Patients with open fractures have a reported history of trauma that is most commonly high velocity in nature. The patient should be adequately undressed to evaluate for other significant, life-threatening injuries per advanced trauma life support protocol. The initial focus should be on assessing the status of the patient's airway, breathing, and circulation, and resuscitation measures should be implemented as necessary. Once the patient has been stabilized, open fractures should be addressed emergently. These injuries are associated with symptoms of pain, deformity, swelling, and a wound that may be bleeding. It should be noted that the wound may not lie directly over the fracture site. The movement and neurovascular status of all involved limbs should be assessed to ascertain whether or not there is a possible nerve or vascular injury associated with the fracture.

The wound should be examined thoroughly and characterized according to the Gustilo-Anderson classification system for open fractures as this will dictate initial treatment. Gustilo-Anderson type I open fractures is a low energy injury with wounds less than 1 cm with minimal soft tissue damage. Type II fractures are low to moderate energy injuries with wounds that are greater than 1 cm with moderate soft tissue and muscle damage. Type III fractures are high-velocity injuries have wounds greater than 10 cm.  Type IIIa injuries have severe crushing soft tissue damage, type IIIb have a significant loss of tissue coverage, and type IIIc have significant loss of tissue with an associated vascular injury.

Because patients with open fractures usually sustain significant trauma, an arterial blood gas (ABG), hemoglobin, hematocrit, platelet count, metabolic panel, serum lactate, and toxicology screens are often warranted. Plain radiographs are usually adequate to assess the extent of the fracture. At a minimum, anteroposterior and lateral views of the injured bone should be obtained. The joints above and below the injury should also be x-rayed as the fracture could extend into the adjacent joints or involve articular surfaces. Air present on plain radiographs in the muscle, subcutaneous tissue or joint and visualized foreign bodies indicate an open injury. If the patient is stable, a CT of the ankle or knee joint may be helpful to characterize the orientation of the fracture and aid in reduction and plans for fixation. In the absence of pulses, a CT angiogram can be used to identify vascular injury.[7][8]

With significant trauma, resuscitation and stabilization efforts are paramount. After the patient is stabilized, open fractures should be addressed emergently. If there is vascular compromise thought to be secondary to fracture fragments compressing a vessel, reduction of the fracture should be attempted immediately.  The wound should be thoroughly irrigated with at least one liter of saline or a combination of saline and betadine, and then a sterile or betadine soaked dressing should be placed over the wound, and the limb should be immobilized in a well-padded splint. Repetitive uncovering of the wound increases infection rates. Antibiotics should be administered as soon as possible in the prehospital setting or emergency department. One study suggested that antibiotic administration within three hours of injury decreases infection rates six-fold. A more recent retrospective study by Lack, et al. indicated that if antibiotics were given within 66 minutes of injury, the infection rate was 0%, but increased to 17% if antibiotics were delayed beyond this time frame. For grade 1 and grade 2 open fractures antibiotics should be given to cover gram-positive organisms.  Cephalosporins such as cefazolin or cefuroxime can be used.  Additional coverage for gram-negative organisms should be administered in grade 3 fractures. Aminoglycosides such as gentamicin are commonly used in this instance. In the presence of fecal or possible clostridial contamination or if the injury occurred in a farmyard, high dose penicillin should also be given. If a patient is truly penicillin allergic, clindamycin is an acceptable substitute. The tetanus status of all patients with open fractures should be assessed. If a patient has not completed the tetanus series or has not had a booster in the last five years, tetanus toxoid should be given. If the wound is high risk for Clostridium contamination or the patient has not had a tetanus booster in more than ten years, both tetanus toxoid and tetanus immune globulin should be administered.

An orthopedic surgeon should be consulted immediately to start planning for definitive management.[9][10][11]

• Infection
• Failure to heal
• Non-union

Patients with open fractures require definitive operative intervention after emergency stabilization and treatment. In the case that there are other concomitant traumatic injuries, the patients will need to be admitted to a trauma center by a trauma service equipped to manage their condition. Depending on the institutional practice and mechanism of injury, patients with isolated open fractures may be admitted by orthopedic services.

Patients with open fractures usually present to the emergency department; however, unlike the routine closed fracture, these fractures are always serious and need prompt treatment. The triage nurse in the ED must be fully aware of the seriousness of this injury and ensure prompt admission and referral to an orthopedic surgeon. Procedures are well established in most emergency departments on how to manage open fractures. The key is to minimize bacterial contamination of the wound and prompt management in the operating room. The outcomes of open wound do vary depending on the extent of the injury, degree of contamination, time to treatment and patient comorbidity. The latest data indicate that internal fixation does lead to better outcomes in most tibial fractures but in severe injuries, external fixation continues to be the appropriate choice. With prompt treatment, the risk of infection and non-union have also decreased. However, for most patients open fractures are always associated with a prolonged recovery period and most patients do develop some degree of functional disability. [12][13]