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Emergency And Acute Medicine – Fracture, Open
Basics Description
An open fracture is defined by continuity between a skin violation and the fracture site, ranging from a small puncture wound to grossly exposed bone. These injuries represent a surgical urgency because delays in care significantly increase infection risk and complication rates. Certain factors increase morbidity, including massive soft tissue damage, severe wound contamination, compromised vascular supply, fracture instability, and host factors such as diabetes or peripheral vascular disease.
Etiology
Open fractures usually result from significant blunt trauma or penetrating injury.
Diagnosis Signs And Symptoms
Patients typically present with deformity and a nearby break in skin integrity. Neurovascular compromise may be present, and associated traumatic injuries are common.
History
A history of significant trauma is typical.
Physical Exam
Perform a complete neurologic and vascular examination of the affected limb. A thorough trauma evaluation is essential to identify associated injuries.
Essential Workup
Obtain plain radiographs including the joints above and below the injury. Additional diagnostic evaluation should be guided by the mechanism of injury and evidence of multisystem trauma.
Diagnosis Tests And Interpretation
Lab
CBC, basic chemistry panel, and coagulation studies are indicated for large-bone fractures (e.g., femur, pelvis) or in polytrauma. Type and screen or type and cross-match should be obtained if significant blood loss is anticipated. Pre- and post-débridement wound cultures have limited value and are not recommended.
Imaging
Doppler ultrasonography or angiography is indicated when vascular injury is suspected, such as with posterior knee dislocation, ischemic extremity, or extensive soft tissue damage in high-risk areas.
Diagnostic Procedures/Surgery
Measure compartment pressures if compartment syndrome is suspected. Consider saline or methylene blue arthrogram if joint violation is a concern. Angiography is warranted if noninvasive testing cannot adequately exclude vascular compromise.
Differential Diagnosis
Noncontiguous laceration or abrasion unrelated to the fracture site.
Treatment
Prehospital
Cover open wounds with moist, sterile dressings. Immobilize joints above and below the fracture. Control bleeding with direct pressure; use a tourniquet for traumatic amputations or uncontrolled hemorrhage. Apply gentle longitudinal traction if distal pulses are absent.
Initial Stabilization/Therapy
Prioritize airway, breathing, and circulation. Perform gentle reduction and immobilization when indicated.
ED Treatment/Procedures
Establish intravenous access and keep the patient NPO. Administer tetanus prophylaxis as indicated. Initiate intravenous antibiotics as early as possible to reduce infection risk. Minimize repeated wound exposure to prevent secondary contamination. Reassess frequently for compartment syndrome and neurovascular compromise. Certain large joint open fracture–dislocations (ankle, elbow, knee) require emergent reduction in the ED. Obtain urgent orthopedic consultation for formal irrigation, débridement, and possible operative fixation. Consult vascular surgery when vascular injury is suspected.
Medication
Cefazolin 1–2 g IM/IV (pediatric: 20 mg/kg).
Add gentamicin 1.5–2 mg/kg IV for severe or highly contaminated wounds (pediatric: 2–2.5 mg/kg).
Add penicillin G 4–5 million units IV for farm-related injuries, vascular injuries, or wounds at risk for Clostridium contamination (pediatric: 50,000 U/kg).
Tetanus booster 0.5 mL IM; tetanus immunoglobulin 250 IU IM if not previously immunized.
Morphine sulfate 2–10 mg IV (pediatric: 0.05–0.1 mg/kg per dose) or equivalent analgesia.
Pediatric Considerations
Administer DTaP booster in children younger than 7 years when indicated.
Follow Up Disposition
Admission Criteria
Most patients require admission for operative irrigation, débridement, intravenous antibiotics, and possible fixation.
Discharge Criteria
Selected simple open fractures may be irrigated and immobilized in the ED after orthopedic consultation, with discharge on oral antibiotics and close follow-up.
Issues For Referral
Nearly all open fractures require emergent orthopedic consultation and may necessitate trauma team involvement due to associated injuries.
Follow Up Recommendations
Patients discharged from the ED should be evaluated by an orthopedic surgeon within 1–2 days.
Key Practice Insights And Common Pitfalls
Open fractures are surgical urgencies requiring prompt antibiotics and orthopedic consultation. A high proportion of patients have associated traumatic injuries, which must not be overlooked. Early, thorough emergency department management significantly reduces morbidity and infection risk.
