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13.03.08 Open fractures

  • Sepsis
    • Augmentin
      • Or clindamycin if allergic
    • 2nd generation cephalosporin
      • Best balance G+ve / G-ve
      • Cefuroxime
    • Gent + Vanc in theatre
  • Irrigate
    • Normal saline
    • NOT iodine (hyperosmolar => tissue damage)
  • Pain relief
    • IV morphine
  • Reduce
    • May restore downstream circulation (removes kink)
  • Photograph for later comparison
  • Dress
  • Immobilise
    • Or maybe not until after Xray
  • X ray

Gustilo-Anderson Open Fracture Classification

I Open fracture, clean wound, wound <1 cm in length
II Open fracture, wound > 1 cm in length without extensive soft-tissue damage, flaps, avulsions
III Open fracture with extensive soft-tissue laceration, damage, or loss or an open segmental fracture
This type also includes open fractures caused by farm injuries, fractures requiring vascular repair, or fractures that have been open for 8 hr prior to treatment
IIIA Type III fracture with adequate periosteal coverage of the fracture bone despite the extensive soft-tissue laceration or damage
IIIB Type III fracture with extensive soft-tissue loss and periosteal stripping and bone damage
Usually associated with massive contamination
Will often need further soft-tissue coverage procedure (i.e. free or rotational flap)
IIIC Type III fracture associated with an arterial injury requiring repair, irrespective of degree of soft-tissue injury.


  • Tetanus toxoid booster:
    • Patient has not completed the tetanus toxoid immunization
    • Patient has not had a booster in the last 5 years
  • Human tetanus immune globulin (HTIG):
    • Wound prone to contamination with Clostridium tetani
    • Give 250–500 IU depending on risk
  • Both toxoid and HTIG:
    • More than 10 years elapsed since the last tetanus booster
    • Patient's immune system is compromised


  • Bone doesn't have to be sticking out (e.g. spike injury)
  • Look for air bubbles on Xray to suggest an open fracture
    • cf Clostridium / Surgical emphysaema
  • Six hour golden rule
    • Injury to theatre time
    • No longer considered crucial, unless gross contamination/mangled/vascular compromise
  • MESS = Mangled Extremity Severity Score
  • Don't bother swabbing - You'll only culture the wrong thing
  • Hormones in COCP/pregnancy => Irreversible worsening of otosclerosis
  • POP = Plaster of Paris