Signs, Symptoms, and Complications of Open Fractures
- Open fractures can range in severity, with some characterised by a broken bone sticking out of the skin.
- Other open fractures may have a small poke-hole skin wound associated with a broken bone.
- Significant blood loss can occur in some open fractures.
- Soft tissues near the fractured bone, such as nerves, tendons, muscles, and blood vessels, are often extensively damaged.
- The severity of open fractures can vary greatly.
- Open fractures increase the risk of infection, both in the surrounding soft tissues and in the bone itself (osteomyelitis).
- Non-union, where the broken bone ends do not heal, and malunion, where the broken bone ends heal in an incorrect orientation, are potential complications.
- Long bone fractures can lead to compartment syndrome, causing damage to surrounding tissue.
- Fat embolism and chronic pain are also possible complications.
- The risk of infection can be influenced by the mechanism of injury, such as the presence of external objects or dirt in the wound.

Causes and Diagnosis of Open Fractures
- Open fractures can result from direct impacts, such as high-energy physical forces, motor vehicular accidents, firearms, and falls from height.
- Indirect mechanisms, such as twisting or falling from a standing position, can also cause open fractures.
- These mechanisms can cause various types of fractures, including closed, open, stress, simple, comminuted, greenstick, displaced, transverse, and oblique fractures.
- Substantial degloving of soft tissues may occur, but open fractures can also have a subtler appearance with a small poke hole and clotted blood accumulation.
- Open fractures can occur in different age groups, with working-age young men and older people with osteoporosis being at higher risk.
- Advanced Trauma Life Support (ATLS) is the initial protocol to rule out life-threatening injuries.
- Once the patient is stabilised, orthopedic injuries can be evaluated, including determining the severity using a classification system.
- Mechanism of injury helps assess the energy transferred and level of contamination.
- Every limb should be exposed to evaluate hidden injuries.
- Detailed assessment of the wound, neurology, and vascular status is important to rule out nerve or blood vessel injuries, as well as maintain suspicion for compartment syndrome.

Management of Open Fractures
- Acute management of open fractures involves urgent interventions such as therapeutic irrigation and wound debridement to minimize infection risk.
- Delayed intervention increases the risk of complications like deep infection and complete limb loss.
- After wound irrigation, gauze should be applied to prevent bacterial contamination, and the limb should be immobilised with a well-padded splint.
- Documenting pulses before and after reduction is important.
- Wound cultures are positive in 22% of cases before debridement.
- Administration of broad-spectrum intravenous antibiotics within an hour reduces infection risk.
- First generation cephalosporin (cefazolin) is recommended for open fractures.
- Combination of first generation cephalosporin and aminoglycoside or third generation cephalosporin is recommended for Type III Gustilo fractures.
- No agreement on optimal solution for wound irrigation.
- No difference in infection rates between normal saline and other forms of water.
- No difference in infection rates using normal saline with castile soap or bacitracin.
- No difference in infection rates using low pressure pulse lavage (LPPL) or high pressure pulse lavage (HPPL).
- Amount of irrigation solution should be determined by severity of fracture.
- Purpose of wound debridement is to remove contaminated and non-viable tissues.
- Viability of bones and soft tissues determined by bleeding capacity.
- Optimal timing of debridement and closure is debated.
- No difference in infection rates for surgery within 6 hours or until 72 hours after injury.
- NICE guidelines suggest immediate debridement for highly contaminated fractures.
- Early fracture immobilization and fixation promotes healing.
- Reamed and unreamed intramedullary nailing are accepted treatments.
- Unreamed intramedullary nailing has lower superficial infection and malunion rates.
- Unreamed intramedullary nailing requires controlled weight bearing.
- Internal fixation using plates and screws is not recommended in children.
- Early wound closure reduces infection rates.
- Wound can be healed by secondary intention or primary closure.
- Conflicting evidence on effectiveness of Negative-pressure wound therapy.
- No proven benefit of vacuum dressing.
- Individualised wound management is necessary.

Outcomes of Open Fractures
- Infection rate depends on injury characteristics, treatment, and patient factors.
- Higher Gustilo classification increases infection risk.
- Delayed antibiotic administration increases risk of deep infection.
- Smoking and diabetes increase risk of infection.
- Staphylococcus aureus is the most common pathogen in infected open fractures.
- Crush injuries are the most common, followed by falls and road traffic accidents.
- Open fractures occur more often in males than females.
- Finger phalanges fractures are the most common.
- Infection rates vary based on Gustilo classification.
- Rates of fracture differ based on anatomy location.
- Ancient Egypt physicians treated open fractures with manual reduction.
- Treatment methods have evolved over time.
- Open fracture diagnosis and treatment have a long history.
- Manual reduction was used in ancient times.
- Advancements in fracture treatment have improved outcomes.

Advances in Bone Healing and Management
- Recent developments in molecular mechanisms of bone healing.
- Gustilo-Anderson classification for open fractures.
- The effect of local antibiotic prophylaxis in treating open limb fractures.
- Meta-analysis of reamed versus unreamed intramedullary nailing for open tibial fractures.
- Negative pressure wound therapy for open traumatic wounds.

Surgical Techniques and Complications
- Time to surgery for open hand injuries and the risk of surgical site infection.
- Controversies in the management of open fractures.
- Evaluation of irrigation solutions in open fractures

Open fracture (Wikipedia)

An open fracture, also called a compound fracture, is a type of bone fracture (broken bone) that has an open wound in the skin near the fractured bone. The skin wound is usually caused by the bone breaking through the surface of the skin. Open fractures are emergencies and are often caused by high energy trauma such as road traffic accidents and are associated with a high degree of damage to the bone and nearby soft tissue. An open fracture can be life threatening or limb-threatening (person may be at risk of losing a limb) due to the risk of a deep infection and/or bleeding. Other complications including a risk of malunion of the bone or nonunion of the bone. The severity of open fractures can vary. For diagnosing and classifying open fractures, Gustilo-Anderson open fracture classification is the most commonly used method. It can also be used to guide treatment, and to predict clinical outcomes. Advanced trauma life support is the first line of action in dealing with open fractures and to rule out other life-threatening condition in cases of trauma. The person is also administered antibiotics for at least 24 hours to reduce the risk of an infection. Cephalosporins are generally the first line of antibiotics. Therapeutic irrigation, wound debridement, early wound closure and bone fixation are the main management of open fractures. All these actions aimed to reduce the risk of infections. The bone that is most commonly injured is the tibia and working-age young men are the group of people who are at highest risk of an open fracture. Older people with osteoporosis and soft-tissue problems are also at risk.

Open fracture
Gustilo Type III fracture
Specialty	Orthopedics