s) (save a limb next)
  • To prevent and eradicate infection
  • To restore function of the affected limb(s)

Non-pharmacological treatment

  • Remove all foreign bodies
  • Cover with sterile dressing
  • Splinting of affected limb(s)
  • P.O.P. backslab
  • Prefabricated splints
  • Customized splint
  • Elevation of affected limb(s)
  • Early range of motion physiotherapy
  • Keep nil per os until final decision about management has been made.
  • Surgical - under general anaesthesia 
    • Irrigation 
    • Debridement
    • External fixation or backslab

Pharmacological treatment 

For treatment of infection

1st Line Treatment

Evidence Rating: [A]

  • Cefuroxime, IV,

Adults

750 mg 8 hourly

Children 

25 mg/kg body weight 12 hourly 

Or 

  • Clindamycin, IV,

Adults

300-600 mg 6 hourly for 4 weeks or until clinical improvement

Children

3-6 mg/kg 6 hourly for 2-4 weeks

If the fracture is in perineal region

  • Above antibiotics in section A.

And 

  • Metronidazole, IV, 

Adults

500 mg 8 hourly for 7 days

Children

7.5 mg/kg 8 hourly for 7 days

Tetanus prophylaxis 

All patients with open fractures must have tetanus prophylaxis. 

Referral Criteria

Refer complicated fractures e.g. pelvic and intra-articular, and multiple injuries to an orthopaedic surgeon.