Open fractures occur across a spectrum of patient ages and through a variety of mechanisms. Despite their frequent occurrence and abundant research supporting their care, open fractures remain a clinical challenge with many unresolved questions. These injuries occur at a rate of 3.4 per 100,000 and at a mean age of 45.5 years with a male predominance. Seventy-five percent of open fractures are attributable to finger, distal radial, and lower extremity injuries, particularly tibial and ankle fractures. Motor vehicle collisions account for 34.1% of open fractures.¹ However, a single-center epidemiologic study showed a decline in motor vehicle-related open fractures between 1988 and 2010, which can be attributed to improved safety features of vehicles as well as alcohol and speeding restrictions.²

Open fractures are classified in an attempt to guide treatment, improve communication, predict outcomes, and allow for comparative analysis. Classification is performed at the time of surgical débridement. The Gustilo-Anderson classification is the most commonly used system based on their pivotal research in 1976.³ The original classification has been modified, but in its contemporary form the Gustilo-Anderson classification stratifies open fractures by the size of the open wound, fracture pattern, the amount of periosteal stripping, contamination, and need for free-tissue transfer or vascular repair.³,⁴ The Orthopaedic Trauma Association published an open fracture classification (OTA-OFC) in 2010 based on expert consensus. The OTA-OFC stratifies injuries based on severity of injury to skin, muscle, and arteries as well as level of contamination and amount of bone loss.⁵

Although classification systems enhance communication about open fractures, they do not always provide enough information to make specific treatment decisions. A comparative study found similar moderate rates of interobserver reliability between the Gustilo-Anderson classification and the OTA-OFC but note that the OTA-OFC provides more information about the injury.⁶ Photographs of injuries before and after débridement have become invaluable as data-sharing technology has improved. A 2019 study in the United Kingdom found that use of a smartphone-based app improved government-compliant information transfer of open fracture images to patient medical records.⁷ Clinical photographs often provide information to providers that description or classification cannot and may prove a useful tool in interdisciplinary communication regarding care of open fractures (Figure 1).

Ideally, classification would predict outcomes. A multicenter retrospective review shows subcategories of the OTA-OFC to be predictive of outcomes. Specifically, the OTA-OFC skin subcategory correlated strongly with type of definitive closure, the OTA-OFC muscle subcategory was predictive of nonunion, and the subcategories muscle and arterial were predictive of amputation.⁸ A 2021 retrospective review of upper extremity open fractures shows that the OTA-OFC correlates with definitive type of closure. This same study shows that the OTA-OFC muscle subcategory correlates with 90-day wound complications.⁹

The mechanism of injury of open fractures can vary widely. Initial management includes a general trauma assessment based on Advanced Trauma Life Support guidelines. Open fractures can be a dramatic source of distracting injury, and a systematic evaluation is essential to avoid missing other injuries. Although open fractures in isolation are the focus of discussion, the overall condition of the patient is an essential component of decision making. In the most severe cases, life over limb is a valuable treatment-guiding mantra.

Related to open fracture management, early administration of parenteral antibiotics is essential to infection prevention. The importance of systemic antibiotics in open fractures was first demonstrated in 1974.¹⁰ A subsequent study showed that timing of antibiotics is also important in identifying a significant difference in infection rates if antibiotics were administered within 3 hours of injury.¹¹ This finding has been corroborated in multiple studies and trauma guidelines, including Eastern Association for the Surgery of Trauma (EAST), Surgical Infection Society, and British Orthopaedic Association Standard for Trauma, that recommend antibiotic administration as soon as possible to prevent infection in open fractures.¹²,¹³,¹⁴,¹⁵ In the emergency department, open fractures should be cleared of gross contamination, covered in a saline-soaked gauze dressing, and splinted to avoid further soft-tissue injury. Neurovascular examination and compartment syndrome assessment are critical.¹³

Antibiotic selection and duration for prophylaxis in open fractures is an evolving issue. Traditionally, antibiotic treatment has been guided by the Gustilo-Anderson classification and the presence of gross contamination. Seasonal and geographic variations in antibiograms make a single best-practice protocol challenging to define.¹⁶

