Summary

An open fracture (also called a compound fracture) is a broken bone where the broken ends have pierced through the skin, creating a direct connection between the fracture site and the outside environment. Think of a broken bone like a snapped stick—when the sharp ends break through the skin, bacteria from the outside can get into the bone, causing a high risk of infection. This is a serious orthopedic emergency that requires urgent treatment to prevent infection, preserve function, and ensure proper healing. Open fractures are classified by severity (Gustilo-Anderson classification), with higher grades having more soft tissue damage and higher infection risk. The key to management is immediate assessment (ABCs, neurovascular status), wound care (cover, don't probe), antibiotics (broad-spectrum), tetanus prophylaxis, urgent surgical debridement and fixation, and close monitoring for complications (infection, compartment syndrome, non-union). Most open fractures heal well with proper treatment, but infection remains a significant risk, especially in higher-grade injuries.

Key Facts

• Definition: Fracture with breach of skin/soft tissue, exposing bone
• Incidence: Common (5-10% of all fractures)
• Mortality: Low (<1%) unless complications (infection, vascular injury)
• Peak age: All ages, but more common in young adults (trauma)
• Critical feature: Broken bone visible through skin or wound communicates with fracture
• Key investigation: Clinical diagnosis, X-ray, assess for complications
• First-line treatment: Urgent surgical debridement, antibiotics, fixation

Clinical Pearls

"Time to surgery matters" — Open fractures should go to surgery within 6 hours ideally (golden period). Delayed treatment increases infection risk significantly.

"Don't probe the wound" — Never probe or extensively examine the wound in the emergency department. Cover it, give antibiotics, and get to surgery. Probing can push bacteria deeper.

"Gustilo classification predicts infection risk" — Grade I (low energy, small wound) has ~2% infection risk. Grade III (high energy, extensive soft tissue damage) has 10-50% infection risk.

"Always check neurovascular status" — Open fractures can have associated vascular or nerve injuries. Check pulses, sensation, movement immediately and repeatedly.

Why This Matters Clinically

Open fractures are serious injuries with high infection risk if not treated promptly and properly. Early recognition, appropriate wound care, antibiotics, and urgent surgical debridement are essential to prevent infection and preserve function. This is a condition that emergency and orthopedic clinicians manage, and prompt treatment can prevent serious complications.

Structured Approach: ABCDE

A - Airway

• Assessment: Usually patent (unless other injuries)
• Action: Secure if compromised

B - Breathing

• Look: Usually normal (unless chest injury)
• Listen: Usually normal
• Measure: SpO2 (usually normal)
• Action: Support if needed

C - Circulation

• Look: May have blood loss (check for shock)
• Feel: Pulse (may be high), BP (may be low)
• Listen: Heart sounds (usually normal)
• Measure: BP (may be low), HR (may be high)
• Action: IV fluids if blood loss, control bleeding

D - Disability

• Assessment: Neurological status (GCS if head injury)
• Action: Assess if other injuries

E - Exposure

• Look: Full examination, check for other injuries
• Feel: Neurovascular status
• Action: Complete examination

Specific Examination Findings

Wound Examination (Limited):

• Don't probe: Never probe wound in ED
• Cover: Cover with sterile dressing
• Assess: Size, contamination, soft tissue damage (visual only)
• Document: Gustilo grade if possible

Neurovascular Examination (Critical):

• Pulses: Check distal pulses (doppler if needed)
• Sensation: Check sensation in distribution
• Movement: Check active movement
• Color: Check color
• Temperature: Check temperature
• Capillary refill: Check capillary refill

Signs of Compartment Syndrome:

• Pain: Severe, out of proportion
• Tense swelling: Hard, tense compartment
• Pain on passive stretch: Very painful
• Paresthesia: Numbness
• Pulses: Usually present (late sign if absent)

Special Tests

Natural History (Without Treatment)

Untreated Open Fracture:

• High infection risk: Almost certain infection
• Poor healing: Non-union likely
• Functional loss: Significant disability

