OPEN FRACTURE: FIRST AID, TREATMENT - ANATOMY AND PHYSIOLOGY - 2025

An open fracture is one in which, in addition to the interruption in bone continuity, there is injury to the skin or adjacent tissues, which establishes communication between the focus of the fracture and the exterior. In other words, the risk of contamination is high. Fractures are defined as a break in the continuity of bone or cartilage.

They usually occur as a consequence of trauma whose intensity exceeds the bone's bearing capacity. In open fractures, communication with the outside can occur in two ways, one of these is that the fractured bone has a sharp edge that pierces the muscle tissue and the skin.

Another way is that the fracture is due to an object that, after causing a soft tissue injury, reaches the bone and fractures it; for example, a bullet. This does not mean that the wound has to be at the same level as the bone fracture, but it is a sinequanon condition that is in the same body segment.

In both cases, the greatest concern is due to the risk of infection of the exposed bone, which can generate sepsis, osteonecrosis with its respective inability to consolidate and loss of the limb. Losing the soft tissue covering, such as the musculature at the fracture site, greatly reduces the potential for bone healing.

From this it follows that infection and alterations in the consolidation process are the main complications presented in this type of fracture.

Classification

At an international level, to categorize both open and closed fractures, the Gustilo and Anderson classification is used, in order to unify trauma criteria. According to Gustilo and Anderson, open fractures are classified as follows:

Grade I

When the bone fragments are the cause of the wound; that is, the wound is produced from the inside out. The wound is less than 1 cm and the degree of contamination is minimal.

Grade II

The wound is greater than 1 cm but less than 10 cm. The degree of contamination is moderate.

Grade III

The wound is larger than 10 cm and is produced by a foreign body that penetrates the segment from the outside to the inside. The degree of contamination is maximum and according to the affectation of the soft tissues it is divided into:

Grade IIIA

The soft tissues can cover the surface of the exposed bone (primary closure).

Grade IIIB

The soft tissues cannot cover the entire surface of the exposed bone and it is necessary to resort to procedures such as flaps or grafts to close the wound.

Grade IIIC

It complies with the characteristics of grade IIIB, but vascular lesion is attached.

First aid

Open fractures are a medical emergency, and the initiation of treatment must be prompt and adequate to minimize the risk of complications to a minimum.

The initial indication is to transfer the patient to a specialized center as soon as possible; however, in most cases this can get complicated and there are certain actions that can be taken at the accident site while waiting for a transfer to the emergency room.

First, never attempt to reintroduce the exposed bone fragment under any circumstances. Only a little pressure should be applied to the wound site without actually making a tourniquet, in order to help haemostasis and stop bleeding.

To minimize the risk of infection, the wound should be covered with whatever cloth is on hand, such as a shirt or a towel.

An immobilization should be attempted with any object that is at hand, in order to prevent bone fragments from damaging soft tissues or any vessels during the transfer of the patient to the emergency department.

Cleaning the wound can be done if you have the implements for it, but the priority should be to transfer the patient as soon as possible.

Treatment

The objective of the treatment of fractures is aimed at obtaining the maximum functional recovery of the fractured bone segment.

For this, measures are established that meet the conditions to facilitate normal physiological processes of consolidation; for example, the proper position of the segment, thorough cleaning to avoid infection, reconstruction of soft tissues, among other measures.

However, open fractures require surgical treatment in 100% of cases, not only due to the nature of the fracture itself, but also because of the possibility of associated injuries that can bring major complications, such as a vascular or nerve injury., interarticular fractures, multiple trauma, among others.

Process

The first step in the medical management of open fractures is to perform surgical debridement of all necrotic soft tissue or bone. The more radical and thorough the debridement, the lower the infection and complication rate.

Antibiotic coverage is performed using a first-generation cephalosporin together with intravenous aminoglycosides. In case of soil contamination, penicillin is added as a cover against anaerobes.

Immobilization should be as rigid as possible, usually using external fixators or intramedullary nailing, the latter being the first choice and leaving external fixators for cases of multiple trauma.

The use of bone grafts arises in the case of total or almost total healing of soft tissues, and the inability to consolidate bone despite this.

If the vascular lesion cannot be reconstructed and the patient is hemodynamically unstable or at risk of being so, early amputation may be considered.

However, the decision on whether or not to amputate a limb is one of the most difficult to make, and for this, assessment scales have been established for making the decision, such as the MESS scale (Mangled Extremity Severity Score).), which is translated as the severity scale of the mutilated limb.

Difference between open and closed fracture

The fundamental difference lies in the communication with the outside. In a closed fracture there may also be vascular or nerve injury, the fractures can be inter-articular in both types, but the risk of infection is minimal in closed fractures, since it is maintained in the same physiological environment within the segment.

References

1. M. Muñoz Vives. Open fractures. Spanish Journal of Orthopedic Surgery and Traumatology. Vol 54. Num. 6 December 2010. Recovered from: elsevier.es
2. CTO Manual of Medicine and Surgery. Volume of Traumatology and Orthopedics. 8th Edition. Page 2-6
3. Thomas M Schaller, MD Orthopedic Trauma Surgeon, Steadman Hawkins Clinic of the Carolinas. Open Fractures. Orthopedic Surgery. Medscape. Recovered from: emedicine.medscape.com
4. Cross, William. Tratment principles in the management of open fractures. Indian Journal of Orthopedics. 2008 Oct-Dec 42 (4): 377-378 Retrieved from: ncbi.nlm.nih.gov
5. Ramón B. Gustilo. Treatment of open fractures and their complications. Editorial Interamericana 1983.