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Management of open fractures

Shankar Acharya*, Gurdeep S. Ratra**, Bhartendra Jain***

Department of Orthopaedics, Sir Ganga Ram Hospital, Rajinder Nagar, New Delhi.
Address for Correspondence
Gurdeep S. Ratra
1830, Sector 10-A, H.U.D.A., Near Housing Board Colony,
Gurgaon - 122001, Haryana.
Phone:  +91 9891397301


With high-energy trauma on the rise, open fractures are a common occurrence. An understanding of fracture pathology and classification is fundamental to deciding the appropriate management. While final management depends on various factors such as locally available resources and facilities/ financial constraints/ technical expertise etc, review of literature helps us arrive at a consensus as to what treatment is best in the given situation. We review here, the available literature and discuss the preferred lines of management. While each method has its merits and demerits, this article attempts to briefly outline the general prevalent protocols. 

J.Orthopaedics 2007;4(1)e18


     Tscherne1 described 4 major eras in the treatment of open fractures:

  • the era of life preservation

  • the era of limb preservation.

  •  the era of avoidance of infection.

  •  the era of  preservation of function.

In spite of the advances made in fracture care and management of infection, open fractures remain a serious surgical problem. The annual incidence of open fractures of long bones has been estimated to be 11.5 per 100000 persons with 40% occurring in the lower limb, most commonly at the tibial diaphysis2.


An open fracture is one in which a break in the skin and underlying soft tissues communicates with the fracture and its hematoma.


Open fractures are becoming common due to high energy trauma, as in road traffic accidents. Broadly, the circumstances of injury fall into 3 main categories:

  • the body  is stationary and is struck by a moving object.

  • the body is in motion and strikes a stationary object.

  • the body is in motion and strikes another moving object.

     Depending on the extent of trauma, 4 consequences may result:

  • contamination of the area of injury by bacteria from the external environment.
  • crushing and devascularization of  soft tissues render this area of injury more susceptible to infection.
  • the loss of normal soft tissue cover may affect the methods by which the fracture is usually immobilized and may deny the fracture site the usual contribution from overlying soft tissues in the bone healing process.
  • direct loss of function owing to damaged muscles, tendons, nerves and vessels


Several classification systems have been proposed for open fractures- Allgower3, Tscherne1. The Gustilo-Anderson system4  is probably the most widely accepted. It was modified in 1984 and groups open fractures into the following categories:

  • Type I: Clean wound less than 1 cm long.

  • Type II: Laceration more than 1 cm long but without extensive soft tissue damage, skin flaps or avulsions.

  • Type IIIA: Extensive soft tissue laceration but maintain adequate soft tissue coverage of bone.

  • Type IIIB:  Extensive soft tissue loss with periosteal stripping and bony exposure.

  • Type IIIC:  Open fractures with arterial injury requiring repair, regardless of wound size.

Higher the velocity of trauma, higher the type, more the soft tissue injury, more the chances of wound contamination.

When combined with an assessment of the surgeon’s capabilities, facility and resources, classification of fracture and associated soft tissue injuries allows determination of the best treatment. Analysis of fracture pattern reveals the amount of energy imparted to the extremity and stability of the fracture after reduction. The AO alphanumeric classification published by Muller et al5 is based on the morphological characteristics and location of the fracture. Taylor and Martin6 proposed a classification of fractures (SUD) in which the main fracture is characterized as stable (S), unstable (U) or with diaphyseal extension (D). These are further divided into 3 subgroups: 0- extra articular, 1- intra articular with displacement less than 2mm and 2- intra articular with displacement more than 2mm. According to Taylor and Martin, with progression from type S to type D, treatment shifts towards external fixation and away from open reduction. Conversely, with progression from subgroup 0 to subgroup 2, open reduction is indicated.

