This document discusses the management of open fractures. It begins by defining an open fracture and classifying open fractures using the Gustilo and Tscherne systems. It then outlines the treatment principles of open fractures which include antibiotic prophylaxis, wound debridement, and fracture stabilization. The initial management, primary surgery including further debridement, irrigation, and skeletal stabilization are described. Factors determining limb salvage versus amputation are provided. The document concludes with discussions on external fixation, internal fixation, and wound closure approaches.

1. Management of
Open Fractures

2. Introduction
• An open fracture is one in which a break in the
skin and underlying soft tissue leads directly into
or communicates with the fracture and its
hematoma
• When wound occurs in the same limb segment as
a fracture, the fracture must be considered
open until proven otherwise

3. Classification
• Gustilo classification of open fractures
• Type I: These are fractures with a clean wound of less than
1 cm in size with little or no contamination. The wound
results from an inside-out perforation by one of the
fracture ends. The fracture pattern is simple (eg, spiral or
short oblique fractures)
• Type II: Skin laceration is longer than 1 cm but the
surrounding tissues have minor or no signs of contusion.
There is no dead muscle present and the fracture instability
is moderate to severe
• Type III: There is extensive soft-tissue damage, frequently
with compromised vascularity with or without severe wound

4. • Type IIIA: It usually results from an high-energy
trauma. There is still adequate soft-tissue coverage of
fractured bone, despite extensive soft-tissue
flaps
• Type IIIB: There is extensive soft-tissue loss with
periosteal stripping and bone exposure. These injuries
usually associated with massive contamination
• Type IIIC: This is associated with any open fracture
associated with arterial injury requiring repair. It is
independent of the fracture type

5. • Tscherne classification
• Open fracture grade I (Fr. O 1): The skin is lacerated by a bone
fragment from the inside. There is no or minimal contusion of the
these simple fractures are the result of indirect trauma
• Open fracture grade II (Fr. O 2): There is a skin laceration with a
circumferential skin or soft-tissue contusion and moderate
All open fractures resulting from direct trauma
• Open fracture grade III (Fr. O 3): There is extensive softtissue
damage, often with an additional major vessel and/ or nerve injury.
open fracture that is accompanied by ischemia and severe bone
comminution belongs in this group. Farming accidents, high-velocity
gunshot wounds, and compartment syndrome are included because of
high risk of infection
• Open fracture grade IV (Fr. O 4): These are subtotal and total
amputations. Subtotal amputations are defined by the Replantation
Committee of the International Society for Reconstructive Surgery as
“separation of all important anatomical structures, especially the
vessels, with total ischemia”. The remaining soft-tissue bridge may

6. • AO classification
• IO 1 – Skin breakage from inside out

7. • IO 2 - Skin breakage from outside in < 5 cm, contused edges

8. • IO 3 - Skin breakage from outside in > 5 cm, increased contusion,
devitalized edges

9. • IO 4 - Considerable, full-thickness contusion, abrasion, extensive
open degloving, skin loss

10. • IO 5 - Extensive degloving

11. Treatment
• Goals of treatment
1. Preserve life
2. Preserve limb
3. Preserve function
• Also
• Prevent infection
• Fracture stabilization
• Soft tissue coverage

12. • Principles of treatment
• Antibiotic prophylaxis
• Wound debridement
• Fracture stabilization

13. Initial Management
• Patient assessment: ABC
• Address life threatening injuries.
• Rule out cervical injuries, chest, abdominal injuries, head injuries
in polytrauma patients.
• Identify all injuries to extremities and assess neurovascular status
of injured limb.
• Assess skin and soft tissue damage.
• Obvious foreign bodies that are easily accessible may be removed-
don’t do digital exploration.
• The open wound should be covered with a sterile saline soaked
gauze pad.
• Identify skeletal injuries and obtain necessary radiographs.
• IV Tetanus
• IV Antibiotics

14. Primary Surgery
• Objectives of initial surgical management
• Preservation of life and limb
• Wound debridement
• Definitive injury assessment
• Fracture stabilization

15. Debridement
• Most important step.
• Aim - Removal of dead tissue and foreign material to ensure
good blood supply.
• Debridement done as soon as possible. (within 6 hours of
initial injury)
• With delay risk of infection increases

16. Superficial Debridement
• Wound margins are excised to identify and explore the
entire zone of injury and to access ends of bone
fragments. Extensile longitudinal incision to visualize
deep tissue and can be extended till normal tissue
encountered clearly.
• Nonviable skin and subcutaneous tissue excised but of
marginal viability may be left for later debridement.
• Do not detach skin and subcutaneous tissue from the
fascia. Any nonviable shredded fascia and even the
marginally viable ones excised.

