To treat open fractures effectively, we need to understand what they are and how they occur.

What is an open fracture?

Open fractures are also referred to as exposed or compound fractures.

An open fracture is a broken bone that has a direct communication between the fracture site and the external environment through a wound in the skin and/or soft tissues^1,2. In simple terms: there is both a break in the bone and a skin wound that exposes the fracture or its hematoma to the outside world.

Example - Even a very small skin puncture (from a sharp bone fragment poking out from the inside) qualifies the injury as an open fracture.

The disruption of both the bone and surrounding soft tissues leads to exposure to external contaminants such as dirt, bacteria, and other microorganisms. This exposure significantly increases the risk of infection¹. Severe soft tissue damage further hinders normal healing by impairing blood circulation, which can prevent the fracture site from receiving adequate nourishment and oxygen³.

Open Fracture of the Tibia

Management of open fractures poses a serious challenge to surgeons, both in high and low resource settings, despite recent advances in treatment protocols³. The most dangerous early complication is death due to blood loss. The most common complication is fracture related infection, potentially leading to sepsis, tissue necrosis and high risks on delayed and non-union of the fracture⁴.

The aim of treatment of open fractures is to enable healing of bone and other tissue involved with a good functional outcome. An open fracture can only be adequately managed when both bone and soft tissue components are treated¹.

Open fractures are surgical emergencies.

The sooner the treatment is provided, the better the outcome because it reduces the infection risk. That's why open fractures are medical emergencies, especially if they present early (which is almost always the case in high income settings). When patients present late (days or weeks after the injury), already with signs of sepsis, this is of course also an emergency. If the patient presents late without signs of sepsis, there is more time to optimize the patients' general condition and to plan the treatment with the best possible team in your setting¹.

Take into account that the timing of surgery should be a balanced decision between:

1 The need to act fast and

2 The time needed to be able to provide the best possible treatment, preferable by an experienced orthoplastic team.

Approximately 1.7 billion people worldwide suffer from musculoskeletal conditions, which are leading contributors to disability. These conditions encompass bone fractures, joint problems, muscle injuries, widespread pain, and amputations due to trauma or disease¹. 

In 2019, there were an estimated 178 million new fractures globally, contributing to the overall total of 445 million people with fractures².

Open fractures are not uncommon, and they occur in 2.6–23.5% of fracture cases, depending on the country. However, the exact global prevalence of open fractures remains unknown, as there are no existing registries dedicated to collecting this data.

Globally, the number of patients who lose their lives due to injuries is higher than the number of deaths from HIV/AIDS, tuberculosis and malaria combined³. Open fractures can result from such injuries.

Global Burden of Disease ^4,5

Did you know? Open fractures are included on the list of Neglected Surgical Diseases (NSDs) – surgical conditions that result in a significant burden of disease on a global scale, even though cost-effective solutions exist.

Open fractures in low- and middle-income countries

Open fractures disproportionately impact people in low- and middle-income countries (LMICs). In our experience, orthopedic wards in these settings see a high number of open injuries. Closed fractures are in many LMICs more often primarily treated by traditional bone setters.

Cultural context: About traditional bone setters

Open fractures place an enormous burden on society, with lost economic productivity, social stigma, and reduced quality of life ⁶.

Risk factors for sustaining an open fracture

Certain populations are more at risk for open fractures, due to several factors, known as social determinants of health⁷. When compared to adults, younger males have the highest incidence of open fractures due to increased exposure to risk factors associated with motor vehicle accidents and active lifestyles⁸.

Its important to realize that among younger female patients, road traffic accidents still account for 4 in 10 fractures in a survey in low- and middle-income countries⁹. And If individuals live in an area with poor roads and heavy rainfall, the risk of road traffic accidents increase even more.

Risk factors by impact of trauma

The risk factors differ depending on the amount of energy that caused the open fracture. Examples of high-energy traumas are motor vehicle accidents or falls from significant heights. Low-energy trauma examples include falls in or around the house or soccer injuries.

While you may not be able to modify all these determinants, as a clinician it is vital to be aware of their existence to advocate prevention.

There is a need to implement prevention strategies¹, such as promoting road safety, enhancing infrastructure, and raising awareness about the risks of high-energy trauma. Prevention involves both primary prevention (avoiding injuries), secondary prevention (treat the injuries adequately as soon as possible) and tertiary prevention (minimizing complications with adequate rehabilitation and additional reconstructions to improve function, e.g. contracture release, muscle transfers etc,)².

