An overview of open fracture management

Abstract

Open fractures are complex and potentially limb-threatening injuries. Early, systematic and thorough treatment of all fractures can reduce the risk of life-changing consequences, regardless of injury severity. In the UK, national guidelines have been established to standardize care and improve outcomes. The recent adoption of the multidisciplinary orthoplastics approach focuses on the key management principles of reducing infection risk, skeletal stabilization and timely soft tissue coverage. These principles encompass multiple aspects of care, starting from standardized trauma care at the time of injury, to the complex management of potential critical-sized bone defects. These injuries and their consequences can also lead to significant psychological distress. Therefore, recognizing and addressing this is vital in providing holistic care for the patient. This review aims to summarize the current management of open fractures and explore the evidence surrounding these aspects of care.

Introduction

Open fractures can be life-changing injuries. They are characterized by a direct communication between the fracture and the external environment through breach in the skin, with any wound near a fracture site arousing suspicion. Despite being recognized for millennia, these injuries remain challenging to manage due to the risk of extensive bone and soft tissue devascularization. Complications are common, with reported infection rates as high as 50% and fracture non-union rates up to 18%. Long bones, particularly the tibia ( Figure 1 ), are most commonly affected and were historically associated with high mortality, often requiring amputation as a lifesaving intervention to prevent sepsis. Treatment strategies for open tibial fractures are now well-established and are frequently applied to other fracture types.

Nearly one-third of patients with open fractures present with multiple other injuries as these fractures are often the result of high-energy trauma like road traffic collisions, falls from height, agricultural incidents, or blasts. ^, However, they may also occur in older patients with fragile tissues following low-energy trauma, such as falls from standing.

Optimal management of open fractures involves collaboration between orthopaedic and plastic surgeons as part of a multidisciplinary ‘orthoplastic’ approach. ^, Core treatment principles emphasize minimizing infection risk, skeletal stabilization, and establishing effective soft tissue reconstruction. Consequently, many patients require multiple surgical interventions to meet these objectives. In cases of severe injury, amputation may still be necessary, resulting in significant morbidity and the potential for considerable psychological and socioeconomic consequences to ensue.

This review aims to provide a comprehensive overview of current management strategies for open fractures, focusing on the principles of care from the point of injury through to definitive management.

National guidance

In the UK, trauma care has been reorganized into Major Trauma Networks. The streamlining of resources into a ‘hub and spoke’ model has led to an improvement in outcomes for the polytrauma patient, including those with open fractures. Furthermore, the introduction of evidence-based protocols aims to further reduce complication rates. The UK National Institute for Health and Care Excellence (NICE) has published guidelines for the management of complex fractures, including open fractures, in the UK. The British Orthopaedic Association Standards for Trauma (BOAST) for the management of open fractures, jointly developed by the British Orthopaedic Association (BOA) and the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS), provides a stepwise approach to improving the management of open fractures. It is imperative that all team members are aware of and adhere to these national standards to ensure optimal care and improve the chances of a successful outcome for patients with open fractures.

Immediate management

Accurate pre-hospital identification of open fractures is essential, as the time between injury and admission has been shown to significantly improve the risk of infection. However, confounding factors such as prolonged entrapment in more significant injuries could lead to delays in treatment. Patients with open fractures of long bones, the hindfoot or midfoot should be transported directly to the nearest specialist centre offering orthoplastic care.

As open fractures can act as a distracting injuries, it is crucial that initial management adheres to the principles of Advanced Trauma Life Support (ATLS) ^, to identify and manage any life-threatening conditions. Secondary injuries caused by hypoxia, hypovolaemia or hypothermia can be minimized through prompt resuscitation efforts. A review of the patient’s allergies, co-morbidities, medications, and the timing of their last food or drink intake should also be conducted. Following this, a thorough assessment of the open fracture must be completed following the BOAST guidelines, including evaluation for compartment syndrome, as the presence of an open wound does not eliminate the risk of its occurrence.

Antibiotics should be administered within 1 hour of injury along with adequate analgesia, and tetanus prophylaxis given if indicated. It is critical to accurately assess and document the neurological and vascular status of the limb, with repeat assessments particularly after any fracture reduction or splinting.

Prior to formal debridement in the operating theatre, the wound should be handled minimally and limited to the removal of gross contaminants. The open wound should then be covered with saline-soaked gauze and sealed with an occlusive dressing. Irrigation outside of the operating theatre is not recommended due to the risk of advancing debris and contaminants deeper into the wound. Serial photography should occur at initial exposure of the wound, prior to debridement and any other key stage of the patient’s management, with all images stored in their records. Information governance policies should be in place for all trauma networks to allow photography from staff members for clinical decision-making.

Plain radiographs with orthogonal views should be obtained. For adults with blunt trauma and suspected multiple injuries, whole-body computed tomography (CT) is recommended. This should include a head to toes scanogram which can guide further imaging of the affected limb. The inclusion of angiography should follow locally established protocols, ensuring a comprehensive approach to diagnosis and treatment of vascular injury. Arterial injuries and compartment syndrome should be managed according to their respective BOAST guidelines.