Basics Description
An open fracture is defined by continuity between a skin violation and the fracture site, ranging from a small puncture wound to grossly exposed bone. These injuries represent a surgical urgency because delays in care significantly increase infection risk and complication rates. Certain factors increase morbidity, including massive soft tissue damage, severe wound contamination, compromised vascular supply, fracture instability, and host factors such as diabetes or peripheral vascular disease.
Etiology
Open fractures usually result from significant blunt trauma or penetrating injury.
Diagnosis Signs And Symptoms
Patients typically present with deformity and a nearby break in skin integrity. Neurovascular compromise may be present, and associated traumatic injuries are common.
History
A history of significant trauma is typical.
Physical Exam
Perform a complete neurologic and vascular examination of the affected limb. A thorough trauma evaluation is essential to identify associated injuries.
Essential Workup
Obtain plain radiographs including the joints above and below the injury. Additional diagnostic evaluation should be guided by the mechanism of injury and evidence of multisystem trauma.
Diagnosis Tests And Interpretation
Lab
CBC, basic chemistry panel, and coagulation studies are indicated for large-bone fractures (e.g., femur, pelvis) or in polytrauma. Type and screen or type and cross-match should be obtained if significant blood loss is anticipated. Pre- and post-débridement wound cultures have limited value and are not recommended.
Imaging
Doppler ultrasonography or angiography is indicated when vascular injury is suspected, such as with posterior knee dislocation, ischemic extremity, or extensive soft tissue damage in high-risk areas.
Diagnostic Procedures/Surgery
Measure compartment pressures if compartment syndrome is suspected. Consider saline or methylene blue arthrogram if joint violation is a concern. Angiography is warranted if noninvasive testing cannot adequately exclude vascular compromise.
Differential Diagnosis
Noncontiguous laceration or abrasion unrelated to the fracture site.
Treatment
Prehospital
Cover open wounds with moist, sterile dressings. Immobilize joints above and below the fracture. Control bleeding with direct pressure; use a tourniquet for traumatic amputations or uncontrolled hemorrhage. Apply gentle longitudinal traction if distal pulses are absent.
Initial Stabilization/Therapy
Prioritize airway, breathing, and circulation. Perform gentle reduction and immobilization when indicated.
ED Treatment/Procedures
Establish intravenous access and keep the patient NPO. Administer tetanus prophylaxis as indicated. Initiate intravenous antibiotics as early as possible to reduce infection risk. Minimize repeated wound exposure to prevent secondary contamination. Reassess frequently for compartment syndrome and neurovascular compromise. Certain large joint open fracture–dislocations (ankle, elbow, knee) require emergent reduction in the ED. Obtain urgent orthopedic consultation for formal irrigation, débridement, and possible operative fixation. Consult vascular surgery when vascular injury is suspected.
Medication
Cefazolin 1–2 g IM/IV (pediatric: 20 mg/kg).
Add gentamicin 1.5–2 mg/kg IV for severe or highly contaminated wounds (pediatric: 2–2.5 mg/kg).
Add penicillin G 4–5 million units IV for farm-related injuries, vascular injuries, or wounds at risk for Clostridium contamination (pediatric: 50,000 U/kg).
Tetanus booster 0.5 mL IM; tetanus immunoglobulin 250 IU IM if not previously immunized.
Morphine sulfate 2–10 mg IV (pediatric: 0.05–0.1 mg/kg per dose) or equivalent analgesia.
Pediatric Considerations
Administer DTaP booster in children younger than 7 years when indicated.
Follow Up Disposition
Admission Criteria
Most patients require admission for operative irrigation, débridement, intravenous antibiotics, and possible fixation.
Discharge Criteria
Selected simple open fractures may be irrigated and immobilized in the ED after orthopedic consultation, with discharge on oral antibiotics and close follow-up.
Issues For Referral
Nearly all open fractures require emergent orthopedic consultation and may necessitate trauma team involvement due to associated injuries.
Follow Up Recommendations
Patients discharged from the ED should be evaluated by an orthopedic surgeon within 1–2 days.
Key Practice Insights And Common Pitfalls
Open fractures are surgical urgencies requiring prompt antibiotics and orthopedic consultation. A high proportion of patients have associated traumatic injuries, which must not be overlooked. Early, thorough emergency department management significantly reduces morbidity and infection risk.
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