Author:
Christy RosaMohler
Description
- Continuity between skin violation and fracture site, ranging from a puncture wound to grossly exposed bone
- Surgical urgency, as delays in care increase risk of infection and rate of complications
- Predisposition to complications in certain patients:
- Massive soft tissue damage
- Severe wound contamination
- Compromised vascularity
- Fracture instability
- Compromised host (diabetes, vascular disease)
Etiology
Open fractures typically result from significant blunt force or penetrating trauma
Signs and Symptoms
- Deformity with nearby violation in skin integrity
- Neurovascular compromise may occur
- Additional traumatic injuries are frequently present
History
Significant trauma
Physical Exam
- Complete neurologic and vascular exam
- Examine thoroughly for other traumatic injuries
Essential Workup
- Plain radiographs including joints above and below the affected area
- Guided workup based on mechanism and evidence of other traumatic injuries
Diagnostic Tests & Interpretation
Lab
- CBC, chemistry panel, coagulation studies for large-bone (femur, pelvis) fractures or multiple-trauma victims
- Type and screen or type and cross-match for potential of significant blood loss
- Predebridement wound cultures have limited value and are not recommended
Imaging
Doppler or angiography if vascular damage is suspected:
- Posterior knee dislocation
- Ischemic extremity
- Massive soft tissue injury in high-risk areas
Diagnostic Procedures/Surgery
- Measurement of compartment pressures if concern for compartment syndrome
- Consider arthrogram by intra-articular injection of saline or methylene blue if joint involvement is suspected
- Angiography if noninvasive techniques are inadequate for ruling out vascular compromise
Differential Diagnosis
Noncontiguous laceration/abrasion
Prehospital
- Moist, sterile dressings over open wounds
- Immobilize joints above and below fracture
- Control bleeding with local compression
- Consider tourniquet for traumatic amputations or uncontrollable hemorrhage
- Longitudinal traction of involved extremity if distal pulses absent
Initial Stabilization/Therapy
- Management of ABCs
- Remove clothing and any immediately accessible contaminants, foreign bodies
ED Treatment/Procedures
- Intravenous access
- Keep patient NPO
- Tetanus vaccination, if needed
- Antibiotics reduce the incidence of early infection in open fractures and should be given early in the ED course
- Minimize number of times dressing is removed to avoid secondary contamination
- Examine limb regularly for compartment syndrome and neurovascular status
- Certain large joint open fracture/dislocations should be reduced emergently in the ED (ankle, elbow, knee)
- Urgent orthopedic consultation for formal irrigation, debridement, and possible operative fixation
- Vascular surgery consultation for injuries with potential vascular damage
Medication
First Line
Cefazolin
: 1-2 g IV (peds: 25 mg/kg IM/IV)- Add gentamicin: 1.5-2 mg/kg IV for more extensive injuries and highly contaminated wounds (peds: 2-2.5 mg/kg IV)
- Add penicillin G: 4-5 million units IV in farmyard injuries, extensive crush and vascular injuries, and in wounds at risk of contamination with Clostridium (peds: 50,000 U/kg IV)
- Tetanus booster: 0.5 mL IM
- Tetanus immunoglobulin: 250 IU IM if not previously immunized against tetanus
- Morphine sulfate: 2-10 mg IM/IV (peds: 0.05-0.1 mg/kg per dose IV) or equivalent analgesic
Second Line
- Clindamycin: 900 mg IV (severe β-lactam allergy)
- Aztreonam: 1 g IV (severe β-lactam allergy/contaminated/extensive wounds
Pediatric Considerations |
| DTaP booster for children <7 yr of age |
Disposition
Admission Criteria
Most patients will be admitted for irrigation, debridement, IV antibiotics, and possibly operative fixation
Discharge Criteria
Simple open fractures may be washed out and immobilized in the ED after consultation with an orthopedic surgeon. The patient should be discharged with oral antibiotics
Issues for Referral
Most open fractures will require emergent orthopedic consultation and may require trauma team evaluation for other injuries
Follow-up Recommendations
Patients discharged from the ED should be followed up with an orthopedic surgeon in 1-2 d