Proper management of all fractures and dislocations—regardless of location, extent, or severity—is based on three criteria: the integrity of the overlying skin and soft tissues (i.e., open or closed fracture), the specific location of the fracture within the bone, and the degree of displacement of the injured parts. Therefore, the initial evaluation must describe the musculoskeletal injury in terms of these variables.

Open and Closed Fracture

In a closed fracture, the overlying skin remains intact; in an open fracture, the integrity of the overlying skin and soft tissues has been violated (see Plate 7-21). Disruption of this envelope of soft tissue around the fracture site substantially increases the risk of complications. Open fractures result in greater blood loss, decreased healing rate, and increased risk of infection.

Bleeding occurs with every fracture because, at the time of injury, the periosteal vessels and the vessels supplying the soft tissues surrounding the fracture are disrupted, which leads to the formation of a large hematoma. In a closed fracture, the increased interstitial pressure within the hematoma compresses the blood vessels, limiting the accumulation of blood and thus the size of the hematoma. Nevertheless, the amount of bleeding in closed fractures remains substantial. For example, a closed fracture of the femoral shaft may result in blood loss of as much as 1 liter before the increased pressure within the hematoma tamponades the bleeding vessels. However, because the tamponade effect is lost in an open fracture, blood loss is even greater and may be life threatening.

Any open fracture can become infected because the hematoma that forms around the open fracture site is contaminated by contact with the external environment. The risk of infection is directly related to the severity of soft tissue damage. An infection that becomes established at a fracture site is much more resistant to treatment than a soft tissue infection and may be impossible to eradicate. Chronic purulent drainage from the fracture site may persist for the rest of the patient’s life. The chronic infection of the bone, called post-traumatic osteomyelitis, often cannot be cured or even controlled in spite of repeated and aggressive surgical debridement and appropriate antibiotic therapy (see Plate 7-21).

Because of the devastating nature of chronic post-traumatic osteomyelitis, all open fractures must be identified immediately and prompt treatment instituted to prevent infection in the fracture hematoma. The best means of managing the contaminated fracture is through prompt and thorough surgical debridement combined with intravenous administration of broad-spectrum antibiotics immediately after the injury. The current standard of care is to administer antibiotic prophylaxis as soon as possible based on the work of Patzakis et al. A first-generation cephalosporin (e.g., cefazolin) should be given for all open fractures. For grossly contaminated fractures, an aminoglycoside may be added as well or a penicillin used in cases of organic contamination to protect against Clostridium. Debridement is usually repeated in the first few days after injury. Primary closure of the wound is delayed until there is no evidence of residual contamination at the fracture site.