Open Fractures

Introduction

Open fractures are orthopaedic emergencies associated with a high risk of infection, non- union, and limb loss. They require a structured trauma approach, urgent antibiotics, careful handling, and early orthoplastic input.

This is a common exam scenario whether it be ST1, CST or ST3. So you must have a structured approach to answering your questions. All open fracture questions must be approached using ATLS. Always go through your A-E, the examiner will stop you once they have heard enough.

“As this is a high-energy injury, I would approach this patient using ATLS principles starting with my airway assessment and triple immobilization of the cervical spine.

Note: Another good line to commit to memory when dealing with a normal fracture (Distal radius, NOF etc, not an open fracture.) à ‘I will confirm this is a closed, neurovascular intact injury, with no signs of compartment syndrome’. Do not just jump to the answer saying ‘I’ll reduce this/backslab’.

ATLS Approach

A: Airway Assessment with triple immobilization of the spine.

B: Breathing and oxygenation + your full chest examination and oxygenation.

C: Circulation and haemorrhage control. Apply direct pressure, avoid tourniquets unless life-threatening bleeding. G+S +-Cross Match.

D: Disability – neurological assessment, BM’s and GCS + any Focal Neurology.

E: Exposure – identify all injuries, keep patient warm.

Classification: Gustilo-Anderson

Normally they won’t ask you to define the classification but it will look slick if you can define it by looking at the image or by they may mention it in the stem. An important point to note: Gustillo Anderson classification can only happen in theatre. Not at the time of presentation to A+E.

Type I: Clean wound < 1 cm, minimal contamination/soft tissue damage.

Type II: Wound > 1 cm, moderate contamination/soft tissue injury, no extensive

flaps/avulsion.

Type IIIA: High-energy injury, extensive soft tissue damage, but adequate bone

coverage possible.

Type IIIB: Extensive soft tissue loss, periosteal stripping, bone exposure, usually

requires flap coverage.

Type IIIC: Any open fracture with associated arterial injury requiring repair.

BOAST Guidelines: Open Fractures

Initial ED Management

1. Specialist centres: Long bone, hindfoot, midfoot injuries → transfer to centre with orthoplastic care.

2. Antibiotics: IV prophylactic antibiotics as soon as possible (within 1 hour).

Why? Very high chance of infection. As per local guidelines is sufficient. This is partcicularly important in practice as well. This will be the second question consultants ask at the trauma meeting (the 1st being, is it neurovascularly intact?).

3. Limb assessment: Document vascular & neurological status; repeat after reduction/splintage.

Essential that you mention you will document NV status pre and post reduction. This is an important point for the entire interview. Any question you get where you ‘do something’ e.g. reduce or splint, always document NV status before and after and also post reduction x-rays.

4. Re-align & splint the limb.

5. Arterial injury: Follow BOAST for arterial trauma.

6. Imaging:

o Trauma CT with scanogram to plan further sequence if concerned about other injuries.

o If unsure on distal arterial supply the pathway is normally: Pulses then ABPI then CT Angiography.

Note: You are applying for an ST1 job, not ST3 and definely not consultant. Always mention you will escalate to the senior registrar in patients with life/limb threatening injuries. In this case, you have to mention that.

7. Wound care:

o Only remove gross contamination.

o Cover with saline-soaked gauze + occlusive film.

o No “mini washouts” outside theatre.

8. Photography: Must be taken, stored, and documented at each stage – often forgotten in the heat of the exam. But these are where the extra marks will come from.

Operative Management

9. Orthoplastic approach: Initial debridement and fixation plan by both orthopaedic + plastic consultants.

10. Debridement:

o Immediate: highly contaminated (agricultural, aquatic, sewage) or vascular compromise. (call the consultant/senior SpR Out of Hours)

o 12 hrs: solitary high-energy fractures.

o 24 hrs: all other low-energy open fractures.

11. Surgical principles:

o Use fasciotomy lines for wound extension.

o After debridement, re-prep + fresh instruments for definitive fixation.

12. Soft tissue coverage: Definitive closure or flap within 72 hrs if not at initial surgery.

13. Internal fixation: Only with immediate soft tissue cover.

14. Amputation: If salvage questionable, decision via multidisciplinary discussion. Delayed primary amputation (if indicated) within 72 hrs.

Key Exam Questions/Pointers

ATLS approach first, open fracture = trauma call.
IV antibiotics within 1 hour is critical.
Never “mini-washout” in ED — cover with saline gauze + film.
Debridement timing: immediate for gross contamination and sewage, 12 hrs for high energy, and rest at 24 hrs
Definitive coverage within 72 hrs.
Always mention key words like ‘BOAST Guidelines of approach to Open Fractures.’ ‘ATLS Approach’, ‘Neurovascular Assessment pre and post reduction/splintage’.
Learn the BOAST Guidelines.