Overview
Definition:
An open fracture, also known as a compound fracture, is a bone break where the fractured bone protrudes through the skin, or there is a break in the skin and underlying soft tissues that communicates with the fracture
This creates a direct pathway for microorganisms to enter, significantly increasing the risk of infection, including osteomyelitis and tetanus
In pediatric populations, open fractures require prompt and meticulous management due to their vulnerability to long-term functional impairment and the unique considerations in childhood.
Epidemiology:
Open fractures represent 1-3% of all fractures, with a higher incidence in males
Pediatric open fractures are less common than in adults, often resulting from high-energy trauma such as motor vehicle accidents, falls from height, or sporting injuries
The risk of infection is directly related to the degree of wound contamination and the delay in treatment.
Clinical Significance:
Open fractures are orthopedic emergencies due to the high risk of infection, delayed healing, non-union, and malunion
In pediatrics, these complications can have profound effects on skeletal growth and long-term function
Proper and timely management, including tetanus prophylaxis and judicious antibiotic use, is critical to minimizing morbidity and ensuring optimal outcomes.
Clinical Presentation
Symptoms:
Visible bone protruding through the skin
Open wound at the fracture site
Severe pain at the injury site
Bleeding from the wound
Inability to move the affected limb.
Signs:
Obvious deformity of the limb
Presence of a laceration or avulsion injury communicating with the fracture
Palpable crepitus over the fracture site
Signs of neurovascular compromise distal to the fracture
Signs of gross contamination of the wound with dirt, debris, or foreign bodies
Associated soft tissue injury (e.g., degloving, avulsions).
Diagnostic Criteria:
Diagnosis is primarily clinical, based on the presence of a bone break with associated skin and soft tissue injury communicating with the fracture site
The Gustilo and Anderson classification system is commonly used to grade open fractures based on wound size, contamination, and soft tissue damage, which correlates with infection risk and treatment strategies.
Diagnostic Approach
History Taking:
Mechanism of injury: type of trauma (e.g., gunshot, farm injury, fall, motor vehicle accident)
Energy of injury: high vs
low
Environment of injury: clean vs
contaminated (e.g., farm, water, soil)
Time elapsed since injury: crucial for antibiotic and surgical timing
Previous tetanus immunization status: date and type of last dose
Presence of comorbidities: immunocompromise, diabetes (less common in children but relevant).
Physical Examination:
Assess and document the neurovascular status distal to the injury (pulses, capillary refill, sensation, motor function)
Thoroughly inspect the wound for size, depth, degree of contamination, and damage to underlying structures (nerves, vessels, tendons)
Gently probe the wound to assess extent and involvement of the fracture
Assess the surrounding soft tissues for swelling, bruising, and signs of compartment syndrome
Do not attempt to reduce the fracture in the field unless necessary for limb preservation or circulation
this should be done in a controlled environment.
Investigations:
Radiographs of the affected limb: anteroposterior (AP) and lateral views are essential to visualize the fracture pattern, displacement, and extent of comminution
If a foreign body is suspected, obtain additional views or consider CT scan
Complete Blood Count (CBC) with differential: to assess for leukocytosis, which may indicate infection
Erythrocyte Sedimentation Rate (ESR) and C-Reactive Protein (CRP): baseline inflammatory markers, though may not be significantly elevated early on
Blood cultures: if systemic signs of infection are present
Wound cultures: obtained intraoperatively before antibiotic administration, ideally from deep tissue
Tetanus antibody titres are generally not useful for acute management decisions.
Differential Diagnosis:
Closed fractures with severe soft tissue injury
Pathologic fractures
Traumatic amputations
Degloving injuries without bone exposure
While the diagnosis of an open fracture is generally straightforward, distinguishing the severity and extent of contamination is critical for management.
Management
Initial Management:
Immediate transfer to a facility capable of managing orthopedic emergencies
Prompt assessment and resuscitation (ABCs)
Control of external hemorrhage with direct pressure
Cover the wound with sterile, saline-moistened gauze
Immobilize the limb with a splint to prevent further soft tissue damage and reduce pain
Administer intravenous fluids and analgesia
Avoid probing or excessive manipulation of the wound in the pre-hospital setting.
Tetanus Prophylaxis:
Administer tetanus immunoglobulin (TIG) and/or tetanus toxoid vaccine based on the wound characteristics and patient's immunization history
For clean, minor wounds in inadequately immunized individuals, give Td (tetanus and diphtheria toxoids)
For all other wounds (including contaminated, dirty, or neglected wounds) in inadequately immunized individuals, administer TIG and Td
If immunization status is unknown or incomplete (less than 3 doses of toxoid), give Td
If the patient has received 3 or more doses and the last dose was more than 5 years ago, administer Td
If the last dose was within 5 years, no further prophylaxis is needed for clean wounds
For dirty/contaminated wounds, if the last dose was more than 1 year ago, administer Td
Guidelines may vary slightly
consult current CDC/WHO recommendations
In pediatrics, use pediatric formulations where available.