Antibiotics

Preventing deep infections in open fractures is crucial as they can lead to devastating complications such as sepsis, amputation and death. Postoperative bone and soft tissue infections can be particularly challenging to treat due to the formation of bacterial biofilms and the difficulty in delivering antimicrobials to the affected area. BOAST emphasizes the importance of trauma networks having guidelines for the use of antibiotics in open fractures, as they play a critical role in infection prevention and their systemic use is well-supported in the literature. The choice of an antimicrobial agent should follow local policy but combined Gram-positive and Gram-negative cover is generally recommended for more severe injuries. A Cochrane meta-analysis involving 1106 participants across 8 studies demonstrated that antibiotics significantly reduce the incidence of early infections in open limb fractures compared to no treatment or placebo. Similarly, a systematic review by Chang et al. involving 472 patients found a significantly lower infection rate in those receiving antibiotic prophylaxis, even with a course as short as one day.

Whilst the use of antibiotics is widely accepted, there remains uncertainty about the ideal duration of therapy. Short courses have shown efficacy, but the debate continues over whether extended use provides additional benefit.

In terms of timing of antibiotic administration, the recommendations are clearer. BOAST guidelines advise administering antibiotics as soon as possible, ideally within 1 hour of injury. However, the evidence in the UK has been clouded by poor documentation of both the use and timing of antibiotics. One study found that only 44% of cases had timing of antibiotics recorded, and so they were not able to correlate this with early infection or amputation. Nevertheless, the BOAST recommendations are supported by a study showing that in patients with type III open tibial fractures, administering antibiotics beyond 66 minutes was an independent predictor of deep infection within 90 days. Therefore, the practice of administering antibiotics as early as possible, even by the pre-hospital team before the patient reaches the trauma centre appears crucial in minimizing the risk of deep infection.

Classification

Reliable classification systems are essential for guiding the treatment and prognosis of open fractures, due to the wide variation in their severity which is largely determined by the degree of bone and soft tissue damage.

The Gustilo and Anderson (GA) classification, first introduced in 1976 for tibial fractures, is now widely used for all open fractures. It categorizes injuries into three main types (I-III) which are based on wound size and soft tissue damage, with each grade correlating with mobility and infection rates. Assessment should be conducted after surgical debridement to improve grading accuracy. Type I includes clean wounds less than 1 cm, Type II includes wounds larger than 1 cm with minimal soft tissue injury, and Type III covers severe injuries with extensive soft tissue damage or vascular injury. Type III was later subdivided in 1984 into IIIA, IIIB ( Figure 2 ), and IIIC to reflect varying prognoses, with type IIIC representing the most severe injuries, involving vascular injury requiring repair. Despite its widespread use and simplicity, the GA system has been criticized for its subjectivity, low inter-observer reliability (as low as 60%), and underestimation of muscle and bone damage. ^,

In response to these limitations, newer classification systems have emerged. The Ganga Hospital Open Injury Severity Score (GHOISS) was developed in 1994 to improve the prediction of limb salvage outcomes in open tibial fractures and guide decisions regarding amputation. The system evaluates injuries across four domains: covering tissues, skeletal structures, functional tissues, and co-morbid factors. Scores for each domain are combined to give an overall total ranging from 3 to 29, where a score of 14 or less suggests likely limb salvage, whilst a score of 17 or more indicates a high probability of amputation. GHOISS has demonstrated higher sensitivity and specificity than the GA classification, particularly in predicting limb outcomes in severe cases such as type IIIB fractures. ^,

In 2010, the Orthopaedic Trauma Association (OTA) introduced a new classification system aimed at enhancing the accuracy of open fracture assessment, with applicability across all bones in both adult and paediatric populations. This system evaluates injuries in five domains: skin injury, muscle injury, arterial damage, contamination, and bone loss. Each is rated on a scale from 1 to 3, with higher scores reflecting greater injury severity. Studies have shown that the OTA system outperforms the GA classification in predicting postoperative complications and treatment outcomes, especially for long bone fractures.

In 2020, the Orthopaedic Trauma Society (OTS) proposed a classification system for open fractures categorizing them as either ‘simple’ or ‘complex’, based on whether the wound can be primarily closed following initial debridement or if a reconstructive procedure is required. Complex fractures are further divided into three groups to indicate the level of reconstruction needed: firstly, when bone deformation or acute shortening is required to facilitate primary wound closure; secondly, when soft tissue reconstruction is required to cover the wound; and finally, when vascular repair or reconstruction is necessary. The OTS classification is based on objective measures and has been shown to correlate with patient-centred outcomes, but it is still relatively new and more research is required to investigate its validity.

Surgical debridement

Technique

Comprehensive debridement is a critical component in the management of open fractures. Debridement involves the systematic surgical excision of non-viable tissue, including any foreign material, in order to reduce the risk of infection and promote healing. Tissue should be excised from superficial to deep and from outer edges towards the centre. A gentle ‘tug test’ can be used to identify devitalized bone that easily separates from its soft tissues. However, a recent study has shown favourable outcomes when retaining mechanically relevant devitalized bone fragments in IIIB open tibial fractures, provided they have been carefully debrided.

When extension of the wound is required, BOAST guidelines recommend performing this via fasciotomy incisions ( Figure 3 ), which preserves the perforating vessels and permits delivery of bone ends. Dead muscle can be identified by assessing colour, contractility, consistency and capillary bleeding (the four C’s). Tourniquet use is not recommended but can allow for better anatomical identification and assessment of tissue viability in significant degloving.