Open Breaks - Initial Management
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Open fractures are a common pathology seen in emergency departments, especially in trauma centers. In open fractures, the skin barrier has been compromised, exposing sterile bone to the environment. Considered a true orthopedic emergency, these fractures have high morbidity due to osteomyelitis, with infection rates up to 55%. (1) Appropriate and timely intervention in the emergency department with proper antibiotic therapy, wound care, and early orthopedic surgery involvement dramatically reduces the risk of developing osteomyelitis. In this post, we will review the management of open fractures and address additional complications from open fractures. Fractures of the axial skeleton (skull, facial bones, spine, ribs, and pelvis) will not be discussed in this post. Antibiotic recommendations for osteomyelitis prophylaxis are discussed in another post.
Initial Management
Open fractures are traumatic injuries that occur approximately 2/3 of the time from blunt trauma and 1/3 from penetrating trauma. (2) As with all trauma resuscitations, the initial management focuses on mitigating immediate life threats prior to addressing other injuries. The ATLS primary survey should prioritize securing the patient’s airway, breathing, and circulation first and foremost.
Many long bone open fractures carry a significant risk of life-threatening hemorrhage. A femur fracture, classically, is associated with significant blood loss from vascular injury. Bleeding may be controlled with direct pressure, fracture stabilization, or, in situations of arterial/massive hemorrhage, application of a tourniquet. Once life-threating hemorrhage is controlled, circulation to the limb should be assessed (distal pulses and capillary refill). Compromised limb circulation requires prompt intervention to preserve the tissues, including fracture reduction or possibly emergent surgery.
A neurologic exam assessing sensory and motor function should be performed early to establish baseline neurologic function of the limb and assess for potential damage.
Immobilization/reduction of the fracture in the pre-hospital or emergency department setting is recommended. Fracture immobilization not only stabilizes the limb for transport, but also prevents further damage. If circulation to the limb appears compromised, fracture reduction may relieve pressure on the vasculature and restore blood flow to the distal tissues. Furthermore, limb immobilization and/or fracture reduction may prevent worsening soft tissue damage. Bone fragments that have not yet pierced the skin may do so if not appropriately stabilized, thus increasing the opportunity for wound contamination and increasing the risk of osteomyelitis. Preventing micromovements of bone fragments through immobilization is also thought to improve wound healing over the subsequent days.
Pain management should be initiated early per standard practices.
The mechanism of injury and contaminants frequently found in open fractures increases the patient’s risk of tetanus infection. Open fractures, puncture wounds, wounds contaminated by organic material and foreign bodies have a high risk for tetanus. As such, all patients with open fractures need their tetanus vaccination status assessed and updated as needed. In patients without previous tetanus vaccination, tetanus immunoglobulin should be administered in addition to the tetanus toxoid (preferably the Tdap) with plans to complete the immunization series. Previously vaccinated patients who have not received a booster in more than five years should receive the tetanus toxoid only. Previously vaccinated patients who received the booster in the last five years do not require a booster. (3,4)
Classification of Open Fractures: Gustilo-Anderson Classification
In the 1960’s -1970’s, two physicians at Hennepin County Medical Center sought to classify open fractures based on the mechanism of injury, degree of soft tissue damage, severity of fracture pattern, and their risk of developing future infection. They performed a prospective-retrospective study evaluating over 1000 fractures. (5) From this data, they devised a fracture classification system with recommended antimicrobial coverage. Fractures were classified as grades I, II, and III. In the 1980’s, they revised the classification system by subdividing grade III fractures into subtypes IIIA, IIIB, and IIIC. (6,7)
Gustilo-Anderson Subtypes: Kyle Schuchter, PharmD Candidate 2021. Edited by: Paige Garber Bradshaw, PharmD, BCCCP
Grade I fractures are characterized by a wound <1 cm, such as a puncture wound. Grade II fractures have wounds between >1 cm and 10 cm and have mild soft tissue damage. Both Grades I and II are typically infected with gram positive organisms (staph and strep) from skin flora. Grade I fractures have an infection rate up to 2%. Grade II fractures have an infection rate of 1% - 10%.
Grade III injuries result from a significant mechanism of injury, such as high-speed projectiles, blast injuries, crush injuries, etc. Grade IIIA injuries may have a large skin laceration or significant bone fragmentation but have enough viable soft tissue to close the wound primarily. In grade IIIB injuries, the soft tissues damage or loss necessitates reconstruction to close the wound, such grafts or tissue flaps. Grade IIIC injuries are not determined by size but evidence of vascular injury to the limb requiring surgical repair. Grade III injuries are prone to gram-positive and gram-negative infections and thus require broader antibiotic coverage. Infection rates in this category range up to 55%. (7)
Critics of the Gustilo-Anderson classification system note that the delineations between grades may be subjective. Furthermore, the fracture pattern may be incorrectly categorized on initial evaluation leading to delay of initiating appropriate antibiotic therapy. Other classification systems with less subjective criteria have been studied, but at this point lack sufficient data to replace the Gustilo-Anderson classification system. (8)
Empiric Antibiotics
Appropriate empiric antibiotic choice is critical in the management of open fractures. Antibiotics are discussed in a separate post.
