Definition: Fracture associated with a break in the skin that communicates with the fracture or hematoma

-Most commonly caused by crush injury > high energy or torsional injuries

-Severity based on grading system (Gustilo classification most commonly used), increased with increasing size and contamination

Evaluation:

-Thorough inspection of affected extremity

-Complete neurovascular exam

-Plain films of extremity

Management:

-Irrigation

-Debridement

-Update tetanus if indicated

-Antibiotics

     - First generation cephalosporin (cefazolin) to cover gram positive organisms; add gentamicin if wound >10cm, severe soft tissue loss and loss of bone coverage for gram negative coverage

     - Could consider adding penicillin/anaerobic coverage if plant or soil contamination to cover for gas gangrene but this is controversial

     - No evidence of improved outcomes for duration of treatment longer than 24 hours, although recommended up to 72 hours with increasing severity

-Reduce and splint, cover open wounds with saline soaked gauze

-Often require ortho consult and washout in OR (some exceptions such as isolated phalangeal fractures)

Complications: 

-infection, osteomyelitis

-compartment syndrome

-nonunion 

References:

-Halawi MJ, Morwood MP. Acute Management of Open Fractures: An Evidence-Based Review. Orthopedics. 2015 Nov;38(11):e1025-33. doi: 10.3928/01477447-20151020-12. PMID: 26558667.

-Mayersak, RJ. Initial Evaluation and Management of Orthopedic Injuries. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8th Ed. Judith E. Tintinalli, et al. New York, NY: McGraw-Hill, 2016.

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