Antibiotic Therapy:
Initiate broad-spectrum intravenous antibiotics as soon as possible, ideally within 1 hour of injury, and before surgical débridement
The choice of antibiotics depends on the Gustilo-Anderson grade of the open fracture: Grade I/II: First-generation cephalosporin (e.g., Cefazolin) is typically sufficient
Grade III: Add an aminoglycoside (e.g., Gentamicin) for broader coverage against Gram-negative organisms, and potentially consider a penicillin or clindamycin for anaerobic coverage if heavily contaminated
For farm injuries or animal bites, broaden coverage to include specific pathogens (e.g., Penicillin for Pasteurella)
Continue antibiotics for at least 24-72 hours postoperatively, or longer depending on wound condition and evidence of infection
Adjust antibiotics based on intraoperative cultures and sensitivities.
Surgical Management:
Urgent surgical débridement and irrigation are paramount
This should be performed as soon as the patient is stabilized and within 6-12 hours of injury to minimize infection risk
Thoroughly irrigate the wound with copious amounts of saline
Remove all devitalized tissue, foreign bodies, and contaminants
Subsequent débridements may be necessary
Fracture stabilization (external or internal fixation) is performed after thorough débridement, balancing stability with the risk of further contamination
Definitive treatment depends on fracture pattern and soft tissue injury.
Supportive Care:
Pain management: multimodal analgesia including opioids and non-opioids
Nutritional support: adequate protein and calorie intake is essential for wound healing
Psychological support: address anxiety and fear related to the injury and prolonged hospital stay
Wound care: regular dressing changes as per protocol, monitoring for signs of infection
Physical therapy: initiated as soon as possible to maintain range of motion and prevent stiffness.
Complications
Early Complications:
Infection: superficial or deep wound infection, osteomyelitis, septic arthritis
Neurovascular injury: nerve damage, arterial injury, compartment syndrome
Gas gangrene (Clostridium perfringens infection)
Hemorrhage.
Late Complications:
Non-union: failure of the fracture to heal
Malunion: healing in an incorrect position
Delayed union: prolonged healing time
Chronic osteomyelitis
Joint stiffness and loss of function
Growth disturbances (in pediatric patients)
Post-traumatic arthritis
Chronic pain syndrome.
Prevention Strategies:
Timely and adequate surgical débridement and irrigation
Prompt administration of appropriate antibiotics
Judicious use of tetanus prophylaxis
Meticulous wound care and infection surveillance
Appropriate fracture stabilization
Patient and family education regarding wound care and signs of infection.
Prognosis
Factors Affecting Prognosis:
The severity of the initial injury (Gustilo-Anderson grade)
Degree of wound contamination
Time to definitive surgical débridement and irrigation
Adequacy of antibiotic therapy
Presence of comorbidities
The patient's overall health status and adherence to treatment
Effective management of open fractures in children generally leads to good functional outcomes, though growth disturbances and deformities can occur with severe injuries or complications.
Outcomes:
With prompt and appropriate management, the majority of pediatric open fractures can achieve union and good functional recovery
However, the risk of infection and long-term complications remains significant
Early recognition and intervention are key to optimizing outcomes
The functional outcome is often more dependent on the extent of soft tissue damage than the fracture itself.
Follow Up:
Close follow-up is essential
This includes regular clinical assessments, wound checks, and radiographic monitoring to assess healing and detect complications
Physical therapy should be continued as needed to regain strength, range of motion, and function
Long-term follow-up may be required to monitor for growth disturbances or the development of post-traumatic arthritis, especially in younger children.
Key Points
Exam Focus:
The "golden hour" for antibiotic administration and débridement in open fractures is critical
aim for antibiotics within 1 hour and débridement within 6-12 hours
Gustilo-Anderson classification guides antibiotic choice
Tetanus prophylaxis is mandatory and depends on wound type and immunization history
Consider risk of Clostridium in contaminated wounds.
Clinical Pearls:
Always document neurovascular status before and after any manipulation
Do not explore the wound extensively in the ER
that is the job of the surgeon in the OR
Use sterile saline for irrigation, and copious amounts are better than minimal
When in doubt about tetanus status, err on the side of prophylaxis.
Common Mistakes:
Delaying antibiotics or surgical débridement
Inadequate wound irrigation and débridement
Failure to administer tetanus prophylaxis
Using oral antibiotics initially instead of IV
Not adequately addressing neurovascular status or compartment syndrome
Underestimating the risk of infection in seemingly minor open fractures.