Prevention of accidents in society

Road safety - Promoting safe driving practices, enforcing seatbelt and helmet laws, and improving road infrastructure can reduce road traffic accidents, a leading cause of open fractures³.

Workplace safety - Ensuring protective equipment and safety protocols in high-risk jobs, such as construction, can prevent fractures. 

Fall prevention - In older adults, modifying homes, promoting balance exercises, and managing osteoporosis can reduce fall-related fractures⁴.

Public health and education

Awareness campaigns - Educating the public about road safety, bone health, and the importance of protective gear can reduce the incidence of open fractures⁵.

Bone health - Promoting calcium and vitamin D intake, and regular bone density screening for high-risk groups, helps maintain bone strength and prevent fractures⁶.

Healthcare system strengthening

Training healthcare workers - Training healthcare providers in trauma care and early fracture management can prevent complications, especially in LMICs⁷.

Infrastructure improvement - Strengthening emergency response and ensuring timely medical intervention can reduce infection risks and improve outcomes⁸.

Basics of Open Fractures Course

Timely intervention

Surgical treatment - Early debridement and stabilization, ideally within 6 hours of injury, significantly reduce infection risk and improve recovery^9,10.

Policy measures

Legislation - Governments should enforce road safety and workplace safety laws and ensure access to affordable care to reduce fracture-related complications^11,12.

Read more about WHO approach to increase road safety WHO approach.

Open fractures not only present significant medical challenges but also create profound social, economic, and healthcare burdens. The impact of open fractures extends beyond the immediate injury and affects multiple aspects of a patient's life, including mobility¹, employment, and mental health².

We will discuss the non-financial and financial impacts of open fractures on both patients and healthcare systems.

Impact on health and social well-being

Open fractures often lead to prolonged hospitalizations, physical rehabilitation, and in many cases, permanent disability³. In severe cases, open fractures can be life-threatening due to massive blood loss in the acute phase.

Common long-term negative effects include:

Fracture-related infection - Open fractures carry a high risk of fracture-related infection (FRI), which may persist long term and, in severe cases, progress to life-threatening septicemia.

Disability and reduced mobility - Open fractures frequently result in permanent functional impairments, particularly if they involve weight-bearing bones such as the tibia or femur. The loss of mobility can lead to difficulties in performing daily tasks and can severely limit a person’s independence, especially in LMICs where access to assistive devices or rehabilitation may be limited⁴.

Psychosocial effects - The emotional burden of living with a disability due to a traumatic injury can cause significant psychological stress. Depression, anxiety, and post-traumatic stress disorder (PTSD) are common among individuals who suffer severe trauma, particularly in younger people who may face challenges in adjusting to a new way of life. Additionally, the inability to engage in social activities or employment⁵ can lead to social isolation⁶ and a loss of self-esteem⁷.

Social stigma - In certain cultures or regions, people with visible disabilities, such as those caused by open fractures, may face social stigma or discrimination. This can further affect their mental health and hinder their reintegration into society⁸.

These impacts disproportionately affect low- and middle-income countries (LMICs), where healthcare resources for rehabilitation, prosthetics, and mental health services may be insufficient⁹.

The financial burden

The financial burden of open fractures is substantial, both for patients and healthcare systems. Open fractures are generally more costly to treat than closed fractures due to the risk of infection, longer recovery times, and the need for more intensive medical interventions such as surgery, wound care, and rehabilitation¹.

Increased healthcare costs - Open fractures, particularly those involving the tibia, are associated with higher rates of complications⁹, such as infections, non-union, and malunion, compared to closed fractures. Studies have shown that open tibial fractures are eight times more likely to be complicated by infections and malunions¹⁰. Infections alone can lead to a 6-fold increase in hospital length-of-stay and a 5-fold increase in total healthcare costs¹¹.

Catastrophic health expenditure - In LMICs, the financial burden is exacerbated by the high costs of treatment, transportation, and accommodations. A 2019 study in Tanzania found that 85% of injured patients in emergency departments faced catastrophic health expenditures, meaning the cost of treatment exceeded a significant proportion of their household income. These out-of-pocket expenses can drive families into poverty, especially in areas where public health systems are underfunded and private insurance coverage is limited¹².

Length of stay - The total length of stay in the hospital is the primary cost driver when treating open fractures. The longer a patient remains hospitalized due to complications such as infections, the greater the financial strain on the healthcare system. This not only affects hospital budgets but also places additional burdens on healthcare staff and resources, potentially delaying care for other patients¹³.

