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,

Infection Prevention	Infection Control
Focused on preventing infections from occurring in the first place.	Focused on managing and containing infections once they have occurred.
Proactive and anticipatory.	Reactive or corrective.
Examples: hand hygiene, sterile surgical technique, vaccination, safe injection practices, sterilization of instruments.	Examples: isolating infected patients, managing outbreaks, contact tracing, using personal protective equipment (PPE) during outbreaks.
Minimizing the risk of infection before it happens.	Limiting spread after an infection is identified.

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.

Literature

¹ Tye, C., Alkhabbaz, O., Miaw, W., Park, K., Newman, S., & Barcak, E. (2025). Outcomes of Patients Treated for Open Pilon Fractures at a County Hospital. Foot & Ankle Specialist. https://doi.org/10.1177/19386400251316921

² Schnetz, M., Wengert, A., Ruckes, C., Jakobi, T., Klug, A., & Gramlich, Y. (2025b). Open fractures of the lower leg: Outcome and risk-factor analysis for fracture-related infection and nonunion in a single center analysis of 187 fractures. Injury, 112303. https://doi.org/10.1016/j.injury.2025.112303

³ M’bra, K. I., Akobe, A. J., Kouassi, A. A. N., Soumahoro, I., Yao, L. B., Sery, B. J. L. N., Krah, K. L., & Kodo, M. (2024). Predictive Factors of Functional Outcome of Open Fractures of the Foot at the Bouaké Hospital and University Center. Open Journal Of Orthopedics, 14(11), 510–523. https://doi.org/10.4236/ojo.2024.1411047

⁴ Bigham‐Sadegh, A., & Oryan, A. (2014). Basic concepts regarding fracture healing and the current options and future directions in managing bone fractures. International Wound Journal, 12(3), 238–247. https://doi.org/10.1111/iwj.12231

⁵ Demidov, V. V., Clark, M. A., Streeter, S. S., Sottosanti, J. S., Gitajn, I. L., & Elliott, J. T. (2022). High‐energy open‐fracture model with initial experience of fluorescence‐guided bone perfusion assessment. Journal Of Orthopaedic Research®, 41(5), 1040–1048. https://doi.org/10.1002/jor.25443

⁶ Von Rüden, C., Wunder, J., Schirdewahn, C., Augat, P., & Hackl, S. (2024). Initial treatment of severe soft-tissue injuries in closed and open fractures to prevent fracture-related infection. Injury, 55, 111935. https://doi.org/10.1016/j.injury.2024.111935

⁷ Effect of soft tissue damage on fracture healing: intravital microscopie and biomechanical investigations in rats. (1999). https://www.ors.org/transactions/50/0120.pdf

⁸ Atwan, Y., Miclau, T., Schemitsch, E. H., & Teague, D. (2020). Antibiotic utilization in open fractures. OTA International The Open Access Journal Of Orthopaedic Trauma, 3(1), e071. https://doi.org/10.1097/oi9.0000000000000071

⁹ Meara, J. G., Leather, A. J. M., Hagander, L., Alkire, B. C., Alonso, N., Ameh, E. A., Bickler, S. W., Conteh, L., Dare, A. J., Davies, J., Mérisier, E. D., El-Halabi, S., Farmer, P. E., Gawande, A., Gillies, R., Greenberg, S. L. M., Grimes, C. E., Gruen, R. L., Ismail, E. A., . . . Yip, W. (2015). Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet, 386(9993), 569–624. https://doi.org/10.1016/s0140-6736(15)60160-x

¹⁰ Sa, W., Shuihong, C., Jingfen, J., Mao, Z., Zhiting, G., Danping, Y., Chang, H., & Yuwei, W. (2023). The effect of trauma advanced practice nurse programme at a Level I regional trauma centre in mainland China. Nursing Open, 10(9), 6559–6565. https://doi.org/10.1002/nop2.1911

¹¹ Open fractures of the lower limb. (z.d.). https://richtlijnendatabase.nl/en/richtlijn/open_fractures_of_the_lower_limb/organisation_of_care_open_limb_fractures.html

¹² Bennett, A., & Smith, K. (2013). (ii) Open fractures. Orthopaedics And Trauma, 27(1), 9–14. https://doi.org/10.1016/j.mporth.2013.01.001