Open fractures are a concern because these injuries can be difficult to heal, and infection can cause significant problems with the healing of the bone and the surrounding tissues. Most of the early treatment of an open fracture is focused on preventing the development or progression of infection at the site of the fracture.
Surgically Cleaning the Bone:
Determining the extent of injury can be difficult just by looking at an open fracture. This is especially true in high-energy injuries including automobile collisions and gunshot wounds. With these types of injuries, even small penetrations in the skin can cover very large areas of soft-tissue damage around an open fracture. Therefore, when surgically cleaning the bone, it is important to do this in the operating room (OR) under anesthesia -- trying to sufficiently assess and clean the bone in the emergency room, without adequate anesthesia, may be insufficient. In addition, even though an injury to the skin is already present, a larger incision may need to be made.
Removing Contaminated or Non-Viable Tissue:
Stabilizing the Bone:
- They can be quickly applied, which is often necessary with severe trauma.
- They allow the wound to be tended to.
- They secure the bone without placing foreign objects directly at the site of injury.
Antibiotics should be administered as soon as possible, even before performing the irrigation and debridement described above. The antibiotics are usually continued for 48 hours. If further infection is suspected, the antibiotics may be continued even longer.
Timing of Events:
More recently, some surgeons feel that open fractures, in particular hand fractures, may not warrant as urgent treatment, and the treatment can be delayed. In addition, an argument can be made that rushing to the OR with an on-call team in the middle of the night may not be as safe as waiting until the following day to perform open fracture surgery.
Most orthopedists agree that each open fracture needs to be treated quickly and safely. If the safest treatment involves a time delay beyond 6 hours, that may be appropriate, but in some cases the safest treatment is to get the patient to the OR as quickly as possible. Either way, open fractures are orthopedic emergencies, and evaluation should not be delayed.
Prognosis of Open Fractures:
People who sustain an open fracture can expect their fracture healing to take longer, and their recovery to be more prolonged, than would be the case with a closed fracture.
Zalavras CG and Patzakis MJ "Open Fractures: Evaluation and Management" J Am Acad Orthop Surg May/June 2003; 11:212-219.
Werner CM, et al. "The Urgency of Surgical Débridement in the Management of Open Fractures" J Am Acad Orthop Surg July 2008 ; 16:369-375.