Open fracture


  • Fractures that have communication with the outside environment are considered open
  • The fractured portion does not have to be overtly exposed
  • True orthopedic emergency

Clinical Features

  • Suspect open fracture with overlying wound regardless of how small
  • Free air on x-ray may suggest open fracture in more equivocal cases

Differential Diagnosis

Extremity trauma


  • ATLS
  • X-ray
  • Trauma labs

Gustilo-Anderson grading scale

As the grade increase, so does the risk of infection

Grade I

  • Wound <1cm
  • Little soft tissue injury or crush injury
  • Moderately clean puncture site
  • Infection risk 0-12%

Grade II

  • Laceration >1cm
  • No extensive soft tissue damage, but slight or moderate crush injury
  • Moderate contamination
  • Infection risk 2-12%

Grade III

  • Extensive damage to soft tissue, including neurovascular structures and muscle
  • High degree of contamination
  • Infection risk 5-50%
  • Further subcategorized:
    • III A: Fracture covered by soft tissue (Infection risk 5-10%)
    • III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%)
    • III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%)

Additional Considerations

  • Fracture with non-communicating overlying wound
  • Additional sites of injury found in 40-80% of cases
  • Nerve, vascular, muscular, and/or ligamentous injury


Pain control

Prophylactic Antibiotics for Open fractures[1]

Initiate as soon as possible; increased infection rate when delayed for >3 hours from injury (NNT 12.5)[2]

Grade I & II Fractures Options

Grade III Fracture Options

  • Treatment as above for Grade I/II
  • PLUS aminoglycoside: e.g. Gentamicin 300 mg (1-1.7mg/kg) IV
    • Once daily dosing has been shown to be safe and effective

Special Considerations

  • Concern for Clostridium (soil contamination, farm injuries, possible bowel contamination): single drug regimen of Pipericillin/Tazobactam 4.5g (80mg/kg) IV TID
  • Fresh water wounds: fluoroquinolones OR 3rd/4th generation cephalosporin
  • Saltwater wounds: doxycycline + ceftazidime OR fluoroquinolone

Wound Managment [3]

  • Surgical debridement and washout within 24 hours.
    • Thorough ED irrigation and debridement appears safe for hand (metacarpal, phalanx) fractures without excessive contamination
  • Irrigation may be started in the ED for grossly contaminated wounds
    • Place a sterile dressing over wound to decrease continued contamination
  • Tetanus prophylaxis


Admission to ortho or trauma surgery

See Also

  • Fracture (Main)


  1. Open Fractures, Prophylactic Antibiotic Use in — Update.
  2. Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
  3. Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y). 2017;12(2):119-126.
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