Open Fractures

Overview

Open fractures (also called compound fractures) occur when a broken bone pierces through the skin, exposing the bone and surrounding tissues to bacteria and environmental contaminants. These injuries are orthopaedic emergencies due to their high risk of infection, delayed healing, and potential for serious complications such as chronic osteomyelitis, sepsis, or even amputation.

Why Are Open Fractures Dangerous?

• Direct exposure to bacteria from the environment
• Soft tissue damage makes healing difficult
• Risk of infection increases with delay in treatment
• Often associated with high-energy trauma (e.g., road accidents)

Infection Prevention: A Multifaceted Strategy

Effective infection control in open fractures depends on:

1. Timely Antibiotic Administration
   • Must be given within 3 hours of injury
   • Early treatment can reduce bacterial colonisation and biofilm formation
   • Recommended agents:
     • Cefazolin or Clindamycin for general coverage
     • Aminoglycosides (e.g., gentamicin) for high-grade fractures (Type III) – used with caution due to kidney/ear toxicity
2. Prompt Surgical Debridement
   • Removes dirt, devitalised tissue, and contaminated bone
   • Critical to creating a clean environment for healing
   • Repeat debridement may be needed depending on contamination
3. Comprehensive Wound Care
   • Includes sterile dressing, wound irrigation, and closure decisions
   • Delayed closure may be necessary in high-risk wounds
   • Advanced options: Bioelectric dressings disrupt bacteria with electric fields and reduce reliance on antibiotics

Open Fracture Classification: Types III A, B, and C

This classification helps predict infection risk, guides treatment plans, and informs prognosis.

Patient Factors That Affect Risk

• Diabetes
• Immunosuppression (e.g., from medication or illness)
• Smoking
• Poor nutrition
• Delayed presentation

Care plans must be tailored to each patient to address these risks and optimise healing.

Innovations: Bioelectric Dressings

Bioelectric dressings:

• Generate low-level electric fields
• Disrupt bacterial cell membranes and biofilm integrity
• Offer non-antibiotic infection control
• Particularly useful in antibiotic-resistant infections or patients at high risk for complications

Clinical Pearls

• Administer antibiotics as early as possible—ideally within 3 hours
• Always assess for vascular injury in severe open fractures
• Debridement is not one-time—plan for reassessment
• Keep wounds moist and protected between debridements
• Document Gustilo classification early to guide therapy

Frequently Asked Questions

Q: What should be done first after an open fracture?
A: Control bleeding, stabilise the limb, cover the wound with a sterile dressing, and administer antibiotics as soon as possible.

Q: Are antibiotics alone enough to prevent infection?
A: No. Surgical debridement and wound care are equally critical to remove contaminants and promote healing.

Q: What happens if an open fracture gets infected?
A: Infection can lead to bone death (osteomyelitis), long-term disability, multiple surgeries, or amputation in severe cases.

Q: How do doctors decide which antibiotics to use?
A: Based on the type of fracture and likely bacteria. Type I/II may need one antibiotic; Type III needs broader coverage including gram-negative bacteria.

Q: Can you close the wound immediately?
A: Not always. Delayed closure may reduce infection risk, especially in heavily contaminated or high-energy wounds.

Call to Action

If you’ve sustained an open fracture or are caring for someone who has:

• Seek emergency care immediately
• Do not delay antibiotics or surgical assessment
• For guidance on recovery and wound care, contact your orthopaedic team

Evidence & Guidelines

• American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines
• Gustilo-Anderson Classification for open fractures
• NICE Trauma Guidelines (NG39): Major trauma – assessment and initial management

Disclaimer

This guide is for educational purposes only. It is not a substitute for professional medical care or advice. Always consult your orthopaedic surgeon or trauma specialist for personalised treatment.