Prognosis of limb salvage

Helfet et al7 reported the Mangled Extremity Severity Score (MESS) based on 4 criteria: skeletal and soft tissue injuries, shock, ischemia and age. In their study, limbs with scores of 7 to 12 ultimately required amputation, whereas scores of 3 to 6 resulted in viable limbs. The LEAP (Lower Extremity Assessment Project) study8, a multicentre prospective study, found that reconstruction and limb salvage typically result in two year outcomes equivalent to those of amputation for high energy injuries (Gustilo type IIIB and IIIC and some IIIA fractures) below the distal femur.


Initial evaluation of a patient with an open fracture should always follow the principles of the Advanced Trauma Life Support System9. The ‘ABC’s of initial management (A- airway, B- breathing, C- circulation) are addressed first. This is followed by assessing consciousness, cervical spine, CNS function, thorax, abdomen, pelvis and spine.

A clean pressure dressing with splintage should be applied to the injured limb. An amputated part should be transported by wrapping it in a clean moist cloth and placing it in a plastic bag and then ice in an insulated container. The stump should be wrapped and bleeding controlled with pressure dressing or a tourniquet. Incompletely severed parts are covered with sterile non constricting bandages and cooled with ice packs for transportation. Cooling of the amputated part to about 4° C prolongs its viability.

X—rays critical to the care of a severely injured patient include a lateral view of the cervical spine and A—P view of chest and pelvis. X—rays of the injured extremities can usually be deferred till the patient’s general condition has been stabilized.

As soon as possible, a careful examination of the wound is performed. Obvious foreign bodies are removed and the wound is flushed with copious amount of Normal Saline. Remember, “the solution to pollution is dilution”.

Alongwith tetanus prophylaxis, bactericidal IV antibiotics should be started as soon as possible. The chosen antibiotics should be active against both gram positive and gram negative organisms. Recommended antibiotics for Type I & Type II fracture wounds, without gross contamination, are cephalosporins. For Type III Open fractures, an aminoglycoside is added alongwith the cephalosporins. In cases with significant contamination, the addition of penicillin to cover anaerobic organisms (specifically clostridium perfringens) is advised. If cultures are positive, the therapy needs to be tailored to the specific situation10.

Management of open fractures can be discussed under the following headings:

  •  initial surgical debridement  

  •  stabilization of bone

  •  definitive wound management

Initial Surgical Debridement

The critical aspect is the removal of all nonviable and contaminated tissue.

Margins of the skin wound are excised to provide adequate visualization for effective debridement. One must be conservative in the excision of skin, particularly where it is at a premium (e.g. over the tibia, hand or foot).

Non viable or contaminated fascia should be excised. Fasciotomy maybe needed in high energy trauma.

Necrotic muscle is a major pabulum for bacterial growth and poses great danger in anaerobic infections. Every effort should be made to remove all non—viable muscle tissue. Muscle viability is judged by red (or robust pink) colour, firm consistency, contractility and capacity to bleed.

 Tendons, unless obviously damaged or contaminated, should be preserved, especially if they are essential to function.

Cortical bone pieces, free of any soft tissue attachment, are generally removed. As a rule, bone debridement initially can be conservative. However, if infection supervenes, early aggressive redebridement of nonviable bone is essential. Remember, a delayed union or non union is a far less challenging complication than an infected non union.

Small vessels and bleeders are ligated or coagulated, while major vessel injuries need immediate end—to—end anastomosis or vein grafting.

 After thorough debridement, the wound should again be lavaged with copious amount of saline.

Stabilization of bone

Once irrigation & debridement have been done, stabilization of bone is the next concern.

The options available are:

  • immobilization in plaster

  • pins and plaster

  • skeletal traction

  • external fixator application

  • internal fixation

Type I and low velocity type II fractures with small wounds, where manipulative reduction produces a stable and acceptable fracture configuration, particularly in children can be managed with plaster cast immobilization with appropriately sized windows for wound inspection and management.

Pins incorporated in plaster casts are occasionally used as a simple, inexpensive method where cost of external fixators precludes their use, most commonly in type I and some type II open tibia fractures.

