OPEN FRACTURE

IQNASIA WINDY
NOVITASARI
I11111059

OPEN FRACTURE
Open if bone penetrated skin resulting in open
wound (surgical emergency for infection risk)
Gustilo and Anderson classification of open
fracture commonly used

GUSTILOS
CLASSIFICATION OF
OPEN
FRACTURES
Grad Wound
Soft-tissue
Bone injury
e
I
II
IIIA

IIIB

injury
<1 cm long

Minimal

Simple low-energy
fractures
>1 cm long + compartment
Moderate
syndrome
comminution
Usually >1
Severe deep
High-energy fracture
cm long
contusion; +
patterns; comminuted
compartment
but soft-tissue cover
syndrome
possible
Usually >10 Severe loss of soft- Requires soft-tissue
cm long
tissue cover
reconstruction for
cover

GUSTILOS
CLASSIFICATION OF
OPEN FRACTURES

Gustilo-Anderson classification of open fracture wounds.

A, Type I open fracture of patella and type II open fracture of tibial
shaft. B, Type IIIA open fracture with extensive laceration of skin and
muscles that involves almost entire leg. C, Type IIIA open tibial
fracture with extensive periosteal stripping but without massive

CHOICE OF
TREATMENT
DEPENDS ON THE
FOLLOWING
The state of the soft tissues
FACTORS
The severity of the bone injury
Stability of the fracture
Degree of contamination

THE SEVERITY OF
THE BONE INJURY
High-energy fractures are more damaging and
take longer to heal than low-energy fractures;
this is regardless of whether the fracture is open
or closed.
Low energy breaks are typically closed or
Gustilo I or II, and spiral. High-energy fractures
are usually caused by direct trauma and tend to
be open (Gustilo III AC), transverse or
comminuted.

THE STATE OF THE

SOFT TISSUES
The risk of complications and the progress to
fracture healing are directly related to the
amount and type of soft-tissue damage.
Closed fractures are best described using
Tschernes method; for open injuries, Gustilos
grading is more useful.
The incidence of tissue breakdown and/or
infection ranges from 1 per cent for Gustilo type
I to 30 per cent for type IIIC.

STABILITY OF THE
FRACTURE
Consider whether it will displace if
weightbearing is allowed. Long oblique fractures
tend to shorten; those with a butterfly fragment
tend to angulate towards the butterfly. Severely
comminuted fractures are the least stable of all,
and the most likely to need mechanical fixation.

DEGREE OF
CONTAMINATION
In open fractures this is an important additional
variable.

PRINCIPLES OF
TREATMENT
Antibiotic prophylaxis
Urgent wound and fracture debridement
Stabilization of the fracture
Early definitive wound cover

ANTIBIOTIC
PROPHYLAXIS
Antibiotics are started immediately. A first- or
second-generation cephalosporin is suitable for
Gustilo grades IIIIA wounds but more severe
grades may benefit from Gram-negative cover
as well (an aminoglycoside such as gentamicin
is often used).
With an adequate debridement, the antibiotics
are continued for 24 hours in a grade 1 fracture
and 72 hours in more severe grades.

URGENT WOUND AND

FRACTURE DEBRIDEMENT
Adequate debridement is possible only if the
original wound is extended.
All dead and foreign material is removed; this
includes bone without significant soft-tissue
attachments. Tissue of doubtful viability may be
left for a second look in 48 hours. The wound
and fracture site are then washed out with large
quantities of normal saline.

STABILIZATION OF
THE FRACTURE
For Gustilo I, II and IIIA injuries, locked
intramedullary nailing is permissible as
definitive wound cover is usually possible at the
time of debridement.
For more severe grades of open tibial fracture,
internal fixation should be performed only at the
time of definitive soft tissue cover. If this is not
feasible at the time of primary debridement, the
fracture should be stabilized temporarily with a
spanning external fixator. Exchange of the
fixator for an intramedullary nail can be done at
the point when definitive soft tissue cover is
carried out ideally within 5 days of the injury.

Fixation (ad) This method of fixation offers the benefit of multilevel

stability and can be carried out with little additional damage to the
soft tissues around the injury.

ANTIBIOTIC
PROPHYLAXIS

EARLY
COMPLICATIONS
Vascular injury
Compartement syndrome
Infection

LATE
COMPLICATIONS
Malunion
Delayed union
Non-union
Joint stiffness
Osteoporosis
Regional complex pain syndrome

FRACTURED TIBIA AND

TIBULA LATE
COMPLICATIONS

(a) Hypertrophic non-union: the exuberant callus formation and

frustrated healing process are typical. (b) Atrophic non-union: there is
very little sign of biological activity at the fracture site. (c) Malunion:

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