Primary survey

A patient who comes to your department with an open fracture is a trauma patient. Always start with the primary survey following the XABCDE approach.

Our Primary survey page for detailed guidance on how to perform the primary survey.

Inspection

In cases of open fractures, it is vital to initially inspect the fracture site properly and asses:

• Wound site - location and size

• Soft tissue damage - e.g. extensiveness of damage to skin, muscle or tendons

• Arterial damage - visible arterial bleeding? Assess pulsations of the affected limb

• Visual contamination - street dirt, debris, or foreign material

Tip - Take a photo of the initial assessment to communicate with the team, and to look back at the initial situation. Later you can reassess your classification if necessary.

Management

Initial management of open fractures in the emergency room (ER) should include:

1 Removing visible dirt

2 Administer antibiotics

3 Reduction of the fracture

4 Debridement

5 Closure of the wound

6 Stabilisation of the fracture

7 Pain management

Remove visible dirt and irrigate

Remove any visible dirt². This can cause infections, and if left in place before irrigation, you might flush it deeper inside the open wound.

Be mindful of removing debris with your hands: sharp elements or bone shrapnel might be dangerous to you!

Irrigation is important in the process of preventing infection from occurring. When irrigating, consider the following:

Mode of irrigation – gravity flow will be easy and cheap but provides inconsistent pressure. High pressure pulsating flow can damage cells and tissues. 

Pressure – too low might not clean enough; too high damages cells and can compromise the healing process. Ideally, provide medium pressure.

Volume – clean wound with a clear fluid until visually clean. The ideal volume has not yet been determined, but proposed volumes are: 3L, 6L and 9L for type 1, 2 and 3 fractures respectively.

Temperature – if the fluids used are too cold, the patient might experience hypothermia; too warm and they can damage the cells and tissues.

Timing – no definitive conclusions have been drawn. Preferably as soon as possible. The longer the bacteria have to settle, the harder it will be to flush the wound clean.

Antibiotics

Providing open fracture patients with antibiotics can reduce their risk of infection. The infection rate is 3% with antibiotics compared to 14% without.⁴ Infections can lead to the need for further additional surgeries, the removal of osteosynthesis materials, and prolonged hospital stays.

• Start antibiotic prophylaxis as soon as possible, preferably within one hour of the accident.
• Start cefazolin in combination with an aminoglycoside or third-generation cephalosporin.
• Treat for at least 24 hours, extending treatment longer than this has not been scientifically proven.

Who needs antibiotics?

In any open fracture case it is advised to administer antibiotics. However, it is important to consider that the category of the fracture affects the risk of infection: the higher the Gustillo-Anderson grade, the higher the risk of infection. Studies show an infection rates ranging from 1.4-7%, 3.6-21% and 22.7-29% for Gustilo-Anderson grades I, II and III respectively.^4,5 Take this into account in preparation for surgery and when using other preventative measures to make sure no infection occurs.

When should you give antibiotics?

As soon as possible. General recommendations are to aim for within the first hour of the accident, although in remote settings this will not always be feasible.

One study showed that infection rates were lower when antibiotics were given within three hours, with an infection rate of 4.7% compared to 7.4% when therapy was delayed.³

Which antibiotics should you choose?

The antibiotics you choose will mainly cover common skin flora. It is useful to start a second antibiotic to cover hospital-acquired gram-negative infections.

The choice of antibiotics was originally based on Gustillo-Anderson classifications: patients with grade I and II open fractures should receive first grade cephalosporin, and an aminoglycoside should be added for grade III. Other guidelines mention that when there is a risk of contamination with fecal matter or soil, a penicillin should be added.⁶

A fixed protocol helps to minimize variation in care and can help research and communication. It is advised to use your local protocol for treatment.

Reduction of the fracture

This will reduce strain on the surrounding soft tissue around the fracture. It is important to always check the vascular and neurologic supply distal to the fracture site before and after reduction and document these findings.

Debridement

This will aid in preventing infection of the fracture. During debridement¹, focus on several steps:

• Removal of devitalized tissue – important because if left in place, it forms a perfect growth site for bacteria.
• Wound excision – to leave healthy skin edges to promote skin healing.
• Wound extension – indicated when the wound is too small to clean thoroughly through the opening. Be mindful that you do not compromise possible skin flaps for definitive closure by extending wounds.
• Debridement of the fracture – can be done to thoroughly clean bone edges and to remove any loose fragments of bone.

Closure

Wound closure is done when the wound is clean and a plan has been made for the final fixation and stabilization of the fracture. Type 1 and 2 fractures can be closed after primary debridement. Type 3 fractures may require full closure, sometimes only after a second look. See for further information the management of soft tissue page.

Remember when closure of a wound is not possible due to extended soft tissue injury it is important to cover the wound that it does not dry out. Different materials can be used for this, for example plastic kitchenfoil, a wet gauze or papaya skins.

Stabilization of the fracture

There are multiple options for fracture stabilization³, including:

Cast – for type 1 and type 2 open fractures. Be aware that you should create a window in the cast for wound examination. If a window compromises the stability the cast is providing, this might not be the best treatment option.

External fixator – Not performed in ER but can be placed in the OR as a temporary measure or definitive treatment. This depends on the achieved reduction with external fixator.

Open reduction and internal fixation (ORIF) – Only performed in OR, can be a good direct treatment of the fracture site with good views for reduction. However, some studies show that there might be an increase of infection rate with ORIF treatment.

Pain management

Pain management is important in the initial management of open fractures and should be given promptly. We advise the reversed WHO pain ladder:

1 Strong opioids
For severe pain that is not adequately controlled with step 2, strong opioids like morphine, oxycodone, or fentanyl are introduced. This step provides the most potent analgesia and is reserved for severe pain.

2 Mild opioids
If pain persists or intensifies, the next step involves adding a mild opioid, such as codeine or tramadol, to the non-opioid regimen. This step is suitable for moderate pain and aims to provide more potent pain relief.

3 Nonsteroidal anti-inflammatory drugs (NSAIDs)
In addition to acetaminophen, nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen or naproxen can be utilized to address mild to moderate pain. NSAIDs work by reducing inflammation and can provide additional pain relief when acetaminophen alone is insufficient.

4 Non-opioid analgesics
Non-opioid medications, such as acetaminophen (paracetamol), are recommended for mild pain. Acetaminophen is effective for managing pain of low to moderate intensity and serves as an essential option in the first step of the ladder.

Additional investigations

In addition to initial management of the wound site, you need to analyze the fracture. This is usually done by means of X-ray or CT-scan, if available.

When using an X-ray, be sure to make an X-ray in two directions: an anterior–posterior (AP) and a lateral view.

By combining the results of initial assessment and additional investigations you can properly describe the open fracture and create an integrated treatment plan accordingly.

In managing open fractures it is also always important to consider a patients vaccination status considering Tetanus. Open fractures usually occur outdoors so double check if the tetanus status of your patient is up to date or new vaccinations will be necessary.