Orthopaedic Emergency Module

Open Fractures

A practical interactive module for healthcare professionals, covering the recognition, assessment, classification, early treatment, and definitive management of open fractures.

8Sections

45Minutes

2Clinical Cases

Learning objectives

Define open fractures and recognise clinical features at the bedside

Apply the Gustilo-Anderson classification accurately

Conduct a systematic ATLS-based assessment

Implement BOAST 2023 guideline-directed management

Recognise key complications including compartment syndrome and osteomyelitis

Patient arrives — resus

James, 32M — Pedestrian struck by a car

A trauma call is activated. James was struck by a car at a pedestrian crossing. He is conscious, talking, and haemodynamically stable. His left leg is visibly deformed with an obvious wound near the fracture site. You are the first clinician to assess him.

$Open fracture clinical illustration$

Core definition

What is an open fracture?

An open fracture is a fracture with direct communication with the external environment through a disruption in the overlying skin and soft tissues. This may be obvious, such as bone protruding through skin, or subtle, such as a small puncture wound adjacent to a fracture site. This is most often through the skin – however, pelvic fractures may be internally open, having penetrated in to the vagina or rectum. Fractures may become open by either an “in-to-out” injury, whereby the sharp bone ends penetrate the skin from beneath, or an “out-to-in” injury, whereby a high energy injury (e.g. ballistic injury or a direct blow) penetrates the skin, traumatising the subtending soft tissues and bone.

Clinical rule: If there is any doubt, treat as open until proven otherwise in theatre. Do not probe the wound in the Emergency Department.

Clinical features

Soft tissue

Visible wound

Laceration, puncture, or degloving near the fracture. A sub-centimetre “poke hole” still constitutes an open injury.

Haemorrhage

Continuous bleeding

Bleeding from a wound near the fracture may indicate open injury even without visible bone.

Radiology

Air in soft tissues

Subcutaneous emphysema or air tracking to the fracture site on plain radiographs confirms communication.

Standard signs

Pain, deformity, swelling

Classic fracture signs. Bruising may be extensive in high-energy injuries, with reduced range of movement and loss of function.

Epidemiology & clinical importance

Open fractures are limb-threatening and potentially life-threatening injuries. Tibial shaft fractures are the most common long bone open fracture, followed by phalangeal, forearm, ankle, and metacarpal fractures. Infection risk rises substantially with increasing injury severity, so systematic and time-critical BOAST-guided management is essential.

Why classify?

The Gustilo-Anderson classification grades open fractures by wound size, soft tissue injury, contamination, and fracture pattern. Grade correlates directly with infection risk, need for soft tissue reconstruction, and prognosis, and underpins BOAST guidance.

The five grades

Grade IInfection 0–2%

Clean wound <1 cm. Typically a “poke hole” from inside-out injury. Minimal muscle contusion and a simple fracture pattern.

$Grade I open fracture clinical illustration$

Grade IIInfection 2–5%

Laceration 1–10 cm with more extensive soft tissue damage and minimal to moderate crush. Usually a simple fracture with limited comminution.

$Grade II open fracture clinical illustration$

Grade IIIAInfection 5–10%

Wound >10 cm with extensive laceration but adequate bone coverage remains possible. Often due to high-energy mechanisms regardless of wound size.

$Grade IIIA open fracture clinical illustration$

Grade IIIBInfection 10–50%

Extensive periosteal stripping and bone exposure requiring flap coverage. Usually associated with severe contamination.

$Grade IIIB open fracture clinical illustration$

Grade IIICInfection 25–50%

All criteria of IIIB plus arterial injury requiring vascular repair. Highest risk of amputation. Emergency vascular input is mandatory.

$Grade IIIC open fracture clinical illustration$

Gustilo–Anderson Classification — Memory Aid

A quick way to remember the classification:

Grade I = 1 cm → small, clean wound
Grade II = 2+ cm → larger but still relatively clean
Grade III = “Severe” → high-energy, segmental, or major soft tissue injury

Grade III breakdown:

A = Adequate soft tissue → can cover bone
B = Bad soft tissue → needs plastics (coverage required)
C = Circulation problem → vascular injury present

Management shortcut:
3A → Orthopaedics
3B → Plastics
3C → Vascular

Clinical reality:

Grade is confirmed in theatre after debridement
Injuries are often upgraded after exploration
All Grade II + → should be managed in at an tertiary centre with orthoplastic services. At WSH most open fractures should be discussed with the major trauma network.

MESS — Mangled Extremity Severity Score

Limb salvage vs primary amputation

The MESS score may help decision-making in severe injuries, particularly Grade IIIC. A mangled limb has multiple major functional components injured, usually involving combinations of bone, vessels, nerves, and soft tissue.

