Priorities
An open fracture is a fracture associated with a wound that communicates with the fracture or its haematoma. Management is an orthoplastic emergency because the outcome depends on both skeletal injury and soft-tissue damage.
Immediate priorities are:
- assess and resuscitate according to major-trauma principles
- document neurovascular status before and after splintage
- photograph the wound once, then cover it with a sterile saline-moistened dressing and an occlusive layer
- splint the limb
- give appropriate intravenous antibiotics promptly according to local protocol
- update tetanus protection when indicated
- involve orthopaedic and plastic-surgery teams early for severe injuries
Repeated wound inspection in the emergency department is avoided because it adds contamination without improving definitive assessment.
An open fracture is a fracture associated with a wound communicating with the fracture or its haematoma. The size of the visible wound can underestimate the zone of injury.
Initial priorities follow major-trauma principles:
- identify and treat life-threatening problems
- control major haemorrhage
- document neurovascular status
- cover the wound with a sterile dressing
- splint the limb
- give appropriate intravenous antibiotics promptly
- assess tetanus status
Repeated examination of the wound outside theatre should be avoided.
Classification
The Gustilo-Anderson system remains widely used, but classification is most reliable after formal debridement.
- Type I: small, relatively clean wound with limited soft-tissue injury
- Type II: larger wound without the extensive soft-tissue destruction of type III injury
- Type III: high-energy injury, extensive contamination or major soft-tissue damage
- IIIA: adequate viable soft-tissue coverage can be achieved
- IIIB: major periosteal stripping or bone exposure requiring formal soft-tissue reconstruction
- IIIC: associated arterial injury requiring repair
Classification communicates severity but should not replace a description of contamination, vascular injury, bone loss and soft-tissue viability.
Debridement
The aim is to convert a contaminated traumatic wound into a surgically clean wound while preserving viable tissue.
Principles:
- extend the traumatic wound in a planned fashion when necessary
- remove foreign material and clearly non-viable tissue
- assess muscle by appearance, consistency, contractility and bleeding rather than by a single feature
- retain viable bone that contributes to reconstruction; devascularised loose fragments without meaningful soft-tissue attachment are usually removed
- irrigate adequately with low-pressure isotonic fluid
- reassess viability after systematic debridement
- use fresh instruments and re-preparation when proceeding to reconstruction
Formal debridement aims to remove:
- foreign material
- gross contamination
- non-viable skin
- devitalised muscle
- non-viable bone fragments when appropriate
Muscle viability is judged by a combination of colour, consistency, capacity to contract and bleeding, not by one feature alone.
Debridement should be systematic and extensile enough to expose the entire zone of injury.
Skeletal stabilisation
Stabilisation should restore length, alignment and rotation while respecting soft tissues. Options include temporary spanning external fixation, definitive external fixation, internal fixation or staged conversion. The choice depends on injury pattern, contamination, physiology, vascular repair and the soft-tissue plan.
Stabilisation:
- reduces pain
- protects soft tissues
- restores length/alignment
- facilitates wound care and reconstruction
Choice between external fixation, internal fixation and staged strategies depends on contamination, soft tissues, fracture pattern, physiology and reconstructive plan.
Soft-tissue coverage
Stable fixation and definitive coverage should be planned together. Local rotational muscle flaps, fasciocutaneous flaps or free-tissue transfer may be required. Coverage should not be delayed simply to wait for granulation tissue when definitive reconstruction can safely be achieved.
Limb salvage versus amputation
The decision is individualized. Consider:
- life-threatening systemic injury
- warm ischaemia and revascularisation feasibility
- extent of muscle and nerve loss
- contamination and bone loss
- expected function after salvage
- number and burden of reconstructive procedures
- patient goals and rehabilitation potential
Injury scores can support communication but should not be used as an automatic amputation rule.
Assessment of the limb
Document:
- wound location and contamination
- vascular status
- nerve function
- compartment status
- skin viability
- associated soft-tissue loss
- fracture pattern
Classification is most meaningful after formal debridement because the true injury cannot always be judged from the emergency department appearance.
Antibiotics
Antibiotic choice depends on local protocol, injury severity and contamination pattern. The important principle is early administration followed by a defined duration and review strategy.
Antibiotics reduce infection risk but cannot compensate for retained devitalised tissue or poor soft-tissue management.
Irrigation
Copious low-pressure irrigation is commonly used after adequate debridement. Irrigation is not a substitute for excision of devitalised tissue.
Soft-tissue cover
Definitive soft-tissue reconstruction should be planned early with plastic surgery when required. Stable fixation and durable vascularised coverage are interdependent.
Temporary negative-pressure therapy can help bridge to definitive coverage but should not become an excuse for repeated delay.
Vascular injury
A pulseless or poorly perfused limb requires urgent vascular assessment and coordinated restoration of perfusion and skeletal stability.
Infection and non-union
Risk rises with:
- severe soft-tissue injury
- contamination
- devascularisation
- bone loss
- delayed or inadequate debridement
- unstable fixation
- poor host factors
FRCS synthesis
The core sequence is: resuscitate → antibiotics → sterile cover/splint → meticulous debridement → stable skeleton → early definitive soft-tissue reconstruction. Treat the injury as a combined bone-and-soft-tissue problem.