Open fracture definition

Fracture with direct communication between the fracture site and the external environment due to defect in the skin and soft tissues. This exposes the bone to contamination and increases the risk of infection.

A soft tissue wound in proximity to a fracture should be treated as an open fracture until proven otherwise

BOAST Guidelines: Open Fractures (December 2017)

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Background

Open fractures require prompt multidisciplinary management to minimise infection risk and optimise recovery. Trauma networks and hospitals must have appropriate pathways and infrastructure to manage these injuries effectively.

Inclusions

• All patients with open fractures of long bones, hindfoot or midfoot (excluding hand, wrist, forefoot or digits)

Standards for Practice

1. Specialist Centre Care
   • Patients with open fractures of long bones, hindfoot or midfoot should be taken directly or transferred to a specialist centre capable of providing orthoplastic care.
   • Patients with injuries to the hand, wrist, forefoot or digits may be managed locally following similar principles.
2. Antibiotic Administration
   • Administer intravenous prophylactic antibiotics as soon as possible, ideally within one hour of injury.
   • Ensure a readily accessible, published network guideline for antibiotic use in open fractures is available.
3. Limb Assessment and Management
   • Assess and document the vascular and neurological status of the injured limb, repeating systematically, particularly after reduction manoeuvres or splint application.
   • Re-align and splint the limb as necessary.
   • Manage suspected compartment syndrome according to established guidelines.
4. Arterial Injuries
   • Treat patients presenting with arterial injuries associated with their fracture in accordance with arterial injury management guidelines.
5. Imaging Protocols
   • For patients requiring an initial "Trauma CT," implement protocols to maximise useful information and minimise delay:
     • Include a head-to-toe scanogram in the initial sequence, using clinical correlation to direct further specific limb sequences during the initial CT examination.
     • Establish a local policy on the inclusion of angiography in any extremity CT related to open fractures.
6. Wound Handling
   • Prior to formal debridement, handle the wound only to remove gross contamination and for photography.
   • Dress with saline-soaked gauze and cover with an occlusive film.
   • Avoid "mini-washouts" outside the operating theatre environment.
7. Photographic Documentation
   • Ensure trauma networks have information governance policies that enable staff to take, use and store photographs of open fracture wounds for clinical decision-making 24 hours a day.
   • Photograph open fracture wounds when first exposed for clinical care, before debridement and at other key management stages, keeping these images in the patient's records.
8. Orthoplastic Approach
   • Consultants in orthopaedic and plastic surgery should concurrently form the management plan for fixation and coverage of open fractures and perform initial debridement using a combined orthoplastic approach.
9. Debridement Timing
   • Perform debridement using fasciotomy lines for wound extension where possible:
     • Immediately for highly contaminated wounds (e.g. agricultural, aquatic, sewage) or when there is associated vascular compromise (compartment syndrome or arterial disruption causing ischaemia).
     • Within 12 hours of injury for other solitary high-energy open fractures.
     • Within 24 hours of injury for all other low-energy open fractures.
10. Clean Surgery Protocol
    • Once debridement is complete, consider any further procedures at the same sitting as clean surgery. Use fresh instruments and re-prep and drape the limb before proceeding.
11. Soft Tissue Closure
    • Achieve definitive soft tissue closure or coverage within 72 hours of injury if it cannot be performed at the time of debridement.
12. Internal Stabilisation
    • Perform definitive internal stabilisation only when it can be immediately followed by definitive soft tissue cover. </aside>

Gustilo-Anderson classification

Severity grading of open fractures

Caveats

• Any grossly-contaminated wound (e.g. agricultural, aquatic, sewage) is automatically Grade III
• Any high-energy injury (e.g. gunshot wound) is automatically Grade III

Problems with this classification:

• Early assessment is unreliable: Best graded intra-operatively. Poor inter-observer reliability in early clinical assessment.
• Deep tissue injury is not well-established: Visible skin-level injury is not always indicative of underlying soft tissue injury severity.