Skeletal / soft tissue

Low energy (stab, simple)1

Medium energy (blunt)2

High energy (GSW, crush)3

Very high (blast)4

Limb ischaemia

Pulse reduced, no ischaemia1*

Pulseless, paraesthetic2*

Cool, paralysed, numb3*

Shock

BP >90 consistently0

Transient hypotension1

Persistent hypotension2

Age

<30 years0

30–50 years1

>50 years2

MESS ≥ 7 — amputation likely indicated *Ischaemia scores are doubled if present for more than 6 hours

ATLS principle: An open fracture may not be the most immediate threat to life. Complete the primary survey first. ABCDE comes before detailed limb assessment.

Primary survey — ABCDE

A

Airway with C-spine protectionAssess airway patency and protect the cervical spine in high-energy mechanisms unless clinically cleared.

B

Breathing & ventilationCheck respiratory rate, oxygen saturation, chest expansion, and auscultation. Exclude tension pneumothorax and haemothorax in polytrauma.

C

Circulation & haemorrhage controlObtain two large-bore IV cannulae, send bloods, control haemorrhage, and consider tourniquet use if there is severe extremity bleeding.

D

DisabilityAssess GCS, pupils, and glucose. Altered conscious level may reflect shock, head injury, or both.

E

ExposureFully expose the patient, inspect for other injuries, and prevent hypothermia as this worsens coagulopathy and shock.

Neurovascular examination

Perform and document — before and after manipulation

Neurovascular examination is clinically and medico-legally critical. Compare with the contralateral limb and document the time of assessment clearly.

Vascular

Pulses

Palpate distal pulses such as dorsalis pedis and posterior tibial. Use Doppler if they are not palpable.

Vascular

Pallor & capillary refill

CRT greater than 2 seconds suggests compromise. Pallor, mottling, and a cool limb are concerning features.

Neurological

Paraesthesia

Test sensation in the nerve distributions distal to the injury. Numbness may indicate nerve or vascular compromise.

Neurological

Power & paralysis

Assess distal motor function. Paralysis plus severe pain on passive stretch should raise concern for compartment syndrome.

Compartment syndrome — must not miss

Open fractures do not exclude compartment syndrome. Key early signs are pain out of proportion, pain on passive stretch, and a tense compartment. Do not wait for loss of pulse, which is a late and unreliable sign. Treatment is emergency fasciotomy.

Wound management in the ED

Photograph the wound before dressing if appropriate
Remove gross contamination gently
Cover with saline-soaked gauze and seal
Splint in an anatomical or safe position
Do not probe the wound in the ED
Do not perform bedside irrigation
Do not repeatedly remove the dressing

Imaging

First line

Plain radiographs

Obtain at least two orthogonal views and image the joint above and below. Look for air tracking from wound to fracture.

Advanced

CT & CTA

CT if intra-articular extension is suspected. CT angiography if vascular injury is suspected.

BOAST guidance is for IV antibiotics within 1 hour of injury. Antibiotics come first.

Antibiotic prophylaxis

BOAST 2023

Antibiotic prophylaxis

Timing

Ideally within 1 hour of injury. Early administration reduces infection risk.

First line (NKDA)

IV Co-amoxiclav 1.2 g TDS, continued until 24 hours after debridement and primary closure.

Second line / penicillin allergy

IV Clindamycin 600 mg QDS plus IV Gentamicin 4 mg/kg. Always check local trust guidance.

Key pathogens

S. aureus is common. Gram-negatives and anaerobes are more relevant in heavily contaminated injuries.

Duration

Stop 24 hours after wound closure rather than 24 hours after injury.

Tetanus prophylaxis

Scenario	Action required
Clean wound, booster within last 10 years	No action required
Clean wound, no booster in 10+ years; or dirty wound, no booster in 5+ years	Tetanus toxoid booster
Immunocompromised, fewer than 3 primary doses, or heavily contaminated wound	Tetanus toxoid + human tetanus immunoglobulin
Wound suspected contaminated with C. tetani	Tetanus toxoid + human tetanus immunoglobulin regardless of immunisation history

What is BOAST?

The British Orthopaedic Association Standards for Trauma are nationally agreed, evidence-based standards developed collaboratively with plastic surgery colleagues. The open fractures standard emphasises time-critical intervention and ortho-plastic collaboration.

Management timeline

1

Within 1 hour of injury

IV antibiotics & tetanus

Administer IV antibiotics promptly, assess tetanus status, photograph the wound if appropriate, dress it, and splint the limb.

2

Within hours — same day

Specialist review

All open fractures require orthopaedic review. Grade IIIB/C injuries need urgent plastics discussion and possible transfer to a specialist limb reconstruction centre.

3

Within 24 hours

Surgical debridement & washout

Formal debridement of devitalised tissue under anaesthesia, lavage, and stabilisation as appropriate.

4

Within 72 hours — Grade IIIB/C

Definitive soft tissue coverage

The “fix and flap” principle aims for soft tissue cover within 72 hours. Delays increase deep infection and osteomyelitis risk.

5

Definitive stage — days to weeks

Fixation & reconstruction

Definitive fixation may include intramedullary nailing, plating, or external fixation, with bone grafting and rehabilitation planning where needed.

Theatre

Debridement

Excise all non-viable tissue. Assess muscle viability using colour, consistency, contractility, and capacity to bleed.

