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Open Fractures - Classification, Causes, Diagnosis, Management, and Complications

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Fractures are a commonly heard term, but what do open fractures mean? This article will give you an insight into open fractures.

Medically reviewed by

Dr. Suman Saurabh

Published At September 23, 2022
Reviewed AtJanuary 22, 2024

What Is a Fracture?

Any partial or complete discontinuity in the bone is termed a fracture. Depending on the intactness of the skin, fractures are classified into:

  • Open fractures.

  • Closed fractures.

What Are Closed Fractures?

Closed fractures are those in which the skin surrounding the bone is intact. It is also called a simple fracture.

What Are Open Fractures?

Also known by the name compound fractures, in this type of fracture, the broken bone traverses the skin and can be seen through naked eyes. In simpler terms, if the bone is seen outside after a fall or a trauma, it is a compound or open fracture. This visible fracture occurs as a result of trauma or excessive force. Excruciating pain is common in all fractures. However, with open fractures, and the unbearable pain, there is also a sense of agitation brought about by the overt bone exposure.

What Is the Cause of Open Fractures?

Although open fractures occur as a result of high-energy events in most cases, they can be caused by low-energy events.

The following are the high-energy events that can result in open fracture:

Low-energy events which cause open fractures include:

What Bones Are Prone to Open Fractures?

Open fractures are not specific to a particular bone in your body and can involve any bone. However, the most commonly affected ones are those present in the upper and lower extremities.

In addition, some other bones in which open fractures can include:

  • Skull bones.

  • Facial bones.

  • Bones of the orbital cavity (eyes).

  • Collarbones.

  • Spine.

  • Pelvic bones.

How Are Open Fractures Classified?

According to Oesternand Tscherne, open fractures are classified into:

open-fracture

Gustilo also classified open fractures, the most commonly used one. The below table summarizes Gustilo’s classification for open fractures:

characteristic-features

How Is an Open Fracture Manifested?

The following are the manifestations of a compound fracture:

  • Visibility of bone through the skin is an important characteristic feature of open fracture.

  • Swelling.

  • Sudden, severe, and sharp pain.

  • Bleeding from the site. Closed fractures do not exhibit external bleeding. While in the case of open fractures, the lacerated wounds produce bleeding, which helps differentiate between open and closed fractures.

  • Injury to the nerves. This can reduce the pain or make it more painful.

  • Tenderness on touching.

  • Deformity.

How Is an Open Fracture Diagnosed?

  • Due to bone exposure, diagnosis of open fractures is relatively easy compared to closed fractures. However, the doctor also makes a note of the following:

    • Any significant bleeding causes blood pressure and pulse values to drop.

    • Temperature and color changes in the skin in and around the injury.

    • Damage to nerves around the site of injury and beyond it.

  • In addition to physical examination, the healthcare provider may take imaging tests like X-rays, MRI (magnetic resonance imaging), and CT (computed tomography) scans. X-rays help determine the extent of the fracture and decide on the alignment that has to be made. Other imaging tests like MRI and CT scans are taken to assess the damage to the adjacent soft tissues, vascular structures, and nerves caused by the open fracture.

  • Also, blood examinations might be needed, like clotting profiles and other essential blood tests.

How Are Open Fractures Managed?

Managing open fractures involves the following, which can be easily remembered with the help of the acronym 'PRICE':

  1. Protection - It is something in the hands of the affected individual or those around them. As soon as an open fracture occurs, it is essential to cover it with the help of a clean and wet towel to avoid contamination. Also, using the joints near the affected area should be avoided unless it is essential for seeking help.

  2. Rest - It is a crucial factor as far as healing with open fractures is concerned. Also, it reduces the chances of further injuries.

  3. Ice - In places around the fracture, the icing should be done immediately. However, care should be taken not to place ice on the actual wound to avoid contamination.

  4. Compression - Casting or other devices help keep your fractured site stable to facilitate healing.

  5. Elevation - It is advised to raise the injured site above the heart level to decrease swelling. However, guidance from a medical professional is needed as elevation depends on the injury site.

Medications:

A telltale sign associated with open fractures is pain.

Therefore, to suppress the pain, the following are carried out:

  1. Oral or intravenous administration of pain-relieving medications.

  2. In severe cases, nerve blocks can be given. These are delivered into the nerves, which helps block the sensation of that particular nerve, thus shutting down the pain.

  3. Also, tetanus toxoid vaccines can be given to prevent the risk of tetanus.

  4. Antibiotics are prescribed depending on the severity of the injury.

The below table depicts the antibiotics specific for different grades of injury:

injury-based-on-gustilo-classification

Also, there are a few considerations while giving antibiotics, which include the following:

considerations-while-giving-antibiotics

Surgery:

The bones that have been fractured are moved back to their original position in a reduction procedure. The reduction can either be an open reduction or a closed reduction.

In closed reduction, the fractured bones are manipulated without being exposed. In contrast, in the case of open reduction, the broken site is surgically opened, and then the bones are fixed. These procedures might require anesthesia or sedatives and pain-relieving medications.

The following hardware devices may be employed in open reduction to keep the fractured bones in place:

  • Plates.

  • Rods.

  • Pins.

  • Screw.

Soon after reduction, immobilization is achieved with the help of casting or other devices. Also, plastic surgery may be considered to close the wound and give an esthetic appearance in patients with severe injuries.

What Complications Are Associated With Open Fractures?

The following are the complications of open fractures:

  1. Damage to the skin.

  2. Damage to the joints brings about compromise in joint functions like mobility.

  3. Injury to the nerves can range from mild to severe. Although it might take some time, mild nerve injuries heal entirely, whereas, with severe injuries, healing does not take place.

