Open Fracture Management

1. Classification

Gustilo-Anderson Classification (most widely used clinically)

Important: There is considerable interobserver variability; the type may change after further debridement. Energy of injury matters more than absolute wound length.

OTA/AO Open Fracture Classification (OTA-OFC) - newer, more predictive

• Rockwood and Green's Fractures in Adults, 10th ed, p.154
• Campbell's Operative Orthopaedics 15th Ed, p.8063
• Miller's Review of Orthopaedics 9th Ed, p.813

2. Initial Emergency Management

Field/ED Care

• Wound irrigation and sterile dressing
• Splinting/immobilization to reduce ongoing soft tissue damage
• Neurovascular assessment (document distal pulses, sensation, motor function)
• Photography before dressing application

Antibiotics (single most effective infection-prevention measure)

• Continue 24 hours if wound is primarily closed
• Continue 24 hours after final closure if not closed at initial debridement

2022 Surgical Infection Society Guidelines: For Type I/II, recommend gram-positive coverage only (avoid broad-spectrum). For Type III, also recommend against extended coverage beyond gram-positive. For Type III with bone loss, use local + systemic antibiotics.

• Miller's Review of Orthopaedics 9th Ed, p.813
• Campbell's Operative Orthopaedics 15th Ed, Box 58.6

Tetanus Prophylaxis

• Tetanus-prone wounds: >6 hours old, >1 cm deep, devitalized tissue, or grossly contaminated
• Unknown immunization status or <3 prior immunizations + tetanus-prone wound: toxoid + human tetanus immunoglobulin (at different sites)
• Fully immunized: tetanus toxoid if wound is severe, >24 hours old, or no booster in 5 years

3. Surgical Wound Management

Timing of Debridement - the "6-hour rule" revisited

• Rockwood and Green's Fractures in Adults, 10th ed, p.632

Wound Excision (Debridement) Principles

• "Debridement" = wound extension to expose injured tissue; "excision" = removal of devitalized material
• An orthoplastic approach (orthopaedic + plastic surgery together from the start) is recommended for all significant open fractures
• Key goals:
  1. Reduce infective burden by removing contaminated debris
  2. Excise devitalized tissue that acts as a nidus for biofilm formation
  3. Minimize dead space and hematoma

• Skin: Excise only nonviable edges (confirmed by absence of bleeding). Retain viable skin flaps. Fascia that is detached, shredded, or nonviable must be excised.
• Subcutaneous fat: Excise areas with thrombosis or loss of integrity.
• Muscle: Assessed by the 4 Cs - Color, Contractility, Consistency, Capacity to bleed
  • Normal muscle: bright red, contracts on stimulation, firm, bleeds when cut
  • Nonviable muscle: dark/gray, no contraction, mushy, does not bleed
• Bone: Devascularized cortical fragments (those without soft tissue attachments) should be removed; however, large segments attached to periosteum may be retained if soft tissue reconstruction is planned

Wound Irrigation

• Lavage with normal saline reduces bacterial load
• Studies (FLOW trial) found low-pressure irrigation with saline is as effective as high-pressure with additives
• Volume: typically 3-6 L for Type I-II, 6+ L for Type III

Wound Closure Options

• Primary closure: Only if wound is clean, <6 hours, Type I with minimal contamination
• Delayed primary closure: Most Type II/IIIA wounds - close at 48-72 hours
• Split skin graft: For clean granulating wounds without exposed bone
• Flap coverage: Required when bone, tendon, or hardware is exposed

• Miller's Review of Orthopaedics 9th Ed, p.895

4. Skeletal Stabilization

External Fixator Tips

• Place pins through intact skin, not through the wound
• Predrill pins to avoid thermal necrosis
• Ensure pin placement does not compromise later soft tissue reconstruction or internal fixation conversion
• Plan the frame to allow access for subsequent flap coverage

Common Definitive Fixation Methods

• IM nail: Gold standard for diaphyseal tibial fractures (including open)
• Plate fixation: Periarticular fractures; anatomic reduction required
• External fixation: Definitive in some pelvic/foot injuries, or as bridge
• Rockwood and Green's Fractures in Adults, 10th ed, p.638+