17. Deep Debridement
• Muscle because of water content are subject to hydraulic
damage by fluid waves during injury. In muscle debridement,
the concept is when in doubt take it out.
• In type I, II, and IIIa open - all non-vital and in doubt muscle
can be debrided.
• IIIb and IIIc fractures- removal of entire muscle compartment
may be needed.
• Viability of muscle is checked by its color, capacity to bleed,

18. • Tendons, unless injured beyond repair should be preserved.
• In open wounds tendons are subject to desiccation and hence it
should be covered with soft tissues if not with moist dressings.
• In general bone devoid of soft tissue attachment are removed and
large fragments with soft tissue attachments are preserved.
• One exception to strict removal of bone without soft tissue
attachment, is significant portion of articular surface attached to
bone fragment

19. Irrigation
• Usual irrigation fluid used is normal saline
• High volume low pressure repeated lavage is performed.
• Volume of fluid used varies- usually about 3 L is used for grade
1 ; 6-10 L is used for grade 2 or 3
• Pulse lavage is more effective than bulb syringe with NS
resulting in 100 fold decrease in St.Aureus in the wound

20. Limb salvage and Amputation
• Limb is nonviable as evidenced by
• irreparable vascular injury
• warm ischemia time >8 hrs
• severe crush injury with minimal remaining viable tissue
• Severely damaged limb may constitute a threat to patients life
especially in patients with severe debilitating c/c illness. The
severity of injury would demand multiple operative procedures
and prolonged reconstruction time.
• Mangled extremity severity score of >7 accurately predicts
amputation.
• Score doubles for ischemia >6 hrs

21. MESS
• MESS( Mangled Extremity Severity Score) for prediction of
amputation
• Developed to identify patients who will be benefited by
primary amputation in retrospective analysis.
• The outcome of injured limb is either salvage or amputation.
• A score of > or equal to 7 is predicative of amputation

23. Skeletal Stabilization
• Done once vascular repair is completed and limb salvaged or
once irrigation and debridement is done.
• Restoring the length, rotational, and angular alignment has
many benefits for healing of soft tissues.
• Fracture reduction frees nerve conduits and helps in soft
tissue healing.
• Minimizing motion of fragments also decreases further
damage, pain and permits mobilization of joints

24. • Extra osseous- In low grade open fractures
splints, plasters, weight bearing casts, etc.
• Internal fixation- usually appropriate if wound is clean, and soft
tissue coverage available.
• External fixation-
• in high grade open fractures
• in dirty wounds,
• or extensive soft tissue injuries.

25. External Fixation
• Excellent stability obtained.
• Reasonable anatomic reduction possible.
• Minimal additional soft tissue trauma
• Risk of infection-minimized.
• Ability to convert to internal fixation

27. Internal Fixation
• Plates and screws- to minimize complications IV anti
staphylococcus antibiotics should be started as soon as
possible, sterile dressing, meticulous debridement, copious
irrigation and minimal stripping and accurate anatomical
reduction is to be done.
• IM nail- currently the treatment of choice for grade I,II,IIIa,
and IIIb fractures as ex-fix devices leads to more
malalignment, nonunion, and delayed return to function

29. Wound Closure
• Wounds without skin loss: tension free primary closure after
thorough debridement.
• Contraindications for primary closure
• Delayed presentation >12 hrs.
• Delayed administration of antibiotics>12 hrs.
• Deep seated contamination
• Immunocompromised
• Nerve injury
• Inability to achieve tension free suture
• High risk of anaerobic contamination like farm yard injuries.
• Wounds with skin loss: healing by secondary intention. Delayed
primary closure, split skin grafts, free flaps