Copyright 2011 American Academy of Orthopaedic Surgeons
Open Fractures

If the bone breaks in such a way that bone fragments stick out through the skin or a wound penetrates down to the broken bone, the fracture is called an "open" or compound fracture. For example, when a pedestrian is struck by the bumper of a moving car, the broken shinbone may protrude through a tear in the skin and other soft tissues.

Because open fractures often involve more damage to the surrounding muscles, tendons, and ligaments than closed fractures, they have a higher risk for complications and take a longer time to heal.

This type of fracture is particularly serious because once the skin is broken, infection in both the wound and the bone can occur.

Cause

Open fractures are caused by high-energy trauma, most commonly from a direct blow, such as from a fall or motor vehicle collision.

These fractures can also occur indirectly, such as a high-energy twisting type of injury.

Description
In this open fracture, the broken end of the tibia has torn through the soft tissues and is protruding through the skin.

Because of the energy required to cause these types of fractures, patients often have additional injuries — some potentially life-threatening — that require treatment. There is a 40% to 70% rate of associated trauma elsewhere in the body when there is an open fracture.

Open fractures can vary significantly in severity. For example, an open fracture may be a pinpoint wound just a few millimeters in diameter. The bone may or may not be visible in the wound. Other open fractures may expose a lot of bone and muscle, and can seriously damage surrounding nerves and blood vessels.

Open fractures represent a spectrum of injury: First, the basic underlying problem of a fracture; second, the exposure of the broken bone to the environment and, therefore, the contamination of the fracture site.

Fractures and Injuries

Several factors can influence the severity of an open fracture. For example, the bones can be broken cross-wise, length-wise, and in several pieces. The pieces of bone can be very sharp and can tear through soft tissue from within.

A direct blow may tear and crush skin and soft tissues, as well as bone. If the bone shatters, there can be a multitude of fragments which may penetrate the neurovascular tissues and surrounding soft tissues.

Contamination

The environment the fracture is exposed to will affect the degree of contamination — dirt, broken glass, or fabric can be driven into a wound. Knowing where the injury occurred — a barnyard, industrial site, city street, battlefield — gives your doctor insight regarding what types of contaminants the fracture may have been exposed to.

Infection

Although open fractures are associated with a higher rate of infection, this depends on many variables. In general, the greater the damage is to the bone, soft tissues, nerves, and blood vessels, the higher the risk for infection.

A bone infection can be difficult to eliminate. It can require long-term antibiotic treatment, as well as several surgeries. In some severe cases, amputating the infected limb is the only way to stop the infection. Preventing infection is the focus of early treatment for open fractures.

Doctor Examination and Initial Treatment
(Top) In this photo of an injury to the lower leg, the broken bones are not visible, but the small wound is directly over the fractures and special care must be taken to prevent infection. (Bottom) An x-ray of this injury provides a clear picture of the fractures in the bones of the lower leg.
Reproduced from Management of Open Fractures and Subsequent Complications *Charalampos G. Zalavras, MD; Randall E. Marcus, MD; Lawrence Scott Levin, MD; Michael J. Patzakis, MD - Instr Course Lect 2008;57:51-63.

In the emergency room, a doctor will assess and stabilize all vital signs and check for additional injuries. He or she will need to know how the injury happened, as well as if you have any other medical problems, such as diabetes. Your doctor also needs to know if you take any medications.

Your doctor will conduct a comprehensive examination of the fracture, and assess soft tissue, nerve, and blood vessel damage.

Most open fractures are obvious because bone is visible - either protruding through the skin or within a wound. Some open fractures are more subtle. Therefore, when there is any wound in the the same area as a fracture, it is assumed to be an open fracture.

An open fracture should be managed as soon as possible. Your doctor's goal is to prevent infection because infection can prevent fractures from healing and possibly lead to amputation of the limb.

Antibiotics and Tetanus

Antibiotics are started as soon as possible in the emergency room. The severity of injury determines which antibiotics are given. Unless you have had a tetanus booster within 5 years of the injury, you will also be given a tetanus shot.

Tests

X-rays will show your doctor how complex the fracture is. These images show how many pieces of bone there are, as well as the extent of displacement (gaps between broken pieces).

Blood and urine tests can provide your doctor with important information about your general health.

Injury Stabilization

While in the emergency room, your injury will be covered with a sterile dressing. Your doctor will gently put the bones back into alignment to prevent the fragments from causing further damage to soft tissues. Then your doctor will apply a splint to your injured limb to protect it and keep it from moving until you are taken to surgery.

Treatment

The goals of treatment for open fractures are to prevent infection, get the broken bones to heal, and restore function.

Débridement and Irrigation

The first steps in controlling the risk for infection are débridement and irrigation.

Débridement. During this procedure, your surgeon will remove all dirt and foreign bodes, as well as any contaminated and unhealthy skin, muscle, and other soft tissues. The bone is also cleaned of all dirt and other foreign material. Any unattached pieces of bone are removed. Severely contaminated bone fragments are also discarded. This bone loss can be corrected later with additional surgeries.

Irrigation. After débridement, the wound is cleansed and irrigated with several liters of saline.

Fracture Treatment

It is important to stabilize the broken bones as soon as possible to prevent further soft tissue damage. The broken bones in an open fracture are typically held in place using external or internal fixation methods. These methods require surgery.

Internal fixation. During the operation, the bone fragments are first repositioned (reduced) into their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone. The fragments may also be held together by inserting rods down through the marrow space in the center of the bone. These methods of treatment can reposition the fracture fragments very exactly.

