Open fractures : Emergency Management

Gustilo Anderson Classification of Open fracture

Progression for grade I to III C implies a higher degree of energy involved in the injury, higher soft tissue and bone damage, and higher potential for complications.

open fracture gustilo anderson

Type I: <1 cm; Mild/minimal energy trauma, soft tissue injury, contamination or communition

Type II: 1-10 cm; Moderate energy trauma, soft tissue injury, contamination or communition

Type III: >10 cm; Severe/extensive energy trauma, soft tissue injury, contamination or communition or segmental fractures

These are automatically Type III open fractures:

  1. Fractures >8 hours old
  2. Farmyard injuries
  3. Gunshot injuries
  4. Traumatic amputation
  • III A: Adequate soft tissue coverage of bone
  • III B: Bony exposure
  • III C: Compromise of neurovascular status

gustilo anderson type III

Mangled Extremity Severity Score (MESS) to Predict Eventual Amputation

Mnemonic: MESS

1. Maturity (Age):

  • <30 years: 0
  • 30-50 years: 1
  • >50 years: 2

2. Extremity ischemia:

  • Pulse reduced or absent but perfusion normal: 1
  • Pulseless (by doppler), paresthesia, diminished capillary refilling, diminished motor activity: 2
  • Pulseless, cool, paralysed, insensate, numb, without capillary refill: 3

3. Skeletal and soft tissue injury:

  • Low energy: 1
  • Medium energy: 2
  • High energy: 3
  • Very high energy (crush): 4

4. Shock:

  • Normotensive: 0
  • Transient hypotension: 1
  • Persistent hypotension: 2


  • Score is doubled for ischemia >6 hours.
  • MESS >7 predicts eventual amputation.

Emergency Room Management of Open fracture

Follow the trauma protocol and stabilize the patient with primary survey followed by secondary survey.

1. Control hemorrhage in field with sterile pressure dressing after carefully removing gross debris (e.g., wood, clothing, leaves).

2. Splint without reduction, unless vascular compromise is present.

3. Irrigate with saline and cover with saline-soaked sponges after arrival in the emergency department.

4. Begin intravenous antibiotic prophylaxis, usually a first generation cephalosporin for grade I, with the addition of an aminoglycoside for grades II and III.

5. Administer tetanus prophylaxis, including tetanus immune globulin, for large crush wounds.

1. Prevention of further contamination:

  • Take wound swab cultures
  • Photograph the wound
  • Cover the wound with sterile dressing soaked in saline or povidone-iodine

2. Prevention of bacterial growth:

  • 6 hour golden rule: All open fractures should be regarded as surgical emergencies and should be definitively treated within 6 hours of injury. But the current evidences suggest that operative care may be delayed upto 24 hours.
  • Empirical IV antibiotics in maximum dose:
    • Type I and II injuries: 1st generation cephalosporin
    • Type III injuries: Add aminoglycoside
    • Suspected anaerobic contamination: Add metronidazole

Rule of 3 for antibiotics: Initiate antibiotics as soon as possible (possibly within 3 hours) and continue for atleast 3 days.

Tetanus Prophylaxis

tetanus prophylaxis

Reference: Frontiers in Fracture Management By Timothy D Bunker, Christopher L Colton, John K Webb

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