Open Fractures

Objectives

To guide the management of patients with one or more open fractures.

Scope

This guideline describes the management of patients with an open fracture in a forward medical context or Deployed Emergency Department. An open fracture is a severe break where a fractured bone breaks through the skin creating an open wound that connects the bone to the outside environment. The bone may still be extruding through the skin or it could have gone back in. Any fracture which has an overlying wound should be assessed for consideration of where the fractured bone may have once broken through the skin. If in doubt it should be treated as an open fracture.

There are separate guidelines for the management of closed fractures and of wound management which may be beneficial.

This guideline does not describe advanced surgical techniques that may be used beyond the Emergency Department in a Deployed Hospital Care (DHC) or forward surgical setting.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a general role in forward medical locations or in an Emergency Department on deployed operations.

Initial Assessment & Management

Open fractures are often associated with high energy trauma, and the initial evaluation and treatment of the patient must occur simultaneously. The following should be considered in every case:

Massive Haemorrhage. Initial assessment and treatment of the casualty should follow standard guidelines identifying and treating life threatening pathology first. External haemorrhage should be controlled by direct pressure, haemostatic agents, pressure dressings or tourniquet. If haemorrhage control has been performed at point of wounding this should be reassessed to determine if tourniquet is still required or haemorrhage control can be downgraded.

Neurovascular status and splintage. Assessment of open fractures should be systematic, careful and repeated in order to identify established or evolving limb-threatening conditions. Neurovascular examination of the limb assessing distal pulses, capillary refill time, sensation and motor function. Analgesia should be provided as per standard guidelines. Straighten and align the limb. As pain allows the limb should be placed into an anatomically normal state and splinted with devices such as a SAM splint or Kendrick traction device. If capability and situation permit then sedation is likely to be helpful to facilitate manipulation of obviously deformed limbs with neurovascular compromise. Repeat neurovascular examination.

Wound Care. Wounds should only be handled minimally to remove gross contaminants, photograph for the record or reach back, and seal from the environment. Wound excision should only be undertaken in a facility equipped with surgical capabilities, not a forward location. Gross contamination should be removed by irrigation. Potable water is acceptable for this purpose. Use enough fluid to remove all loose contamination. Be as thorough as resources allow. Some contamination will inevitably remain embedded in tissues and will require surgical removal. A simple saline soaked dressing should be placed over the wound and held in place with and adhesive film dressing.

Antibiotics and tetanus. If time to reach IV antibiotics is greater than 1-hour, casualties should take antibiotics from their individual first aid kit (if carried). Requirement for tetanus prophylaxis should be assessed using the tetanus-prone wound guideline. 

Antbiotic selection should follow current deployed antimicrobial guidance for high-energy ballistic wound or open fracture. Note that a different regimen may be recommended for blast injury, traumatic amputation or trauma where the demarcation of final zone of injury will evolve - check current guidance carefully.

Patients with an open fracture should receive antibiotics within 1 hour of injury, and surgery without delay.

Record keeping

Following initial assessment, the following information should be recorded for each wound:

• Date/Time of injury
• Mechanism of injury (including whether blast component)
• Distal neurovascular status
• Treatment so far (including whether a tourniquet had been applied at any time and for what duration)
• Antibiotic treatment given
• Is there clinical suspicion of infection
• Site/Size of wound
• General impression (e.g. “heavily contaminated”, “purulent discharge”, “significant necrosis”, “clean”, etc)

Advanced Assessment & Management

Sedation and manipulation. If the limb is deformed with neurovascular compromise or tented skin, the injury should reduced without delay. If capabilities allow then follow guidelines for procedural sedation to facilitate effective reduction.

Imaging. X-ray imaging should include the joint above and below the injury as well as the wound itself. If a vascular injury is identified or suspected then CT angiography is required so the patient should be evacuated to a facility with this capability.

Combat wounds consensus. Timing to surgical excision will be dictated by many factors, the detail of which is beyond the scope of these recommendations, but as a guide casualties with combat wounds should receive wound care within the following timelines:

• As soon as possible for heavily contaminated wounds.
• Within 12 hours for high energy-transfer injuries.
• Within 24 hours for all other wounds requiring surgery.

Prolonged Casualty Care

The principles of open fracture management in prolonged casualty care focus around comfort, recognition of complications and prevention of infection.

Ongoing analgesia should be provided in accordance with the clinical guidelines for analgesia. The limb should be splinted for comfort and continually assessed for areas of pressure concern.

A high degree of suspicion must be maintained for evolving limb threatening pathology. Continued assessment and documentation of neurovascular status and any sign of infection. This should include presence or absence of pulse, sensation and motor function distal to the injury. Pulse, respiratory rate, blood pressure and temperature should be recorded. Any presence of erythema or wound infection should be photographed if possible and marked. Dressings should not be removed routinely to assess for infection during in transit care. Compartment syndrome is a significant risk following open fracture. If acute compartment syndrome is suspected, manage according to the Acute Compartment Syndrome and Fasciotomy CGO.

Paediatric Considerations

Refer to current DMS anti-microbial guidelines and age per page for antibiotic recommendations for paediatric patients. If these are unavailable, use the following as a guide:

Co-amoxiclav 30mg/kg to max 1.2g every 8 hours (every 12 hours for children < 3 months old

or if allergic to penicillin, give clindamycin 3-6mg/kg to max 450mg every 6 hours