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Author: Bill Mulkerin, MD
Stanford/Kaiser Emergency Medicine Residency
Open fractures often result from high-energy impacts, such as motorcycle crashes, motor vehicle collisions, and pedestrians being struck by motor vehicles.[1,2] These injuries are usually associated with poly-trauma. Up to 9% of open fractures result in compartment syndrome. Open fractures are most commonly classified by the Gustilo classification:
- Type I – clean wound less than 1cm
- Type II – laceration more than 1cm long, without extensive soft tissue damage, flaps, or avulsions
- Type IIIA – adequate soft tissue coverage of a fractured bone despite extensive soft tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound
- Type IIIB – extensive soft tissue injury with periosteum stripping and bony exposure. This is usually associated with massive contamination.
- Type IIIC – Exposed fracture with arterial damage that requires repair[4,5]
Reliability of the this classification system has been questioned, however, and some studies show inter-rater agreement when using this classification system to be as low as 60%.
Management of open fractures in the emergency department should focus on identifying open fractures as early as possible. Especially in unstable poly-trauma patients, injured extremities are likely to be preliminarily stabilized and not reassessed.
Infection rates depend on severity of injury: type I open fractures infection rate of 0-2%, type II: 2-10%, type III: 10-50%.[5,7] Most wounds (65%) are contaminated, so antibiotics should be considered therapeutic rather than prophylactic.[5,7-9] It is critical to start antibiotics promptly, as a delay of more than three hours increases the risk for infection.[7,10] Appropriate antibiotic coverage should cover staphylococci and aerobic gram-negative bacilli, for example a first generation cephalosporin (e.g., cefazolin) plus an aminoglycoside (e.g., gentamicin or tobramycin). In farm injuries or vascular injuries, which may cause ischemia and low oxygen tension, ampicillin or penicillin should be added to cover for anaerobes such as clostridial myonecrosis (gas gangrene).
Alternatives to aminoglycosides include quinolones, aztreonam, and third-generation cephalosporins. Aminoglycoside-impregnated beads can also be used for local antibiotic delivery, with the most commonly used delivery vehicle being polymethylmethacrylate (PMMA) cement. Of note, some clinicians use cefazolin as a single agent in type I open fractures, but this does not reliably cover gram negatives. The duration of antibiotic treatment is generally three days, although some investigators have proposed that one day may be enough.
Operative treatment of open fractures is fracture stabilization and either primary or staged soft tissue closure. The definitive treatment of infection in open fractures is aggressive debridement and irrigation in the operating room. Low-pressure lavage has been shown to be more effective in reducing bacterial counts than high-pressure lavage, and saline has been shown to be the most effective irrigating agent.
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