Impact on work and productivity - In many cases, young patients with open fractures who are the primary breadwinners for their families may be unable to work for extended periods, leading to a loss of income and an increase in the financial burden on the household. In LMICs, where social safety nets may be minimal, this loss of income can have devastating effects on families¹³.

Long-term care and rehabilitation - Many patients require ongoing rehabilitation, physical therapy, and sometimes prosthetic devices, which are often not readily available or affordable in resource-limited settings¹³.

Total length of stay in hospital is the most critical cost driver in treating open fractures.

Global health considerations

Surgical care, including open fracture care, is still the neglected stepchild of global health.

The financial and non-financial burdens of open fractures are critical issues that need to be addressed, especially in low-resource settings worldwide.

Global health initiatives should focus on improving access to timely and effective treatment for open fractures, including better trauma care, more affordable surgical options, and post-injury rehabilitation programs. Efforts to reduce the financial burden on patients should also include policies aimed at reducing out-of-pocket costs, strengthening social safety nets, and improving access to affordable medical care.

Outcomes of patients with open fractures are affected by several key factors^1,2,3. Understanding and addressing these factors through comprehensive and timely medical care can significantly improve the prognosis for patients with open fractures.

Some of the factors that influence the outcome of open fractures:

1 Severity of injury

2 Infection control and prevention

3 Timeliness

4 Patiënt-related factors

5 Healthcare provider related factors

6 Resources available in different settings worldwide

7 Early mobilization and rehabilitation

Severity of the injury

The severity of the injury clearly effects the outcome. Apart from the open fracture, other injuries can be life threatening in severe injuries. The more comminuted or displaced the fracture, the more challenging the fracture healing process⁴.

High-energy trauma typically results in more severe fractures with a more comminuted or more displaced fracture with more soft tissue damage that requires more complex treatment strategies compared to low-energy trauma⁵.

More extensive soft tissue injury leads to increased risk of infection and delayed healing⁶. The extent of muscle, nerve, and vascular damage significantly affects the outcome⁷.

The Gustilo-Anderson grading system is the most common used classification for open fractures and it is related to the prognosis. A lower classification number indicates better outcome.

Fracture description

Infection prevention and control

Infection prevention and control (IPC) is a cornerstone of practicing safe surgery.

Simply put,

Open fractures are at high risk for infection due to direct exposure to the environment. The level of contamination at the time of injury is an important predictor of infection risk.

Early and appropriate antibiotic therapy, along with timely debridement (the removal of dead tissue), is critical in managing this risk⁸. 

Infection prevention and control

Timeliness

Important time related factors are:

Time to adequate resuscitation if required - For the Primary Survey see page Treating open fracture in ER.

Time to debridement and irrigation - Early surgical intervention to clean the wound reduces the risk of infection.

Time to stabilization of the fracture - Prompt and adequate stabilization of the fracture promotes better healing outcomes.

Time to adequate soft tissue coverage and definitive fixation - Timely and adequate soft tissue coverage is essential, especially for high-grade open fractures.

Patient-related factors

Patient-related factors such as age, comorbidities, nutritional status, lifestyle habits, financial situation, and socio-cultural circumstances are of, often underestimated, importance on the prognosis. For more information on factors that influence fracture healing,

Bone healing.

Healthcare provider related factors

Questions that influence the success of treatment and should be taken into consideration before a treatment is given:

Orthopedic and/or plastic surgeon - Is there an orthopedic and/or plastic surgeon available that has experience and skills to treat open fractures?

Anesthesia - What types of anesthesia can be provided?

Microbiology - Is there a microbiologist available for consultation?

Aftercare - How well can the aftercare be organized?

Multidisciplinary approaches are vital to improve outcomes in open fractures. This includes medical doctors, nurses, clinical officers and other supporting staff.

The Lancet Commission on Global Surgery specifically reports on the necessity of expanding the surgical workforce and mentions the necessity of non-clinical staff. It shows that surgical care can be cost-effective and even more affordable than other public health interventions⁹.

National, regional or local training programs can be implemented to familiarize healthcare workers with the treatment principles of open fractures.

Allocating dedicated trauma nurses for pre- and postoperative care may improve workflow on a trauma ward or out-patient department, while simultaneously reducing complications¹⁰.