5. Vascular Injury (Type IIIC)

• Warm ischemia time is critical - revascularization should occur within 6 hours
• Temporary vascular shunting can maintain perfusion while fracture stabilization proceeds
• Sequence: skeletal stabilization first, then vascular repair (to avoid disrupting anastomosis during manipulation) - OR vascular shunt, then skeletal fixation, then definitive vascular repair
• Fasciotomy is mandatory after revascularization (prophylactic or therapeutic for compartment syndrome)

6. Special Considerations

Compartment Syndrome

• May complicate any high-energy open fracture
• An open wound does NOT exclude compartment syndrome (only decompresses the compartment directly under the wound)
• Four compartments of the leg must be released: anterior, lateral, superficial posterior, deep posterior

Local Antibiotic Delivery

• PMMA antibiotic beads (tobramycin/vancomycin) can augment systemic antibiotics in contaminated wounds
• Meta-analysis (2,738 patients): local antibiotic prophylaxis reduced fracture-related infection risk by 11.9%
• Topical vancomycin powder at closure reduces gram-positive SSI rates in tibial plateau/pilon fractures (METRC trial)
• Rockwood and Green's Fractures in Adults, 10th ed, p.1752

Amputation vs. Limb Salvage

• IIIC injuries with combined bone, nerve, and vascular injury have high amputation rates
• MESS (Mangled Extremity Severity Score), NISSSA, HFS-97 scoring systems help guide decision making
• OTA-OFC cumulative score ≥10 best correlates with need for amputation

7. Summary Algorithm

Open Fracture
    |
    ├── ABCs, polytrauma assessment
    ├── IV antibiotics within 3 hours
    ├── Tetanus prophylaxis
    ├── Wound dressing + splint in ED
    |
    └── SURGERY (ideally same day, not necessarily <6h)
            |
            ├── Wound extension + systematic excision (orthoplastic)
            ├── Irrigation (saline lavage)
            ├── Skeletal stabilization
            |       ├── Closure possible → definitive fixation + closure
            |       └── Closure not possible → external fixator + planned return
            |
            └── Soft tissue coverage
                    ├── Primary / delayed primary
                    ├── SSG (no exposed bone)
                    └── Flap (exposed bone/tendon/hardware)
                    Goal: <7 days definitive coverage

• Rockwood and Green's Fractures in Adults, 10th ed (2025) - Classification, debridement principles, skeletal stabilization
• Campbell's Operative Orthopaedics 15th Ed (2026) - Antibiotic protocols, OTA classification
• Miller's Review of Orthopaedics 9th Ed - Summary tables, coverage options

Neck of Femur (NOF) & Intertrochanteric Fractures

Anatomical Overview & Key Distinction

PART 1: Neck of Femur Fracture (Intracapsular)

Blood Supply - The Core Problem

• Campbell's Operative Orthopaedics 15th Ed, p.3432

Classification Systems

1. By Anatomical Location (AO/OTA)

• Subcapital - just below the femoral head (most common; highest AVN risk)
• Transcervical - through the mid-neck
• Basicervical - at the base of the neck (functionally behaves more like intertrochanteric)

2. Garden Classification (most widely used clinically)

• Rockwood & Green's Fractures in Adults, 10th ed, p.2638
• Campbell's Operative Orthopaedics 15th Ed, p.3432

3. Pauwels Classification

• Campbell's Operative Orthopaedics 15th Ed, p.3433

4. Posterior Tilt Classification

• Posterior tilt ≥20°: 24.4% treatment failure rate
• Posterior tilt <20°: 10.9% treatment failure rate
• Risk ratio 2.73 (95% CI 1.77-4.21)
• Rockwood & Green's Fractures in Adults, 10th ed, p.2640

