- Fractures that have communication with the outside environment are considered "open".
- The fractured portion does not have to be overtly exposed.
- Infection can lead to serious complications including nonunion and osteomyelitis.
- True orthopedic emergency due to increased risk of infection from exposure of bone.
- Fracture with overlying wound suspected of reaching bone (i.e. "communicating"), regardless of how narrow wound may be
- Compartment syndrome
- Crush syndrome
- Degloving injury
- Myositis ossificans
- Open joint injury
- Peripheral nerve injury
- Tendon injury
- Vascular injury
- Shows fracture type
- Free air on x-ray may suggest open fracture in more equivocal cases (not sensitive)
- Trauma labs
- Additional sites of injury found in 40-80% of cases
- Nerve, vascular, muscular, and/or ligamentous injury
Gustilo-Anderson grading scale
As the grade increases, so does the risk of infection
- Wound <1cm
- Little soft tissue injury or crush injury
- Moderately clean puncture site
- Infection risk 0-12%
- Laceration >1cm
- No extensive soft tissue damage, but slight or moderate crush injury
- Moderate contamination
- Infection risk 2-12%
- Extensive damage to soft tissue, including neurovascular structures and muscle
- High degree of contamination
- Infection risk 5-50%
- Further subcategorized:
- III A: Fracture covered by soft tissue (Infection risk 5-10%)
- III B: Loss of soft tissue and evidence of bone stripping (Infection risk 10-50%)
- III C: Any fracture with an associated arterial injury that requires surgical repair (Infection risk 25-50%)
- Typically opioid pain control
Prophylactic Antibiotics for Open fractures
Initiate as soon as possible; increased infection rate when delayed
Grade I & II Fractures Options
- Cefazolin (Ancef) 2 g IV (immediately and q8 hours x 3 total doses)
- Cephalosporin allergy: clindamycin 900 mg IV (immediately and q8 hours x 3 total doses)
Grade III Fracture Options
- Ceftriaxone 2 g IV (immediately x 1 total dose) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)
- Cephalosporin allergy: aztreonam 2 g IV (immediately and q8 hours x 3) PLUS vancomycin 1 g IV (immediately and q12 hours x 2 total doses)
- Concern for clostridium (soil contamination, farm injuries, possible bowel contamination): additionally add penicillin
- Fresh water wounds: fluoroquinolones OR 3rd/4th generation cephalosporin
- Saltwater wounds (vibrio): doxycycline + ceftazidime OR fluoroquinolone
Wound Managment 
- Surgical debridement and washout within 24 hours.
- Thorough ED irrigation and debridement appears safe for hand (metacarpal, phalanx) fractures without excessive contamination
- Irrigation may be started in the ED for grossly contaminated wounds
- Place a sterile dressing over wound to decrease continued contamination
- Tetanus prophylaxis
- Admission to ortho or trauma surgery
- Discharge may be considered for select fractures (e.g. metacarpal, phalanx without excessive contamination), typically after bedside washout by consulting service (e.g. orthopedics)
- The NNT. Accessed 4/23/2022. https://www.thennt.com/nnt/antibiotics-for-open-fractures/
- Dunkel N, Pittet D, Tovmirzaeva L, et al: Short duration of antibiotic prophylaxis in open fractures does not enhance risk of subsequent infection. Bone Joint J 2013;95-B:831-837.
- Gosselin RA, et al. Antibiotics for preventing infection in open limb fractures. Cochrane Database Syst Rev. 2004; (1):CD003764.
- Garner MR, et al. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. Journal of the American Academy of Orthopaedic Surgeons. April 15, 2020. 28(8):309-315
- HoffWS, Bonadies JA, Cachecho R, Dorlac WC: East practice management guidelines work group: Update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70:751-754.
- Ketonis C, Dwyer J, Ilyas AM. Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review. Hand (N Y). 2017;12(2):119-126.