69.11 Open fractures

A fracture is ’open’ when a break in the skin over it brings it into communication with the organisms of the outside world. The break in the skin can be the result of either a wound from outside, or a bony fragment piercing the skin from inside, in which case the tissues are less likely to be contaminated.

Traumatic osteomyelitis as the result of infection is always a possibility in an open fracture, but it is much less likely to occur if you do a careful wound toilet, and close the wound by delayed suture. So toilet all open fractures carefully and close them by delayed suture (54.4), even if the skin wound is a small one, and occurs from within outwards. This is especially important if the patient presents late. If you fail to do this and the wound becomes infected, traumatic osteomyelitis will probably follow. Failing to do an adequate toilet, and closing the wound by immediate primary suture are very common errors.

Figure 69.9: TWO OPEN FRACTURES OF THE FEMUR. A, shows a small loose fragment of bone, and B, an extreme case in which the whole femur has been stripped bare of muscle. The important measures here are a thorough wound toilet and delayed primary suture, followed by traction. Kindly contributed by John Lowrie.

Although some open fractures can be fixed internally, don’t try it. The wound is already contaminated, and the plates and screws will probably become infected. An occasional Kirschner wire is the maximum amount of internal fixation that is wise.

If you apply the above principles rigidly, infection is unlikely, and antibiotics will make little difference (54.1). So give them only if an infection occurs which needs treating.

Gustillo, Ramon, and Anderson J.T. ’Prevention of infection in the treatment of 1025 open fractures of the long bones.’ Journal of Bone and Joint Surgery. 1976;58A 454