Diagnosis

• Clinical presentation: Shortened, externally rotated leg; inability to weight-bear
• Radiographs: AP pelvis + cross-table lateral; traction internal rotation view is often helpful
• If plain X-ray negative but clinical suspicion high: MRI is the investigation of choice (most sensitive and specific); CT if MRI contraindicated
• ~1% of fractures are initially occult on X-ray; if patient cannot weight-bear at 24h, further imaging is mandatory

Preoperative Traction

Management

Timing of Surgery

• 44.9% 30-day mortality for NOF treated nonoperatively vs. 2.0% operative
• 1-year mortality: 65.3% nonoperative vs. 17.6% operative
• Even nondisplaced fractures treated nonoperatively: 38.7% 30-day mortality

The Core Treatment Decision Tree

NOF Fracture
    |
    ├── UNDISPLACED (Garden I/II, posterior tilt <20°)
    │       └── Internal fixation
    │               ├── Cannulated screws (3 screws, inverted triangle)
    │               └── Sliding Hip Screw (DHS) - for basicervical/valgus impacted
    │
    └── DISPLACED (Garden III/IV)
            ├── YOUNG PATIENT (<65 or physiologically fit)
            │       └── Urgent reduction + internal fixation
            │               (emergent within 6-12h to preserve head)
            │
            └── ELDERLY PATIENT (physiologically older)
                    ├── Not independently ambulant / cognitively impaired
                    │       └── HEMIARTHROPLASTY (cemented)
                    │
                    └── Independently ambulant, cognitively intact
                            └── TOTAL HIP ARTHROPLASTY (THA)
                                    (NICE guidelines)

Internal Fixation (for undisplaced and young displaced)

• 3 partially threaded screws (6.5, 7.0, or 7.3 mm) in inverted triangle configuration
• Inferior screw along calcar (most important for stability)
• Aim for center-center screw position in femoral head
• Garden Alignment Index: trabeculae should measure 160-180° on AP; deviation >20° on lateral indicates malreduction

• Better for basicervical fractures and valgus-impacted fractures
• Basicervical fractures are NOT well treated with cannulated screws (high failure rate)
• Provides dynamic compression along the femoral neck axis

Arthroplasty (for displaced NOF in elderly)

• Standard treatment for most elderly patients with displaced NOF
• Shorter operative time, less blood loss than THA
• Implant types: Unipolar vs Bipolar
  • Unipolar: 20% wear rate at 12 months vs. 5% bipolar; however no significant long-term difference
  • Acetabular erosion rate: 5.3% conversion to THA for patients <75 vs. 1.4% for patients >75
• Cemented vs. uncemented: Cemented preferred - periprosthetic fracture rate 0.5% cemented vs. 2.1% uncemented; less pain and better mobility
• Risk: Bone Cement Implantation Syndrome (fat embolism) - use second-generation cementing technique

• NICE guidelines: recommended for patients who are cognitively intact AND independently ambulant (walking with at most one stick) AND medically fit
• Better functional outcomes and quality of life than HA in selected patients
• Higher dislocation risk than HA (RR 2.02; 95% CI 1.26-3.25) - use anterior/anterolateral approach to minimize this
• THA with Dual Mobility Components (THA-DMC): dislocation rate 1.5% (lower than standard THA)
• Head size: increasing from 28 mm to 40 mm reduces dislocation from 2.0% to 0.1%
• Osteosynthesis/Hemiarthroplasty/THA textbook, p.3-8
• Campbell's Operative Orthopaedics 15th Ed, p.3434-3448

Complications of NOF Fracture

PART 2: Intertrochanteric Fractures (Extracapsular)

Key Features

• Fracture line runs between the greater and lesser trochanters, outside the hip capsule
• Blood supply to femoral head is NOT at risk - AVN is extremely rare
• Prognosis for healing is generally good
• Treatment is always internal fixation (arthroplasty reserved for failed fixation or highly comminuted in frail patients)

Classification

AO/OTA Classification (31-A) - most commonly used

Boyd-Griffin Classification (historical)

• Type 1: Fracture along intertrochanteric line (stable)
• Type 2: Comminuted; main fracture along intertrochanteric line
• Type 3: Subtrochanteric extension
• Type 4: Fracture in trochanteric and subtrochanteric regions with at least two fracture planes

