Open fractures are classified by communication with the environment and can lead to significant soft tissue damage, especially in high-energy traumas like gunshot wounds and lawnmower accidents. Management differs between children and adults primarily in healing rates and infection risk, with a common classification system being Gustilo and Anderson, which correlates soft tissue injury grades to infection and healing rates. Treatment often includes antibiotics, debridement, and, in severe cases, amputation, particularly in the presence of extensive contamination and soft tissue loss.

1. Open fracture
Dr. Mohammad Taqi Ehsani
PGY2 of Orthopedics, FMIC

2. Open Fracture
• A fracture that at some point communicated with the environment
• Break in the skin and underlying soft tissue leading directly into or communicating with the
fracture and its hematoma
• Commonly occurs in bones with minimal soft tissue coverage
• Usually higher energy is required in deep bones
• Open fractures differ between children and adults, but management has traditionally been
similar
• Thicker periosteum and robust blood supply allows better healing and lower infection rates in
children.
• The most common open fractures in children involve the hand and upper extremity and most
of these injuries are the result of falls.
• Open fractures of the lower extremities, particularly the tibia, are usually he result of higher
energy trauma, usually trauma sustained in automobile-pedestrian or automobile-bicycle
accidents

3. Classification
• classification system of
Gustilo and Anderson is still
the most widely used for
classifying open fractures
in children and adults

6. Why use this classification?
• Grades of soft tissue injury correlates with infection and
fracture healing
Grade 1 2 3A 3B 3C
Infection
Rates 0-2% 2-7% 10-25% 10-50% 25-50%
Fracture
Healing
(weeks)
21-28 28-28 30-35 30-35
Amputation
Rate 50%

7. Radiological Examination
• Usually, only AP and lateral radiographs are required
• They should include adjacent joints and any associated injuries.
• plain anteroposterior and lateral radiographs of the area of injury, as well as
the joints above and below the injury.
• Arthrography may be necessary to identify joint penetration by a
projectile.
• MRI and CT scans are rarely required in the acute situation but may
be helpful in open pelvic, intra-articular, carpal, and tarsal fractures.
• If vascular injury is suspected, angiography or arteriography may be
necessary to confirm the diagnosis (Gustilo IIIb or IIIc fractures).

8. Treatment
• First generation cephalosporins, or
clindamycin for allergic patients
• Tetanus toxoid (0.5 ml/IM) if the
patient’s immunization status is
unknown, of if it is more than 5
years since the last does.
• Debridement: 5-10 liter of saline

10. Gunshot Wounds
• Gun shot wounds are high energy injuries that contribute to extensive
soft tissue damage and comminuted bony fractures
• classified as high or low velocity.
• High velocity gunshots: usually produce extensive soft tissue dam-age,
gross contamination, and comminuted fractures. These injuries should
be treated as type III open fractures.
• Low velocity gunshot wounds: have little soft tissue injury or fracture
comminution and often can be treated with local wound debridement
and short-term IV or oral antibiotic therapy.
• children have a better prognosis than adults

11. Lawnmower Injuries
• subcategory of open fractures.
• most children injured by lawnmowers are bystanders rather than
operators or even riders.
• Most reports note that 30% to 50% of patients require some level of
amputation.
• The vortex of air created by the lawnmower and the inherently dirty
setting produce massively contaminated wounds.
• Acute management: an initial thorough débridement and additional
operative débridement at approximately 48-hour intervals until there is
no evidence of debris and there is a healthy granulation bed.
• broad- spectrum antibiotics, including coverage for potential anaerobic
infection.
• If amputation is required, every effort is made to keep the level as distal
as possible.