What is the management of an open fracture?

Management of Open Fractures

Open fractures require immediate antibiotic administration (ideally within 3 hours), urgent surgical debridement and irrigation (within 24 hours), appropriate fracture stabilization, and soft tissue coverage within 7 days to minimize infection risk and optimize functional outcomes. 1

Immediate Initial Management (Emergency Department/Pre-Hospital)

Antibiotic Prophylaxis - Critical First Step

• Administer antibiotics as soon as possible after injury, ideally within 3 hours, as delays beyond this timeframe significantly increase infection risk 1, 2
• For Gustilo-Anderson Type I and II fractures: Use cefazolin (first-generation cephalosporin) or clindamycin if beta-lactam allergic 1, 2
• For Gustilo-Anderson Type III fractures (and possibly Type II): Add gram-negative coverage with an aminoglycoside (gentamicin) or piperacillin-tazobactam to the cephalosporin 1, 2
• Continue antibiotics for maximum 48-72 hours post-injury unless proven infection exists 1, 2
• For wounds with gross contamination, consider adding penicillin to cover anaerobic organisms 2

Wound and Fracture Management

• Apply sterile wet dressing after thorough wound cleaning 1
• Immobilize the fracture temporarily to prevent further soft tissue damage 1
• Verify tetanus immunization status and provide prophylaxis as needed 1

Surgical Management (Operating Room)

Timing and Debridement

• Bring patients to the operating room for debridement and irrigation within 24 hours of injury 1, 3
• Perform thorough surgical debridement of all devitalized tissue and foreign material 1, 4
• The initial debridement and injury severity assessment determine the overall treatment strategy 3

Irrigation Technique

• Irrigate wounds with simple saline solution without additives - this is a strong recommendation as antiseptics or soap additives provide no benefit over saline 1, 2

Fracture Stabilization

• Stabilize the fracture using appropriate fixation based on fracture type, location, soft tissue injury extent, and patient factors 1
• Simple injury patterns can be treated with primary fixation and wound closure 3
• With substantial contamination, bone loss, or extensive soft tissue damage, use temporary fixation and temporary wound closure 3
• Temporizing external fixation remains viable for severe open fractures 1

Local Antibiotic Strategies

• Consider local antibiotic delivery systems as beneficial adjuncts, particularly for Type III fractures with bone loss 1, 2
• Options include vancomycin powder, tobramycin-impregnated beads, gentamicin-coated implants, or gentamicin-covered nails 1, 2

Wound Coverage and Soft Tissue Management

• Achieve definitive wound coverage within 7 days from injury date to reduce fracture-related infection risk 1, 3
• Extensive soft tissue damage may necessitate local or free muscle flaps 4, 5
• Consider negative pressure wound therapy (NPWT) for closed fracture fixation to reduce revision surgery or surgical site infection risk 1
• Note that NPWT after open fracture fixation does not offer advantages compared to sealed dressings 1

Special Considerations and Risk Factors

Patient-Specific Risk Factors

• Patients who smoke, have diabetes, or are obese have increased risk for surgical site infections 1
• Significant alcohol use (>14 units per week) increases postoperative infection risk 1

Severe Open Pelvic Fractures

• Prioritize bleeding control and management of perineal contamination as primary objectives 6
• These injuries should be managed in referral centers due to their rarity, complexity, and need for multidisciplinary approach 6
• Management priorities include: (1) bleeding control, (2) cleaning and debridement, (3) identification and treatment of associated lesions, (4) treatment of the pelvic fracture 6
• Mortality can exceed 50% in open pelvic fractures 6

Vascular Injuries

• 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

• Do not delay antibiotic administration beyond 3 hours - this significantly increases infection risk 1, 2
• Do not use antiseptics or soap additives for wound irrigation - simple saline is equally effective 1, 2
• Do not fail to consider local antibiotic delivery systems in severe Type III fractures, particularly with bone loss 1, 2
• Do not close contaminated wounds primarily - this increases gas gangrene risk 4
• Do not extend systemic antibiotics beyond 72 hours without proven infection 1, 2