Managing Open Fractures in the ED: Break and Enter 

-Case-
A 29-year-old man arrives at the ED after a high-speed motorcycle crash. He has a visibly deformed lower leg with exposed bone and active bleeding. His foot is cool but has a weak dorsalis pedis pulse.

-Evaluation-
Open fractures are orthopedic emergencies. They involve a fracture with a break in the skin and communication between the external environment and the bone. Contamination and infection risk are high.

  • Key Priorities:
    • Assess neurovascular status
    • Evaluate for other trauma (head, chest, abdomen)
    • Control bleeding with direct pressure
    • Expose the wound fully but avoid aggressive manipulation in the ED
  • Classification (Gustilo-Anderson):
    • Type I: Clean wound <1 cm, minimal soft tissue damage
    • Type II: Wound 1-10 cm, moderate soft tissue damage
    • Type III: Wound >10 cm, extensive soft tissue damage, often high-energy trauma

Management in the ED:

  1. IV Antibiotics ASAP:
    • Type I/II: 1st-generation cephalosporin (e.g., cefazolin)
    • Type III: add gram-negative coverage (e.g., gentamicin)
    • Add penicillin for soil-contaminated wounds or gross contamination
  2. Tetanus Prophylaxis:
    • Based on vaccination history and wound characteristics
  3. Irrigation & Dressing:
    • Gently irrigate with saline
    • Cover with sterile, moist dressing
  4. Immobilization:
    • Splint in position of comfort
    • Avoid attempts at fracture reduction in ED unless neurovascular compromise is present
  5. Orthopedic Surgery Consultation:
    • Emergent consult required for all open fractures
    • Timing of operative debridement ideally within 6 hours, but earlier antibiotics are more critical

-Fast Facts-

  • Open = contaminated! Treat with urgency
  • Antibiotics within 1 hour improves outcomes more than speed of surgery
  • Avoid tourniquets unless uncontrolled life-threatening hemorrhage
  • Always document neurovascular status before and after intervention
  • Early ortho involvement is essential

Open fractures are dirty injuries with a fast track to complications. Start antibiotics fast, cover the wound, stabilize the limb, and call ortho early. The open wound may look dramatic, but the real threat is beneath the surface.

Want to learn more? Read our in-depth study guide and listen to our podcast episodes on this topic!

Cheers,

Tamir Zitelny, MD

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-References-

  1. Giannoudis PV, Harwood PJ, Kontakis G, et al. Long-term outcomes of open tibial fractures treated with intramedullary nailing. Clin Orthop Relat Res. 2009;467(11):2855-2865. doi:10.1007/s11999-009-0891-1
  2. Lack WD, Karunakar MA, Angerame MR, et al. Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection. J Orthop Trauma. 2015;29(1):1-6. doi:10.1097/BOT.0000000000000250
  3. Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. EFORT Open Rev. 2017;2(11):363-367. doi:10.1302/2058-5241.2.160068
  4. Gosselin RA, Roberts I, Gillespie WJ. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004;(1):CD003764. doi:10.1002/14651858.CD003764.pub2
  5. Hauser CJ, Adams CA Jr, Eachempati SR. Surgical Infection Society guideline: prophylactic antibiotic use in open fractures: an evidence-based guideline. Surg Infect (Larchmt). 2006;7(4):379-405. doi:10.1089/sur.2006.7.379
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