Theatre

Lavage

Use high-volume low-pressure saline lavage. Soap and high-pressure systems have not shown clear benefit.

Stabilisation

Temporary fixation

External fixation may be used for damage control and to protect soft tissues while further surgery is planned.

Reconstruction

Soft tissue cover

Grade IIIB injuries often require flap coverage. Negative pressure dressings may be used as a bridge, not a definitive substitute.

Scenarios requiring urgent senior involvement

Vascular injury (IIIC): emergency vascular input and timely revascularisation
Compartment syndrome: emergency fasciotomy without delay
Heavy contamination: early microbiology discussion for tailored cover
Paediatric injuries: involve appropriate paediatric orthopaedic expertise

🦠

Surgical site infection

Common early complication. Risk increases with injury severity, contamination, and delayed soft tissue management.

🦴

Osteomyelitis

Deep bone infection that may become chronic and difficult to eradicate. Associated with severe contamination and delayed coverage.

💪

Compartment syndrome

Can still occur despite the wound being open. Missed diagnosis can cause irreversible muscle and nerve damage.

🧩

Non-union / malunion

Healing failure may follow infection, poor biology, or bone loss and can require further reconstructive procedures.

⚡

Neurovascular injury

May be present initially or develop later. Accurate pre- and post-procedure documentation is essential.

🦵

Post-traumatic OA

Especially relevant in intra-articular injuries, with long-term pain, stiffness, and future arthroplasty risk.

Osteomyelitis — key risk factors

Blast mechanism of injury
Acute surgical amputation at index procedure
Delayed definitive soft tissue coverage
Grade IIIB and IIIC injury pattern
Inadequate or incomplete debridement
Diabetes, smoking, immunosuppression, and peripheral vascular disease

Long-term outlook

Recovery from severe open fractures may take many months and often involves multiple procedures, physiotherapy, psychological support, and major occupational impact. Early MDT involvement is important from the time of admission.

CASE 1

James, 32 - Pedestrian RTC

He has an obvious mid-tibial deformity. There is a large anterior wound approximately 12 cm long with contamination and partially exposed bone. He is haemodynamically stable. No known drug allergies. Tetanus is up to date.

Clinical Photograph

$Open fracture clinical illustration$

Question 1 — What is your immediate priority?

Complete the primary survey first. ABCDE takes priority over the limb. Establish haemodynamic stability, haemorrhage control, and identify other life-threatening injuries before moving to definitive limb assessment.

Question 2 — What is the Gustilo-Anderson grade? Justify it.

Likely Grade IIIB. The wound is large, contaminated, and bone is exposed, suggesting extensive soft tissue injury and the probable need for flap coverage. Vascular status must still be assessed and documented to exclude IIIC.

Question 3 — What antibiotic regimen would you prescribe? (NKDA)

IV Co-amoxiclav 1.2 g TDS as soon as possible, ideally within 1 hour of injury. Document the administration time clearly.

Question 4 — After initial management and splintage, what next?

Urgent orthopaedic and plastic surgery review. Grade IIIB injuries require early ortho-plastic planning, formal debridement, and consideration of transfer to a specialist centre.

Case 2

Patricia, 74F — Low-energy fall at home

Patricia fell from an armchair onto her outstretched left hand. She has a dinner fork deformity at the wrist and a 5 mm puncture wound over the ulnar aspect. Radial pulse is present, CRT <2 seconds, and median, ulnar, and radial nerve function are intact.

Lateral Radiograph

$Distal radius fracture X-ray$

Clinical Photography

Question 1 — What is the diagnosis and Gustilo-Anderson grade?

Open distal radius fracture, likely Grade I. This is a low-energy injury with a small puncture wound and intact neurovascular findings.

Question 2 — She has had fewer than 3 lifetime tetanus doses. What prophylaxis is required?

Tetanus toxoid plus human tetanus immunoglobulin. Incomplete primary immunisation means passive and active cover are both needed.

Question 3 — What is the likely operative plan?

Wound debridement with fracture management at the same sitting. Depending on fracture pattern, this may include reduction and fixation, with antibiotics continued appropriately and post-procedure neurovascular status documented.

Module Complete

You have completed the Open Fractures online module and reviewed the core principles of recognition, classification, early management, and BOAST-guided definitive care.

Confirmation of completion

Open Fractures — Online Module

BOAST 2023 · Gustilo-Anderson · ATLS

References & guidelines

1. British Orthopaedic Association / BAPRAS. BOAST: Open Fractures. 2023 update.

2. Gustilo RB, Anderson JT. Prevention of infection in the treatment of open fractures. J Bone Joint Surg Am. 1976.

3. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III open fractures. J Trauma. 1984.

4. FLOW Investigators. A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds. NEJM. 2015.

5. Johansen K et al. Objective criteria accurately predict amputation following lower extremity trauma. J Trauma. 1990.

6. Hoff WS et al. Prophylactic antibiotic use in open fractures. J Trauma. 2011.