Because open fractures may include tissue damage and be accompanied by additional injuries, it may take time before internal fixation surgery can be safely performed. Questions your doctor will consider when planning fracture treatment include:

  • What can the patient tolerate?
  • What can the wound and what can the soft tissues tolerate?
  • What is necessary for stabilization of the bone?

External fixation. Depending on your injury, your doctor may use external fixation to hold you bones in general alignment. In external fixation, pins or screws are placed into the broken bone above and below the fracture site. Then the orthopaedic surgeon repositions the bone fragments. The pins or screws are connected to a metal bar or bars outside the skin. This device is a stabilizing frame that holds the bones in the proper position.

Minor open fractures. For less severe injuries with minimal contamination, the fracture can be stabilized with internal fixation once the wound has been thoroughly débrided.

The minor open fracture shown earlier in this article was treated with intramedullary nailing of the tibia. In this procedure, a rod was placed down the center of the bone to hold the fragments in place.
Reproduced from Management of Open Fractures and Subsequent Complications *Charalampos G. Zalavras, MD; Randall E. Marcus, MD; Lawrence Scott Levin, MD; Michael J. Patzakis, MD - Instr Course Lect 2008;57:51-63.

Severe open fractures. More severe open fractures are typically first stabilized using external fixation. This treatment will keep the bones in place until the wound can tolerate an internal fixation procedure.

In this more severe open fracture, the orthopaedic surgeon closes the wound with stitches after débridement and external fixation.

Complex wounds. In some open fracture cases, a lot of soft tissue has been lost and the wound is too large to be closed.

This open fracture cannot be closed with stitches.

Depending upon the amount of soft tissue lost, these complex wounds can be covered using different methods:

  • Local flap. The muscle tissue from the involved limb is rotated to cover the fracture. A patch of skin taken from another area of the body (graft) is placed over this.
  • Free flap. Some wounds may require a complete transfer of tissue. This tissue is often taken from the back or abdomen. A free flap coverage procedure requires the assistance of a microvascular surgeon to ensure the blood vessels connect and circulation is established.

In these complex wounds, temporary coverage of the fracture must be established to decrease the risk of infection and promote healing. In these cases, many types of dressings can be used, but sometimes the wound is sealed with a semipermeable material until the soft-tissue closure procedure. Antibiotic beads are often placed into a wound before sealing to provide high concentrations of antibiotics directly to the injury.

Antibiotic beads may be used to help prevent infection during temporary wound coverage.
Reproduced from Management of Open Fractures and Subsequent Complications *Charalampos G. Zalavras, MD; Randall E. Marcus, MD; Lawrence Scott Levin, MD; Michael J. Patzakis, MD - Instr Course Lect 2008;57:51-63.
Complications

Open fractures are serious injuries and, therefore, serious complications are associated with them.

  • Infection is the most common complication of open fractures. Infection can occur early, during the healing phase of the fracture, or even later. In general, the greater the extent of soft tissue damage, the greater the risk for infection. If an infection becomes chronic (osteomyelitis), it may lead to further surgeries and amputation.
  • Open fractures may have difficulty healing. If your fracture is failing to heal, further surgery may be required. Surgery to promote healing usually includes placing a bone graft over the fracture, as well as new internal fixation components.
  • Acute compartment syndrome may develop. This is a painful condition that occurs when pressure within the muscles builds to dangerous levels. Unless the pressure is relieved quickly, permanent disability and tissue death may result.
Recovery

How long it takes to return to daily activities will vary depending upon the type of fracture and severity of your injury. It is common to have stiffness, discomfort, and weakness for several months after your injury.

Successful treatment of a fracture also depends greatly on your cooperation. Exercises during the healing process and after the bone heals are essential to help restore normal muscle strength, joint motion and flexibility. Your doctor will provide you with a rehabilitation exercise plan, or recommend physical therapy visits.

Your doctor will talk with you about your concerns and reasonable expectations. He or she will also discuss the impact your injury may have on activities of daily living, work, family responsibilities, and recreational realities.

Research

There is a lot of research being conducted on open fracture treatment. Some of the current studies investigate:

  • The closing of open fractures
  • The timing of débridement
  • The timing of soft tissue coverage
  • The use of antibiotic impregnated devices

Doctors are aggressively searching for new, effective approaches to treating these challenging injuries.

Last reviewed: June 2011

Reviewed by members of the Orthopaedic Trauma Association

AAOS does not endorse any treatments, procedures, products, or physicians referenced herein. This information is provided as an educational service and is not intended to serve as medical advice. Anyone seeking specific orthopaedic advice or assistance should consult his or her orthopaedic surgeon, or locate one in your area through the AAOS "Find an Orthopaedist" program on this website.
Copyright 2011 American Academy of Orthopaedic Surgeons
Related Links
Nonunions (http://orthoinfo.aaos.org/topic.cfm?topic=A00374)
Compartment Syndrome (http://orthoinfo.aaos.org/topic.cfm?topic=A00204)
Fractures (Broken Bones) (http://orthoinfo.aaos.org/topic.cfm?topic=A00139)
Internal Fixation for Fractures (http://orthoinfo.aaos.org/topic.cfm?topic=A00196)
Infection After Fractures (http://orthoinfo.aaos.org/topic.cfm?topic=A00580)
Helping Fractures Heal (Orthobiologics) (http://orthoinfo.aaos.org/topic.cfm?topic=A00525)
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