The EAST guidelines recommend gram-positive coverage alone for type I and II open fractures. For type III fractures, coverage is expanded to provide coverage against gram-negative species. Penicillin may be added for suspected soil or fecal contamination.¹² The British
Orthopaedic Association Standard for Trauma guidelines recommend antibiotic administration ideally within 1 hour of injury but make no antibiotic recommendations.¹³ Based on available literature, the Surgical Infection Society recommends gram-positive prophylaxis with cephalosporin monotherapy as soon as possible but is unable to recommend gram-negative or clostridial coverage.¹⁵

The addition of gram-negative coverage in type III open fractures has been questioned. A single-center retrospective series of type III open fractures showed no change in the incidence of infection with the addition of aminoglycoside but an increased incidence of acute kidney injury from 4% to 10%.¹⁷ Polytraumatized patients have multiple risk factors for acute kidney injury, and the addition of a nephrotoxic antibiotic may not be benign. Risk factors for acute kidney injury in the setting of open fracture and administration of gentamicin include female sex, obesity, intensive care unit admission, CT contrast administration, and age older than 60 years.¹⁸ One study evaluated combat-related open fractures and the addition of extended gram-negative coverage. There was a noted benefit for prevention of skin and soft-tissue infections, but no difference in the rate of osteomyelitis. The patients who had received extended gram-negative coverage and in whom osteomyelitis developed were more likely to have an antibiotic-resistant organism. It was concluded that, for combat-related open fractures, cefazolin or clindamycin monotherapy is recommended.¹⁹ According to a 2020 review on gram-negative coverage and type III open fractures, a strong case was made for cefazolin monotherapy as the antibiotic choice for all open fractures.²⁰

A 2021 multicenter study of more than 1,200 patients reviewed antibiotic selection for open fractures and found moderate adherence to the EAST guidelines in type I and II open fractures and low adherence in type III fractures. In this series, only 17.2% of type III open fractures received cefazolin and aminoglycoside therapies as suggested per the EAST guidelines. A total of 31.0% of type I and II open fractures inappropriately received gram-negative coverage in this series.²¹ The addition of high-dose penicillin for fecal and soil contamination has also been called into question. Penicillin was originally recommended for clostridial gangrene and group A beta-hemolytic Streptococcus coverage. A 2011 guideline endorsed by the Infectious Diseases Society of America and the Surgical Infection Society recommends against the use of penicillin in postinjury antimicrobial coverage for combat-related injuries.²² That was echoed in a prospective study in which aminoglycosides, vancomycin, and penicillin were removed from the treatment protocol for open fracture antibiotic prophylaxis, with no significant difference in rate of infection or rate of resistant organism infection.²³

Antibiotic duration is as controversial as antibiotic selection. It is unclear whether there is any benefit to extending antibiotic coverage beyond 24 hours. A meta-analysis showed no benefit for prolonged antibiotics defined as 72 hours; subgroup analysis showed shorter antibiotic durations of 24 to 48 hours were equivalent to a 72-hour treatment duration.²⁴ A 2020 secondary analysis from the Fluid Lavage of Open Wounds, or FLOW trial, attempted to shed light on the ambiguity of extended antibiotic duration, which they defined as more than 72 hours. This multicenter prospective study found a differential effect of extended antibiotic duration depending on the level of contamination. In open fractures with mild contamination, extended antibiotic duration showed a tendency toward increased infection rate. However, extended antibiotic duration was strongly protective of surgical site infection in highly contaminated open fractures.²⁵

The indications for application of local antibiotics to open fractures, in isolation or in addition to systemic antibiotics, continue to evolve. Although antibiotic beads and pouches have been used for years for local control of or prophylaxis against infection, consensus regarding indications, duration, dosing, and carrier medium has not been reached. A systematic review with pooled meta-analysis including 2,738 patients with open fractures showed a significantly lower infection rate when local antibiotics were applied, with a risk reduction of 11.9%. This review included eight studies, six of which compared antibiotic-loaded polymethyl methacrylate (PMMA) beads with systemic antibiotics with systemic antibiotics alone and two studies that evaluated the addition of antibiotic powder without a carrier medium to standard care.²⁶ An animal study compared irrigation and débridement alone with the addition of vancomycin powder or PMMA beads containing vancomycin and tobramycin. The addition of local antibiotics significantly decreased bacterial colonization 14 days after inoculation. There was no significant difference between bacterial counts when comparing powder with PMMA beads.²⁷ In a 2020 animal study, early application of a gentamicin-loaded hydrogel without the use of systemic antibiotics was more effective than systemic antibiotics at eliminating bacterial contamination 7 days after injury.²⁸