Evans Classification

• Stable: Posteromedial cortex intact; can be reduced to restore medial cortical support
• Unstable: Posteromedial comminution; medial cortex cannot be restored; higher failure rates

Management

General Principle

Fixation Choice: DHS vs. IM Nail

• TAD = distance from lag screw tip to femoral head apex on AP + same on lateral view
• Target TAD: <25 mm (ideally <20 mm)
• Risk of cut-out increases exponentially when TAD >25 mm

• Lateral wall thickness <21 mm predicts lateral wall fracture with 95% sensitivity
• Compromised lateral wall → DHS may cause iatrogenic fracture → use IM nail instead
• Preoperative CT may be indicated to assess lateral wall in borderline A2 fractures

Special Pattern: Reverse Oblique & Transverse (A3)

• DHS is contraindicated - the fracture line runs parallel/perpendicular to the screw, allowing medialization of the shaft
• Must be treated with IM nail (95° blade plate or 95° condylar screw are alternatives)

DHS Technique Summary

1. Patient supine on fracture table, closed reduction
2. Guide wire placed in center of femoral head (center-center position on AP and lateral)
3. Lag screw at 130-135° along femoral neck axis
4. Sliding compression mechanism allows dynamic collapse and union
5. 2-hole vs. 4-hole side plate: 4-hole preferred for most cases
6. Weight-bearing as tolerated postoperatively (for stable fractures)

IM Nail Technique Summary

1. Fracture table, closed reduction
2. Entry point at piriformis fossa or greater trochanter tip (trochanteric entry preferred with modern nails)
3. 10 mm diameter nail typically used; 130° nail angle
4. Lag screw placed center-center in femoral head; TAD confirmed fluoroscopically
5. Nail should not perforate anterior cortex (respect the anterior bow)

• Campbell's Operative Orthopaedics 15th Ed, p.3448-3456

Special Situations

Atypical Femoral Fractures (Bisphosphonate-associated)

• Long-term bisphosphonate use causes subtrochanteric atypical fractures
• Typically transverse, originating at the lateral cortex (tension side)
• Associated with lateral cortical beaking/thickening; often bilateral
• Management: IM nail; stop bisphosphonates; teriparatide may aid healing

Occult Fractures

• ~1% of hip fractures are occult on plain radiograph
• If patient cannot weight-bear at 24h: MRI (investigation of choice)
• A significant proportion of isolated "greater trochanter fractures" on X-ray have intertrochanteric extension on MRI

Lesser Trochanter Avulsion in Adults

• Isolated lesser trochanter fracture in an adult without significant trauma = assume pathological until proven otherwise (metastatic disease, myeloma)

Perioperative Care

Summary Comparison

PROXIMAL FEMUR FRACTURES
        |
        ├── INTRACAPSULAR (Neck of Femur)
        │       ├── Undisplaced (Garden I/II)
        │       │       └── Internal fixation
        │       │               (cannulated screws / DHS)
        │       └── Displaced (Garden III/IV)
        │               ├── Young patient → urgent ORIF
        │               └── Elderly
        │                       ├── Active, fit → THA
        │                       └── Less active → Hemiarthroplasty
        │
        └── EXTRACAPSULAR (Intertrochanteric, AO 31-A)
                ├── Stable (A1) → DHS
                ├── Unstable (A2) → DHS or IM nail (depends on lateral wall)
                └── Very unstable/reverse oblique (A3) → IM nail

• Campbell's Operative Orthopaedics 15th Ed 2026 - Classification, fixation techniques, arthroplasty
• Rockwood and Green's Fractures in Adults, 10th ed 2025 - Classification reliability, posterior tilt, outcome data
• Grainger & Allison's Diagnostic Radiology - Radiological appearances, occult fractures
• Osteosynthesis, Hemiarthroplasty, Total Hip Arthroplasty (NOF textbook) - HA vs. THA evidence, NICE guidelines