Open (Compound) Fracutures
An open fracture is a broken bone that penetrates the skin. When a broken bone penetrates the skin there is a need for immediate treatment, and an operation is often required to clean the area of the fracture. Due to the risk of infection, there are more often problems associated with healing when a fracture is open to the skin.
Causes
Open fractures are caused by high-energy trauma, most commonly from a direct blow, such as from a fall or motor vehicle collision, sports injury or fall.
These fractures can also occur indirectly, such as a high-energy twisting type of injury
These fractures can also occur indirectly, such as a high-energy twisting type of injury
Treatment
The goals of treatment for open fractures are to prevent infection, get the broken bones to heal, and restore function.
Débridement and Irrigation:
The first steps in controlling the risk for infection are débridement and irrigation
Fracture Treatment:
It is important to stabilize the broken bones as soon as possible to prevent further soft tissue damage. The broken bones in an open fracture are typically held in place using external or internal fixation methods. These methods require surgery.
Depending upon the amount of soft tissue lost, these complex wounds can be covered using different methods:
In these complex wounds, temporary coverage of the fracture must be established to decrease the risk of infection and promote healing. In these cases, many types of dressings can be used, but sometimes the wound is sealed with a semipermeable material until the soft-tissue closure procedure. Antibiotic beads are often placed into a wound before sealing to provide high concentrations of antibiotics directly to the injury.
Débridement and Irrigation:
The first steps in controlling the risk for infection are débridement and irrigation
- Débridement- During this procedure, your surgeon will remove all dirt and foreign bodies, as well as any contaminated and unhealthy skin, muscle, and other soft tissues. The bone is also cleaned of all dirt and other foreign material. Any unattached pieces of bone are removed. Severely contaminated bone fragments are also discarded. This bone loss can be corrected later with additional surgeries.
- Irrigation- After débridement, the wound is cleansed and irrigated with several liters of saline.
Fracture Treatment:
It is important to stabilize the broken bones as soon as possible to prevent further soft tissue damage. The broken bones in an open fracture are typically held in place using external or internal fixation methods. These methods require surgery.
- Internal fixation- During the operation, the bone fragments are first re-positioned (reduced) into their normal alignment, and then held together with special screws or by attaching metal plates to the outer surface of the bone. The fragments may also be held together by inserting rods down through the marrow space in the center of the bone. These methods of treatment can re-position the fracture fragments very exactly. Because open fractures may include tissue damage and be accompanied by additional injuries, it may take time before internal fixation surgery can be safely performed.
- External fixation- Depending on your injury, your doctor may use external fixation to hold you bones in general alignment. In external fixation, pins or screws are placed into the broken bone above and below the fracture site. Then the orthopedic surgeon re-positions the bone fragments. The pins or screws are connected to a metal bar or bars outside the skin. This device is a stabilizing frame that holds the bones in the proper position
- Minor open fractures- For less severe injuries with minimal contamination, the fracture can be stabilized with internal fixation once the wound has been thoroughly débrided.
- Severe open fractures- More severe open fractures are typically first stabilized using external fixation. This treatment will keep the bones in place until the wound can tolerate an internal fixation procedure.
- Complex wounds- In some open fracture cases, a lot of soft tissue has been lost and the wound is too large to be closed.
Depending upon the amount of soft tissue lost, these complex wounds can be covered using different methods:
- Local flap. The muscle tissue from the involved limb is rotated to cover the fracture. A patch of skin taken from another area of the body (graft) is placed over this.
- Free flap. Some wounds may require a complete transfer of tissue. This tissue is often taken from the back or abdomen. A free flap coverage procedure requires the assistance of a micro-vascular surgeon to ensure the blood vessels connect and circulation is established.
In these complex wounds, temporary coverage of the fracture must be established to decrease the risk of infection and promote healing. In these cases, many types of dressings can be used, but sometimes the wound is sealed with a semipermeable material until the soft-tissue closure procedure. Antibiotic beads are often placed into a wound before sealing to provide high concentrations of antibiotics directly to the injury.