Outcomes with Treatment

Factors Affecting Outcomes:

Good Prognosis:

• Early treatment: Better outcomes (<6 hours)
• Low grade: Grade I-II have better outcomes
• Proper debridement: Reduces infection risk
• No complications: Better outcomes

Poor Prognosis:

• Delayed treatment: Higher infection risk
• High grade: Grade III have worse outcomes
• Complications: Infection, compartment syndrome worsen outcomes
• Severe contamination: Higher infection risk

Prognostic Factors

Key Guidelines

1. BOA Guidelines (2017) — Standards for the management of open fractures. British Orthopaedic Association

Key Recommendations:

• Urgent surgery within 6 hours
• Broad-spectrum antibiotics
• Proper debridement
• Evidence Level: 1A

2. EAST Guidelines (2012) — Management of open fractures. Eastern Association for the Surgery of Trauma

Key Recommendations:

• Urgent debridement
• Antibiotics
• Evidence Level: 1A

Landmark Trials

Multiple studies on timing of surgery, antibiotic use, infection prevention.

Evidence Strength

What is an Open Fracture?

An open fracture (also called a compound fracture) is a broken bone where the broken ends have pierced through the skin, creating a direct connection between the fracture and the outside. Think of a broken bone like a snapped stick—when the sharp ends break through the skin, bacteria from the outside can get into the bone, causing a high risk of infection.

In simple terms: Your bone is broken and the broken ends have come through the skin. This is serious because it can get infected, but with proper treatment, most people recover well.

Why does it matter?

Open fractures are serious injuries with a high risk of infection if not treated promptly and properly. Early treatment (surgery to clean the wound and fix the bone) is essential to prevent infection and ensure proper healing. The good news? With proper treatment, most people recover well and regain good function.

Think of it like this: It's like breaking a bone and the sharp ends cutting through your skin—it needs urgent treatment to prevent infection and help it heal properly.

How is it treated?

1. Immediate Care:

• Wound: The wound will be covered with a sterile dressing (don't touch it)
• Splint: The fracture will be splinted to keep it still
• Antibiotics: You'll get antibiotics immediately to prevent infection
• Tetanus: You'll get a tetanus shot if needed

2. Urgent Surgery:

• When: Usually within 6 hours (the sooner the better)
• What: The surgeon will clean the wound thoroughly (remove dead tissue, wash it out), fix the bone (with metal plates/screws or an external frame), and manage the wound (may leave it open initially if contaminated)
• Why: To prevent infection and help the bone heal properly

3. After Surgery:

• Antibiotics: You'll continue antibiotics until the wound is closed
• Monitoring: You'll be monitored for infection and other complications
• Rehabilitation: You'll start rehabilitation to regain function

The goal: Prevent infection, help the bone heal properly, and regain function.

What to expect

Recovery:

• Surgery: Usually within 6 hours of injury
• Hospital stay: Usually a few days to weeks (depends on severity)
• Wound: May be left open initially, closed later if needed
• Bone healing: Usually takes weeks to months

After Treatment:

• Wound: Will be monitored for infection
• Bone: Will be monitored for healing
• Rehabilitation: Will start early to regain function
• Follow-up: Regular follow-up to monitor progress

Recovery Time:

• Wound healing: Usually weeks
• Bone healing: Usually months (6-12 weeks or longer)
• Full recovery: Usually months to a year

When to seek help

This is already an emergency — If you have an open fracture, you should already be in the hospital getting treatment.

After treatment, see your doctor if:

• Your wound becomes red, swollen, or has discharge
• You have a fever
• You have increasing pain
• You have concerns about your recovery

Call 999 (or your emergency number) immediately if:

• You have severe pain that's getting worse
• Your limb becomes pale, cold, or numb
• You feel very unwell
• You have signs of infection (redness, discharge, fever)

Remember: Open fractures are serious injuries that need urgent treatment. If you have an open fracture, you should be in the hospital getting treatment. After treatment, follow your doctor's advice and watch for signs of infection or other complications.