Visual Element: An illustrated guide to the Gustilo-Anderson Classification (Type I, II, IIIA, IIIB, IIIC) with cross-sections showing the degree of soft tissue stripping and periosteal involvement.

The Open Fracture: An Orthopaedic Emergency

An open fracture is defined as a fracture where the hematoma communicates with the outside environment. It is a biological crisis involving bone, soft tissue, and skin. The risks are infection, non-union, and amputation.

Management has evolved significantly from the days of "pour some betadine on it." We now rely on combined ortho-plastic networks and strict evidence-based protocols.

Classification: Beyond the Basics

Every registrar knows Gustilo-Anderson, but few know its nuances and limitations.

Gustilo-Anderson Classification (1976, modified 1984)

• Type I: Wound <1cm. Clean. Simple fracture pattern. (Infection risk: 0-2%).
• Type II: Wound >1cm. No extensive soft tissue damage. (Infection risk: 2-7%).
• Type III: Extensive soft tissue damage.
  • IIIA: Adequate soft tissue coverage of bone despite laceration/flaps. High energy.
  • IIIB: Extensive loss of soft tissue. Bone is exposed and requires a flap for coverage. Periosteal stripping. (Infection risk: 10-50%).
  • IIIC: Any open fracture with arterial injury requiring repair. (Amputation rate: >50%).

Trap: The classification is intra-operative. You cannot accurately grade an open fracture in the Emergency Department. What looks like a Type I puncture wound could be a Type IIIA degloving injury underneath. Always document as "Open Fracture (Grading pending debridement)."

Initial Management: The "Golden Guidelines"

1. Photography

Take one high-quality photo of the wound once the dressing is removed. Upload it to the medical record. Do not allow every doctor who walks past to take down the dressing to "have a look." Re-exposure increases nosocomial infection risk.

2. Antibiotics: The Clock is Ticking

The single most important factor in preventing infection is Time to Antibiotics.

• Goal: < 1 hour from injury (or presentation).
• Evidence: Risk of infection increases significantly with every hour of delay.
• Protocol (eTG Australia):
  • Grade I/II: Cefazolin 2g IV (q8h).
  • Grade III: Cefazolin + Gentamicin (to cover Gram Negatives).
  • Farm/Soil/Water: Add Metronidazole or Penicillin (for Clostridium and anaerobes).
• Duration: Stop at 24 hours (Grade I/II) or 72 hours (Grade III) or at definitive closure. Prolonged courses (>7 days) breed resistance and do not lower infection rates.

3. The Debridement

"The solution to pollution is dilution."

• Volume: 3L (Type I) to 9L+ (Type III) of normal saline.
• Additives: Do not use betadine, peroxide, or antibiotics in the wash. They are cytotoxic to osteoblasts. Plain saline is best (FLOW Trial).
• Pressure: Low-pressure lavage is superior to high-pressure (which drives bacteria deeper into the marrow).
• Technique: Excision of skin edges (2mm), removal of all devitalized muscle (check contractility, colour, consistency, capacity to bleed), and removal of loose cortical bone fragments.

The "Fix and Flap" Protocol

Modern management relies on the collaboration between Orthopaedic and Plastic surgeons.

Fixation

• Plate vs Nail: Depends on the fracture. Nails are generally preferred for tibia/femur as they preserve the periosteal blood supply.
• Ex-Fix: Used for temporary stabilization in gross contamination or if soft tissue status is critical.

Coverage (The Flap)

• Timing: The Goddard Standards (BOA/BAPRAS) suggest coverage should occur within 72 hours of injury. Delay > 7 days is associated with a skyrocketing infection rate.
• Ladder:
  • Primary Closure (only if no tension).
  • Split Skin Graft (only if muscle bed is healthy; never over bare bone/tendon).
  • Local Flap (e.g., Gastrocnemius flap for proximal tibia).
  • Free Flap (e.g., ALT or Latissimus Dorsi) for distal third tibia.

Clinical Pearl: Negative Pressure Wound Therapy (NPWT / VAC) is a bridge, not a treatment. It buys you time (days), but it does not treat infection or replace dead tissue. Do not leave a VAC on for 2 weeks hoping the hole will close.

Managing Bone Loss

High-energy open fractures often leave a gap.

1. Acute Shortening: If the defect is small (<2-3cm), you can acutely shorten the limb to dock the bone ends, then lengthen later if needed.
2. Masquelet Technique (Induced Membrane):
   • Stage 1: Put a cement spacer in the gap. Close soft tissues. Wait 6-8 weeks. A biological membrane forms around the cement.
   • Stage 2: Open membrane, remove cement, pack with autograft/allograft. The membrane is rich in growth factors and prevents resorption.
3. Bone Transport (Ilizarov/Taylor Spatial Frame): Corticotomy and gradual distraction to "grow" new bone across the defect.

Outcome Metrics

Success is not just union. It is:

• Infection-free union.
• Soft tissue integrity.
• Function (can they walk?).

Conclusion

Open fractures are unforgiving. A missed compartment syndrome, a delayed antibiotic dose, or a poor debridement can lead to chronic osteomyelitis and a lifetime of disability.

Rules to Live By:

1. Antibiotics in < 1 hour.
2. Debridement by a senior surgeon.
3. Fix and Flap within 72 hours.
4. Treat the soft tissue with more respect than the bone.

References

1. FLOW Investigators. "A Trial of Wound Irrigation in Initial Management of Open Fracture Wounds." NEJM. 2015.
2. Gustilo RB, Anderson JT. "Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones." JBJS Am. 1976.
3. British Orthopaedic Association (BOA) / BAPRAS. "Standards for the Management of Open Fractures." 2020.