  4. Damage to the growth plates in children can disrupt the growth of bone, leading to uneven limbs.

  5. Nonunion (bones do not fuse back together), malunion (bones get united in the wrong position), and delayed union (slower fusion) are some problems that can occur during the healing phase.

  6. Extensive blood loss associated with open fractures reduces blood pressure and might lead to shock.

  7. The risk of contamination and infection is high with open fractures.

  8. Compromised blood supply to the bone can result in osteonecrosis of the affected bone.

  9. Pulmonary embolism might occur. It is most commonly seen after fractures of the pelvis or hip bones.

  10. Compartment syndrome is seen which is characterized by diminished or no blood supply to a particular area caused by compression of blood vessels. It is due to the pressure exerted by the bone or tissues at the affected site on the blood vessels. As a result, there is tissue damage or death of tissues that might raise the need for amputation.

What Is the Prognosis With Open Fractures?

Healing and prognosis with open fractures depend on the following factors:

  • Age of the patient.

  • Presence of adjuvant medical conditions like peripheral artery disease and diabetes.

  • The extent of the injury.

  • Degree of contamination.

  • Complications during and after treatment.

How Can We Prevent Open Fractures?

Since accidents and injuries always cause open fractures, preventing them is not always possible. However, taking adequate measures and using protective gears while playing or traveling on motorbikes can help avoid the risk of fractures to some extent.

What Steps Should Be Carried Out in the Event of an Open Fracture?

  • Soon after the injury, emergency help should be sought.

  • Mobilization should be restrained as it can increase pain and damage.

  • Try to keep the wound free from dust and other contaminants.

  • If possible, the injury can be covered with wet sterile gauze.

  • Realigning the fractured bones should not be attempted without the help of a medical professional.

Conclusion:

Open fractures can bring about a terrifying feeling in the affected individual. This is because of bone exposure. However, medical advancements have made the management of these fractures feasible. Reaching out to a healthcare provider at the earliest is vital to aid in proper treatment and prevent life-threatening complications.

Frequently Asked Questions

1.

What Does an Open and Closed Fracture Mean?

When a fracture occurs, it is usually open or closed. Open fractures, also called compound fractures, are those in which the wound is open, and the bone pokes out through the skin, and through this deep wound, the bone may be seen. A closed fracture, also called a simple fracture, is one in which the bone is broken but not visible to the naked eye as the skin is intact.

2.

What Is the Classification of Open Fractures?

Classification of open fractures -
Type 1: A clean wound of less than one centimeter.
Type 2: Clean wound of size 1 to 10 cm. 
Type 3A: Wounds over 10 centimeters and high-energy, but with adequate soft tissue coverage.
Type 3B: Wound over 10cm and high-energy, but with inadequate soft tissue coverage.
Type 3C: All injuries with vascular injuries

3.

What Are the Types of Fractures?

Some of the common types of fractures include -
- Stable Fracture - A simple fracture in which the broken ends of the fractured bone line up and are barely out of place.
- Open (Compound) Fracture - The bone may protrude out of the skin by piercing it, and bone is most visible through the skin.
- Transverse Fracture - This type of fracture has a horizontal fracture line.
- Oblique Fracture - This type of fracture has an angled pattern.
- Comminuted Fracture - In this form of fracture, the fractured bone may break into two or three pieces.

4.

Are Open Fractures Serious?

Open fractures may or may not be serious, depending on the type of injury. But usually, they require immediate medical assistance as it poses a risk of infection and infection of the bone may be difficult to treat. In cases of open fractures, patients may have to stay longer in hospitals and require multiple surgeries.

5.

How to Know if the Fracture Is Open?

An open fracture usually punctures the skin or exposes the bone in the wounded area. This fracture is also very painful, and the patient may experience extreme pain without attempting to move the injured body part. The treatment is different for every fracture type and may require multiple surgeries.

6.

What Is the Best Diagnostic Test for a Fracture?

An X-ray is considered one of the best methods to diagnose any fracture. X-rays can evaluate the amount of bone damage, which helps determine the fracture type. X-rays show clear images of the fractured bone, such as where and how the bone gets fractured, and help in the treatment.

7.

Can an Open Fracture Be Healed?

Open fractures can be very painful and serious injuries, but with the right care and treatment, these fractures can be treated. However, some open fractures may be difficult to treat and may take longer to heal completely because of the damage to the blood flow around the bone at the time of injury. Most fractures heal within six to eight weeks, whereas fractures of the tibia may take around 20 or more weeks.

8.

What Are the Signs of Fracture?

The signs and symptoms of a fracture include -
- A visible out-of-place limb or joint.
- Intense pain.
- Swelling or bleeding.
- Numbness and tingling sensations
- Ruptured skin with protruding bones.
- Inability to move a limb or limited mobility.

9.

How to Manage Open Fractures at Home?

In case of an open fracture at home, some of the following steps can be done -
- Stop the bleeding by putting pressure on the wound.
- Immobilize the injured part.
- The affected area should be kept clean.
- The patient should be monitored until help arrives and placed in a suitable position.

10.

What Is the Most Common Open Bone Fracture?

The most common open fracture is of the tibia or shin bone. This is the most commonly affected bone in the body, with an annual incidence rate of 3.4 per 100,000. This bone is present between the knee and above the ankle. The fracture usually occurs along the length of the bone and is more commonly seen in athletes.
Dr. Suman Saurabh
Dr. Suman Saurabh

Orthopedician and Traumatology

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