Skeletal traction and suspensions are generally used as temporary means of fracture stabilization until definitive, more invasive methods are indicated or possible, as in open fractures of femur or pelvis.

External fixation started gaining popularity for treatment of open fractures during World War II. Today external fixation is most often indicated for type III B and III C open fractures. The use of Ilizarov ring fixators and hybrid fixators have expanded the usefulness of external fixators. External fixators offer the following advantages - they are relatively easily and rapidly applied; excellent stability is achieved; and reasonably anatomical reduction is achieved with minimal additional soft tissue trauma. Disadvantages include – frequent need for secondary definitive procedures; occasional interference with soft tissue reconstructive surgery and pintract infection or loosening.

For infection prone injuries with severe soft tissue contamination, the desire to avoid internal fixation has led to the popularity of stabilization by external fixation remote from  the zone of injury. Severe open fractures of the tibial diaphysis are the most common injuries stabilized with external fixation. Early teaching prescribed only temporary stabilization with fixators and prompt removal of the device was recommended to avoid pintract problems. Typically, fixators were removed soon after wound healing. More recently, authors have stressed the need to maintain the fixation until the fracture has healed sufficiently to allow for removal of the device without loss of reduction. If initial reduction is adequate enough to establish a stable construct, partial weight bearing should be initiated as soon as possible. If the fracture is transverse or inherently stable, the fixator can be dynamized early on. With less stable fractures, dynamization is delayed until early signs of fracture healing are evident. Conversion of external fixator to intramedullary nailing is preferably done about 3 weeks after fixator removal (if possible) to minimize the chances of pintract induced infection.

With early, meticulous and aggressive wound debridement and use of appropriate parenteral bactericidal antibiotics, the inclination for immediate internal fixation is increasing. The development of biological techniques in plate fixation and the design of implants which cause the least possible interference with the periosteal blood supply have enhanced the use of plates and screws for stabilization of even open tibial fractures11.  Today, almost all type I, most type II and some type III A open fractures (without gross wound contamination) are being treated with primary internal fixation in form of screws, plates or nails, with primary (or secondary) wound closure (or coverage procedure) .Prospective randomized studies comparing non-reamed interlocking tibial nails with external fixation for open tibial shaft fractures have reported no significant difference in rates of infection12, 13. Keating et al14 compared a group of 50 open tibia fractures treated by reamed nailing with another group of 44 open tibia fractures treated by undreamed nailing. They found no statistically significant difference between the two groups with regards to functional outcome, rate of union or infection.

Since open fractures often involve bone loss and soft tissue stripping (especially type III open fractures), they frequently need bone grafting. The options include Autogenousbone grafts/ allografts/ vascularized bone grafts/ bone graft substitutes. Autogenous cancellous bone grafting may be done (if required) at the time of primary closure of primary or delayed primary closure in type I and type II fractures and preferably deferred to a later stage in type III open fractures (usually 6 to 9 weeks later). Fischer and associates15 demonstrated a decreased incidence of infection when bone grafting of type III open fractures was done on a delayed basis.  

Definitive wound management

After wound debridement and fracture stabilization, the final decision is how to manage the open fracture wound. The options available are –

  • primary closure by suture (clean type I and some type II; NEVER in type III) : When in doubt, leave it open.
  • primary closure with split thickness or full thickness grafting.
  • biological dressings.
  • delayed primary closure by suture (by 5th day).
  • delayed skin graft or flap.
  • secondary closure.

The optimal timing of wound coverage is debatable. The advent of early microsurgical free flap transfer for complex trauma of the limbs has been a valuable advance, helped by the shift from external to internal fixation, which has facilitated microsurgical soft tissue reconstruction. Thus, a radical ‘very early fix and flap’ protocol has developed. The main drawback is the need for a joint orthopaedic and microsurgery service, which is not easily available in many centers, and the fact that major microsurgical reconstructions are not always feasible in patients with multiple injuries and hypovolaemic shock.


