Open fracture

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE
DEFINITION
Open fracture is a break in the
structural continuity of bone
where the skin or one of the
body cavities is breached that
liable to contamination and
infection.
EPIDEMIOLOGY
1. Incidence 30.7 per 100,000
persons per year
2. Demographics : average age
is 45 years old
3. Anatomic location : tibia and
finger phalanx are most
common
SEBELAS MARET UNIVERSITY
 OPEN FRACTURE

ETIOLOGY
• Pathophysiology : mechanism of
injury:
• high-energy trauma
• "inside-out" open
fractures

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE

CLASIFICATION
• Gustilo’s classification of open fractures into three types is widely used
(Gustilo et al., 1984)

SEBELAS MARET UNIVERSITY

OPEN FRACTURE

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE

TREATMENT
• Nonoperative
Urgent IV antibiotics, tetanus prophylaxis, and extremity stabilization and
dressing
i. indications
1. initial treatment for all open fractures
a. a soft tissue wound in proximity to a fracture should be treated as an open fracture
until proven otherwise
b. mutlidisciplinary training of open fracture management has been associated with
decreased timing to antibiotic administration 
2. antibiotic type indicated by injury pattern and location

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE

TREATMENT

Antibiotics
i. timing
1. initiate as soon as possible    
a. studies show increased infection rate when antibiotics are delayed for more than 3
hours from time of injury
2. continue for 24 hours after initial injury if wound is able to be closed primarily
3. continue for 24 hours after final closure if wound is not closed during initial surgical
debridement (48 hours for type III wounds)

SEBELAS MARET UNIVERSITY

OPEN FRACTURE

TREATMENT

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE

TREATMENT
Tetanus prophylaxis
i. timing
1. initiate in emergency room or trauma bay
ii. two forms of prophylaxis
1. toxoid
a. 0.5 mL, regardless of age
2. immunoglobulin
a. < 5 years old receive 75 U
b. 5-10 years old receive 125 U
c. >10 years old receive 250 U
3. toxoid and immunoglobulin should be given intramuscularly with two different syringes in two different
locations
iii. guidelines for tetanus prophylaxis depend on 3 factors 
• complete or incomplete vaccination history (3 doses)
• date of most recent vaccination
SEBELAS MARET UNIVERSITY
 OPEN FRACTURE

TREATMENT

• Extremity stabilization & dressing

i. stabilization
1. splint, brace, or traction for temporary stabilization
2. decreases pain, minimizes soft tissue trauma, and prevents disruption of clots
ii. dressing
1. remove gross debris from wound, do not remove any bone fragments
2. place sterile saline-soaked dressing on wound
3. little evidence to support aggressive irrigation or irrigation with antiseptic solution in the ED,
as this can push debris further into wound 

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE

TREATMENT OPERATIVE
• I&D, temporary fracture stabilization, local antibiotic administration
and soft tissue coverage 
• indications
• consider I&D as soon as possible, may be beneficial within 6 hours in terms of decreasing
infection risk
• ideal time of soft tissue coverage controversial, but most centers perform within 5-7 days
• outcomes
• infection rates of open fracture depend on zone of injury, periosteal stripping and delay
in treatment
• incidence of fracture related infection range from <1% in grade I open fractures to 30%
in grade III fractures

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE

TREATMENT OPERATIVE
• Definitive reconstruction and fracture fixation
• indications
• once soft tissue coverage is obtained and an adequate sterility is achieved
• outcomes
• definitive treatment with internal fixation leads to significantly decreased time to union,
improved functional outcomes, and decreased time in the hospital compared to those
definitively fixed with external fixation

SEBELAS MARET UNIVERSITY

 OPEN FRACTURE

COMPLICATION
• The General comcplications of fracture (blood loss, shock, fat
embolism, cardiorespiratory failure, etc)
• Local complications can be divided into early (arising during the first
few weeks following injury) and late

SEBELAS MARET UNIVERSITY