What is the management of an open fracture?

Management of Open Fractures

The management of open fractures requires prompt administration of systemic antibiotics, thorough wound irrigation with saline solution, surgical debridement, fracture stabilization, and appropriate wound coverage to minimize infection risk and optimize healing outcomes. 1

Initial Management

• Administer antibiotic prophylaxis as soon as possible after injury (ideally within 3 hours) to reduce infection risk 1, 2
• Use cefazolin or clindamycin (if allergic to beta-lactams) for Gustilo-Anderson Type I and II open fractures 1, 3
• Add gram-negative coverage (aminoglycoside or piperacillin-tazobactam) for Gustilo-Anderson Type III (and possibly Type II) open fractures 1, 3
• Continue antibiotics for 48-72 hours maximum unless infection is proven 1
• Perform thorough wound cleaning and apply sterile wet dressing prior to surgical management 1
• Check tetanus immunization status and provide prophylaxis as needed 1
• Immobilize the fracture temporarily to prevent further soft tissue damage 1

Surgical Management

• Bring patients with open fractures to the operating room for debridement and irrigation ideally within 24 hours of injury 1
• Irrigate the wound with simple saline solution without additives (strong recommendation) 1
• Perform thorough surgical debridement of all devitalized tissue and foreign material 1, 2
• Consider local antibiotic strategies (vancomycin powder, tobramycin-impregnated beads, gentamicin-covered nails) as beneficial adjuncts 1
• Stabilize the fracture using appropriate fixation method based on fracture type, location, soft tissue injury extent, and patient factors 1, 2
• Definitive fixation at initial debridement and primary closure may be considered for selected open fractures 1
• Temporizing external fixation remains a viable option for open fractures 1

Wound Management

• Achieve wound coverage within 7 days from injury date (moderate recommendation) 1
• Consider negative pressure wound therapy (NPWT) for closed fracture fixation to mitigate revision surgery or surgical site infection risk 1
• Note that NPWT after open fracture fixation does not appear to offer advantages compared to sealed dressings 1
• For severe open pelvic trauma, prioritize bleeding control and management of perineal contamination 1

Special Considerations

• Patients who smoke, have diabetes, or are obese may have increased risk for surgical site infections 1
• Significant alcohol use (>14 units per week) increases postoperative infection risk 1
• The Gustilo-Anderson classification system remains widely used, though the OTA open fracture classification system (OTA-OFC) may provide better interobserver agreement 1
• For open fractures with vascular injuries, time to ischemia reversal is important but should be considered a relative criterion rather than an independent predictor for amputation 1

Common Pitfalls to Avoid

• Delaying antibiotic administration beyond 3 hours post-injury significantly increases infection risk 3, 2
• Continuing antibiotics beyond recommended duration without evidence of infection 3
• Using soap or antiseptic additives for wound irrigation, which provide no additional benefit over simple saline 1
• Failing to consider local antibiotic delivery systems as adjuncts in severe cases 3
• Underestimating the importance of soft tissue management in open fractures, which should be considered during initial assessment and not as a secondary process 2