All in all, the recommended steps in the care of open fractures are:

  1. Evaluate the patient and stabilize all life threatening situations.

  2. Treat all open fractures as an emergency.

  3. Tetanus prophylaxis and appropriate antibiotic therapy should be institute at the earliest.

  4. Irrigate and debride the wound (redebride, if needed).

  5. Stabilize the fracture.

  6. If in doubt, leave the wound open.

  7. Perform bone grafting, if needed.

  8. Rehabilitate the patient and the involved extremity as soon as possible.

Although all methods have their proponents, the generally accepted consensus for fracture stabilization is:

         Type I: Plaster immobilization (in undisplaced fractures and children)/ primary internal fixation.

         Type II: Primary internal fixation (if wound reasonably clean)/ external fixation (if contamination suspected or present).

         Type III: External fixator (preferable)/ internal fixation (only in adequately clean type IIIA open fractures).   

While open fractures will continue to test the decision-making and technical skills of the orthopaedic surgeon, the most common, and probably the most serious error is to attempt definitive care of an open fracture in one step.

Reference :

  1. Tscherne H, Gotzen L. Fractures with soft tissue injuries. Berlin 1984, Springer—Verlag.

  2. Court-Brown CM, Rimmer S, Prakash U, McQueen MM. The epidemiology of open long bone fractures. Injury 1998; 29: 529—34.

  3. Allgower M. Weichteilprobleme und Infektrisiko der Osteosynthese. Langenbecks Arch Chir 1971; 329: 1127.

  4. Gustilo R.B., Anderson J.T. Prevention of infection in the treatment of One Thousand and Twenty five open fractures of long bones: Retrospective and prospective analysis. J.Bone Joint Surg 1976; 58—A: 453—458.

  5. Muller ME, Nazarian S, Koch P, Schatzker J. The comprehensive classification of fractures of long bones. Berlin 1990, Springer—Verlag.

  6. Taylor JC, Martin SL. Use of Ilizarov external fixator for fractures, nonunions and malunions. In Gustilo RB, Kyle RF, Templeman DC: Fractures and dislocations. St. Louis, 1993, Mosby.

  7. Helfet DL, Howey T, Sanders R, Johansen K. Limb salvage versus amputation: preliminary results of the Mangled Extremity Severity Score. Clin. Orthop. 1990; 256: 80.

  8. MacKenzie EJ, Bosse MJ, The LEAP Study Group. Disability persists long term following severe lower limb trauma. Procs Orthopaedic Trauma Association Annual Meeting, 2004.

  9. Advanced Trauma Life Support program for doctors. Sixth ed. Chicago: American College of Surgeons, 1997.

  10. Zalavras CG, Patzakis MJ, Holtom PD, Sherman R. Management of open fractures. Infect. Dis. Clin. North Am. 2005 Dec; 19(4): 915—29.

  11. Gopal S, Majumder S, Batchelor AGB et al. Fix and flap: the radical orthopaedic and plastic treatment of severe open fractures of the tibia. J. Bone Joint Surg. (Br) 2000; 82—B: 959—66.

  12. Bhandari M, Guyatt GH, Swiontkowski MF, Schemitsch EH. Treatment of open fractures of the shaft of the tibia: a systematic overview and meta-analysis. J. Bone Joint Surg. (Br) 2001; 83—B: 62—68.

  13. Shannon FJ, Mullett H, O’Rourke K. Unreamed intramedullary nail versus external fixation in grade III open tibial fractures. J. Trauma 2002; 52: 650—4.

  14. Keating JF, O’Brien PJ, Blachut PA, Meek RN, Broekhuyse HM. Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft: a prospective, randomized study. J. Bone Joint Surg. (Am) 1997; 79— A: 339—41.

  15. Fischer MD, Gustilo RB, Vareka TF. The timing of flap coverage, bone grafting and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft tissue injury. J. Bone Joint Surg. 1991; 73—A: 1316—22.


This is a peer reviewed paper 

Please cite as : Shankar Acharya:Management of open fractures

J.Orthopaedics 2007;4(1)e18





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