Open fracture management

What it is

The first question to ask when managing any fracture is whether it is open or closed. An open fracture is a laceration or wound at the site of the fracture or around the area of the fracture; a closed fracture has intact skin. The wound does not have to lie over the broken bone, because when the fracture occurs the skin may be pulled away from the site of fracture, so a radial fracture can carry a wound a little away from the fracture site. The injury is therefore two injuries at once, damaged soft tissue plus broken bone, and both have to be treated.

How it is diagnosed

The Gustilo-Anderson classification rates the degree of the open fracture in three grades, depending on the size of the laceration, which stands for the amount of damaged soft tissue.

• Type I: a clean skin wound under 1 cm with a simple fracture pattern and no skin crushing.
• Type II: a laceration over 1 cm and under 10 cm without extensive soft tissue crushing; the wound bed may appear moderately contaminated.
• Type III: an open segmental fracture, or a single fracture with extensive soft tissue injury over 10 cm. Gunshot fractures and open fractures caused by farm injuries are placed here.
• Type IIIA: adequate soft tissue coverage of the fracture despite high energy trauma or extensive laceration or skin flaps.
• Type IIIB: inadequate soft tissue coverage with periosteal stripping, exposed bone that requires soft tissue transfer to achieve coverage.
• Type IIIC: an open fracture associated with vascular injury that requires repair for limb preservation; the peripheral artery pulse is absent.

With significant soft tissue damage the pulse separates the last two: a palpable dorsalis pedis puts the injury in B, an absent dorsalis pedis in C. B is chosen over A when there is not enough soft tissue for coverage and soft tissue flapping will be needed.