Overview
Definition:
An open (or compound) fracture is a fracture in which the broken bone is exposed to the outside environment through a break in the skin and soft tissues
This significantly increases the risk of infection and complications.
Epidemiology:
Open fractures are less common in children than in adults, accounting for approximately 0.5% to 5% of all pediatric fractures
They are most often caused by high-energy trauma such as motor vehicle accidents or falls from height
Gustilo and Anderson classification is used to grade severity and predict outcomes.
Clinical Significance:
Prompt and appropriate management of pediatric open fractures is crucial to minimize the risk of infection (osteomyelitis, soft tissue infection), promote wound healing, achieve bone union, and restore function
Delayed or inadequate treatment can lead to severe morbidity, including chronic infection, limb length discrepancies, and deformities.
Clinical Presentation
Symptoms:
Severe pain at the fracture site
Obvious deformity of the limb
Visible wound with potential bone protrusion
Bleeding from the wound
History of high-energy trauma.
Signs:
Presence of a penetrating wound communicating with the fracture site
Degree of soft tissue damage (swelling, ecchymosis, contamination)
Neurovascular compromise (absent distal pulses, paresthesia, paralysis)
Skeletal alignment abnormalities
Exposed bone fragments.
Diagnostic Criteria:
The diagnosis is primarily clinical, based on the presence of a full-thickness skin wound communicating with a fracture
Gustilo and Anderson classification is vital for categorizing severity: Type I: Minimal skin wound (<1 cm, clean)
Type II: Moderate laceration (>1 cm, moderate soft tissue damage)
Type III: Extensive soft tissue damage with contamination (IIIA: adequate soft tissue coverage, IIIB: inadequate coverage, IIIC: associated arterial injury).
Diagnostic Approach
History Taking:
Mechanism of injury (fall, collision, gunshot)
Time of injury
Nature of the wound (clean, dirty, animal bite)
Patient's vaccination status (tetanus)
Co-morbidities (diabetes, immunosuppression)
Previous orthopedic history
Medications.
Physical Examination:
Thorough assessment of the entire injured limb, not just the fracture site
Assess for distal neurovascular status (pulses, capillary refill, sensation, motor function)
Evaluate the wound for size, depth, contamination, and presence of foreign bodies
Assess surrounding soft tissues for swelling, crepitus, and lacerations
Examine for associated injuries.
Investigations:
Radiographs of the affected bone and adjacent joints are essential
Include anteroposterior (AP) and lateral views
Gram stain and culture of wound exudate or bone biopsy (if performed)
Complete blood count (CBC) with differential, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) for baseline assessment and monitoring of infection
Consider plain X-rays of other potentially injured areas if multiple traumas suspected.
Differential Diagnosis:
Closed fractures with significant soft tissue injury
Pathological fractures
Birth trauma
Non-accidental injury
Septic arthritis.
Management
Initial Management:
Immediate measures in the Emergency Department include: Airway, Breathing, Circulation (ABC) stabilization
Control external hemorrhage with direct pressure
Cover the wound with a sterile, saline-soaked dressing
Immobilize the affected limb using splints (e.g., plaster, traction splint) to prevent further soft tissue damage and pain
Administer intravenous fluids and analgesia as needed
Obtain tetanus prophylaxis based on vaccination history.
Medical Management:
Antibiotic therapy is critical to prevent infection
For Gustilo and Anderson Type I and II fractures, the recommended regimen is a first-generation cephalosporin (e.g., Cefazolin 25-50 mg/kg IV, max 2g) administered within 1-3 hours of injury
For Type III fractures, an aminoglycoside (e.g., Gentamicin 5-7.5 mg/kg IV, max 240mg, once daily) should be added to the first-generation cephalosporin, especially in cases of significant contamination
For farm or marine-related injuries, consider adding coverage for Gram-negative anaerobes (e.g., Clindamycin or Metronidazole)
Antibiotics are typically continued for 24-72 hours, or until the wound is closed surgically.
Surgical Management:
Urgent surgical debridement and irrigation (SOAP) of the wound is paramount, ideally within 6-8 hours of injury
This removes devitalized tissue, foreign bodies, and bacterial contaminants
Multiple debridements may be necessary until the wound is clean
Definitive fracture stabilization (e.g., external fixation, internal fixation) is then performed based on the fracture pattern, degree of soft tissue injury, and patient factors
For open fractures with exposed bone, irrigation should be copious, using isotonic saline.
Supportive Care:
Pain management with appropriate analgesics
Neurovascular monitoring
Wound care and dressing changes as per surgical protocol
Nutritional support to promote healing
Rehabilitation and physical therapy to regain range of motion and strength.
Complications
Early Complications:
Infection (cellulitis, osteomyelitis, gas gangrene)
Neurovascular injury
Compartment syndrome
Soft tissue necrosis
Hemorrhage.
Late Complications:
Delayed union or nonunion
Malunion
Joint stiffness
Post-traumatic arthritis
Growth disturbances
Chronic osteomyelitis
Amputation (in severe cases).
Prevention Strategies:
Prompt and aggressive surgical debridement
Appropriate and timely antibiotic administration
Meticulous wound care
Early fracture stabilization
Careful neurovascular assessment
Patient education regarding wound care and signs of infection.
Prognosis
Factors Affecting Prognosis:
Gustilo and Anderson classification (higher grade = worse prognosis)
Time to debridement
Degree of contamination
Presence of neurovascular injury
Patient's age and overall health status
Type of fracture and mechanism of injury.
Outcomes:
With optimal management, most pediatric open fractures have a good prognosis, with functional recovery
However, higher-grade injuries are associated with a higher risk of infection and long-term sequelae
Severe injuries may result in limb shortening, deformities, or chronic pain.
Follow Up:
Regular clinical and radiographic follow-up is essential to monitor for signs of infection, assess fracture healing, and detect complications such as malunion or delayed union
Physical therapy should be initiated early and continued throughout the recovery period
Long-term follow-up may be necessary to monitor for growth disturbances in skeletally immature patients.
Key Points
Exam Focus:
Always consider open fractures in any high-energy trauma
Gustilo and Anderson classification is a key determinant of management and prognosis
Prompt surgical debridement (within 6-8 hours) is critical
Antibiotic choice is guided by fracture severity and contamination.
Clinical Pearls:
Never probe an open fracture wound in the ED
cover with saline-soaked gauze
Administer tetanus prophylaxis promptly
Initial antibiotics are crucial even before surgical debridement
The "Golden Hour" for debridement is critical for infection prevention.
Common Mistakes:
Delaying surgical debridement
Inadequate antibiotic coverage or delayed administration
Underestimating the severity of soft tissue injury
Failing to assess neurovascular status diligently
Inadequate irrigation of the wound during debridement.