Resources available in different settings worldwide

The very basic open fracture care has a minimum resource requirement:

1 Plaster of Paris or cast

2 Intravenous antibiotics

3 Equipped and clean operating theater (OT) with at least orthopedic surgery instruments

4 External fixator set with compatible bars, pins and clamps

5 X-ray machine (preferably also fluoroscopy in the theatre)

6 Crutches

7 Wound care materials

Traditionally, healthcare resources in low-resource settings have been focused on communicable diseases, leaving fewer resources allocated to open fracture care.

As surgical care usually requires specialized equipment and consumables, initial setup costs may be high.

Early mobilization and rehabilitation

Good postoperative care, including wound care and physiotherapy, and close monitoring by skilled personnel is important to early identify and manage complications¹¹.

Make sure there is a well-organized and supervised postoperative follow-up system in your hospital to optimize outcomes.

Early rehabilitation, focusing on early exercises to increase range of motion of the nearby joints, can improve functional outcomes and reduce the risk of long-term complications such as joint stiffness and muscle atrophy¹².

In most countries, the practice of traditional bone setters is dominated by male practitioners. They typically lack formal education, with the practice often passed down through paternal lineage or apprenticeship with neighboring men^1,2.

Traditional bone setting (TBS) is a widely practiced form of traditional medicine in various parts of the world. This practice continues to play a significant role in providing healthcare to many communities around the world^3,4.

What does traditional bone setting involve?

TBS involves the manual manipulation of fractured or dislocated bones, often using a combination of fracture massage, splinting, reduction, and herbal remedies to promote healing and relieve pain⁷.

However, many less scientific and less safe variations of this practice exist. The well-documented life- and limb-threatening complications of seeking treatment from bonesetters include:

1 Malunion

2 Nonunion

3 Joint stiffness

4 Chronic osteomyelitis

5 Ischemia

6 Gangrene

Why patients choose TBS

Despite the risks, many patients still opt for TBS services, for many reasons⁸, including:

1 Low cost of treatment⁹

2 Impersonal or abusive treatment at hospital (dissatisfaction with modern medicine)¹⁰

3 Lack of awareness¹¹

4 Fear of surgery and amputation

5 Cultural belief^12,13

6 Perceived effectiveness of traditional methods¹⁴

7 More accessibility to the wider population¹⁵

8 Social pressure

9 Spiritual guidance¹⁶

Research about the practice of TBS and its use for musculoskeletal disorders among Nigerian rural dwellers shows that 69.4% of respondents indicate that they have (at some point) used the services of a traditional bone setter for musculoskeletal problems¹⁶.

Most stakeholders within the system of fracture treatment, see the potential benefits and challenges of intersectoral collaboration between traditional bonesetters and formal healthcare systems. Training and integration being commonly suggested resulting in beneficial effects on trainee knowledge and skills, as well as improved patient outcomes¹⁷.

Prevalence of TBS-use

In addition, 16.9% of the users of TBS services reported it to be as effective as orthodox medicine. Massage (61.0%) and splinting (14.3%) were the most common forms of treatment by TBS received for musculoskeletal disorders.

Factors to consider when treating a patient

Looking for common ground between traditional and modern medicine can facilitate integration¹⁹. By providing structured training and stimulating collaboration, recent studies have shown promising results in improving patient outcomes and reducing complications.

Be aware that if an open fracture patient in a resource-limited setting enters the hospital, it is likely they:

1 Were sent to the hospital by a bonesetter

2 Are only planning on getting an X-ray

3 Plan on returning to the bonesetter

4 Fear judgment by the physician for this fact

5 Fear amputation of the affected limb if treated at the hospital

6 Fear metal implants, which are commonly believed to slow healing, cause chronic pain, and cause cancer

7 Fear abuse from nurses or doctors

8 Fear high treatment costs

It is important to address these common fears, to avoid the patient requesting early discharge, which could result in suboptimal treatment.

Take your time and discuss the following with the patient:

1 The exact diagnosis.

2 The goal: to avoid amputation of the limb.

3 The recommended treatment and what the treatment involves.

4 If treatment involves metal implants: address beliefs regarding slow healing, chronic pain, and cancer. Explain the possibility of removal of osteosynthesis materials.

5 The duration of hospital stay.

6 The duration until return to work.

7 The risk of complications.

8 The exact cost of treatment.

9 Whether the patient plans to consult, or has already consulted a TBS. If so, most patients appreciate communicating with the TBS to find common ground and a treatment plan that is acceptable to all parties.

It may be more desirable to accept a traditional bone setter providing traditional massage in the hospital ward, if that means the patient agrees to surgical treatment as well.