Irrigation/Debridement
In conjunction with antibiotics, open fractures require irrigation and debridement to prevent osteomyelitis. While these fractures typically undergo washout in the OR, this can be delayed by several hours. Early irrigation and removal of gross contaminants/foreign bodies significantly reduces the risk of osteomyelitis by physically removing the microbes and other niduses for infection from the wound. Obvious contaminants (plant material, dirt, inorganic foreign bodies) should be removed. Low pressure wound irrigation in the emergency department carries minimal risk of further injury with the benefit of early bacterial count reduction in the affected tissues. High pressure irrigation is not recommended initially due to the risk of tissue injury and the risk of forcing contaminants deeper into the wound. Normal saline is the irrigant of choice. It is inexpensive, readily available in the emergency department, and has been shown to be equivalent to fluids with added antimicrobial agents or soaps for initial wound irrigation. Gravity assisted low-pressure lavage with normal saline (normal saline bags suspended from an IV pole, open to gravity, attached to large bore IV tubing) is an easy-to-use method with adequate results until definitive washout and debridement are performed in the OR. (9) The wound should be covered with sterile gauze soaked in sterile saline to prevent further contamination.
Additional Considerations
Joint spaces may also be violated in open fractures, predisposing the patient to a septic joint. Traumatic arthrotomyshould be considered when there is evidence of skin disruption near a joint. Large wounds in which the joint space is clearly visible virtually guarantees traumatic arthrotomy and requires emergent orthopedic consult. Smaller/subtle wounds near the joint, or that probe deep in the direction of the joint, must be evaluated, especially if fluid is seen seeping from the wound. Classically, the test of choice is a saline load. In this invasive procedure, sterile normal saline is injected into the joint space contralateral to the wound. The joint is then monitored for injected fluid escaping out of the wound. This procedure requires a minimum of 50 ml of saline to evaluate for joint involvement, with larger joints requiring as much as a few hundred ml of normal saline. In recent years, CT scan use has been investigated for its sensitivity in detecting traumatic arthrotomy. Most studies focus on the knee as it is the most commonly affected joint. A review article from 2020 surveyed multiple studies comparing CT scan to saline load testing and their comparative ability to detect traumatic arthrotomies. CT scan overall has sensitivities between 90%-100% and similar specifies. Saline load testing on the other hand required 150 ml – 200 ml of saline to reach 40-50% sensitivity and 95% specificity. (10) Based on these results, there is a high likelihood of practice pattern changes in the upcoming years with more reliance on CT scans to evaluate for traumatic arthrotomy.
Presence of an open fracture does not exclude the possibility of compartment syndrome. Tibia fractures in particular stand a 10% chance of developing compartment syndrome regardless of their Gustilo-Anderson grade. In compartment syndrome, the muscle groups surrounded by thick fascia become edematous secondary to trauma (classically crush injuries). As the muscles swell inside their encasement, the rising pressure will eventually prevent blood flow to the muscles, leading to necrosis. Lab abnormalities include elevated CK and hyperkalemia from muscle death. To treat this condition, a fasciotomy is performed in which surgical incisions are made along the length of the compartments, incising the fascia and allowing the muscles to swell unimpeded. (11) Open fractures, even those with large skin lacerations, may not sufficiently open the affected compartments or may not open all compartments impacted by the injury. As a result, the large skin wound may give the impression of a fasciotomy, but in reality, it is at best a partial fasciotomy or none at all.
Classically, this condition presents with pain (especially with passive movement of the affected extremity), paresthesia, pallor, paralysis, and pulselessness. Pulselessness is a late finding. Classically, the compartments will feel taught on exam. (11) However, this physical exam finding is not sufficiently sensitive or specific, even from the hands of experts. In a study from 2010 in the Journal of Bone and Joint Surgery, orthopedic surgery faculty and senior residents were asked to examine the limbs of cadavers and determined if the compartmental pressures were elevated based on their physical exam. The cadavers’ compartments were monitored with a manometer and adjusted with infusions of saline to keep the pressures at normal pressures (20 - 40 mmHg) vs those seen in compartment syndrome (60 - 80 mmHg). They found that physical exam was 24% sensitive and 55% specific for compartment syndrome with a PPV of 19%. (12) Consequently, a high index of suspicion must be maintained for compartment syndrome despite a reassuring exam. For definitive rule out, compartment pressure measurement must be performed.
Fractures of the hand are managed based on the location of the fracture as well as the age of the patient. Fractures occurring in the palm, or involving the proximal or middle phalanges, are managed similarly to open fractures in the rest of the body. (13,14) Distal phalangeal fractures in adults (classically the Tuft fractures) are typically the result of a crush injury. These can be managed in the ED with copious irrigation. Antibiotics are not necessary in this case (so long as the wound is uncomplicated) but necessitate close orthopedic follow up. (15) Pediatric patients with open distal phalangeal fractures (Seymour fracture), however, necessitate a prompt hand surgeon consult in addition to IV antibiotics. These fractures involve the growth plate, thus increasing the risk of deformity, poor function, and infection. (16)
Conclusion
Open fractures are a common pathology seen in emergency departments that can result in high morbidity. Though definitive management of these injuries is provided by our orthopedic surgery colleagues, appropriate management in the emergency department can significantly reduce the complication patients experience from open fractures.
References
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Brubacher JW, Grote CW, Tilley MB. Traumatic Arthrotomy. J Am Acad Orthop Surg. 2020 Feb 1;28(3):102-111. doi: 10.5435/JAAOS-D-19-00153. PMID: 31977606.
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Authorship
Written by: Kelly Tillotson, MD, PGY-1 University of Cincinnati Department of Emergency Medicine
Peer Review and Editing: Jeffery Hill, MD MEd
