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Classifying open fractures

Medical Professionals

Professional Reference articles are designed for health professionals to use. They are written by UK doctors and based on research evidence, UK and European Guidelines. You may find one of our health articles more useful.

Synonym: compound fracture

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What is an open fracture?

An open fracture can be defined as a broken bone that is in communication through the skin with the environment. The amount of communication can vary from a small puncture wound in the skin to a large avulsion of soft tissue that leaves the bone exposed.


The diagnosis is usually obvious but may be missed, especially if the puncture wound is very small, or a fracture of the terminal phalanx which is technically open.

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Open fractures were historically classified by Gustilo and Anderson.1 The classification of open fractures is based on descriptors of the size of the wound and the amount of soft-tissue injury but subjectivity could lead to misclassification. There is also a lack of evidence that correlates classification with outcomes such as infection and amputation rates.

Gustilo and Anderson classification of open fractures

  • Type I: clean wound smaller than 1 cm in diameter, appears clean, simple fracture pattern, no skin crushing.

  • Type II: a laceration larger than 1 cm but without significant soft-tissue crushing, including no flaps, degloving or contusion. Fracture pattern may be more complex.

  • Type III: an open segmental fracture or a single fracture with extensive soft-tissue injury. Also included are injuries older than eight hours. Type III injuries are subdivided into three types:

    • Type IIIA: adequate soft-tissue coverage of the fracture despite high-energy trauma or extensive laceration or skin flaps.

    • Type IIIB: inadequate soft-tissue coverage with periosteal stripping. Soft-tissue reconstruction is necessary.

    • Type IIIC: any open fracture that is associated with vascular injury that requires repair.

The Orthopaedic Trauma Society classification2

  • This is based on objective descriptors which are measured after the first surgical excision (or debridement).

  • Injuries are broadly classified into 'simple' or 'complex' based on the need for a reconstructive procedure to achieve wound closure.

  • Simple fractures require no additional procedures to achieve wound closure.

  • Complex fractures need either bone, vascular or soft tissue reconstruction to achieve closure and can be further subdivided into types A-C.

Open fracture treatment3

The aims of management are to prevent infection, ensure healing of the fracture and promote the restoration of function.

  • The treatment of open fractures should be considered as an emergency. Adequate fluid/blood replacement, analgesia, splinting, antibiotics and tetanus prophylaxis are required before surgical treatment. Start broad-spectrum antibiotics (eg, IV co-amoxiclav) as soon as possible after injury (certainly within three hours).

  • Wounds are handled only to remove gross contaminants (or to obtain a photographic record and to seal from the environment). They are no longer 'provisionally cleaned' or routinely irrigated. Immediate surgical exploration is only indicated if there is gross contamination, a compartment syndrome developing, a devascularised limb or if the patient has multiple injuries.

  • Debridement is then performed by orthopaedic and plastic surgeons working together on a scheduled trauma list in normal working hours (within 24 hours of the injury) unless there is marine, agricultural or sewage contamination.

  • Associated injuries may be severe and also require urgent treatment.


  • The most important surgical aspect of care in open fractures includes early and complete debridement of non-viable tissue and stabilisation of the fracture.

  • Delayed debridement is associated with increased infection rates.

  • Early wound management generally includes the use of antibiotic-impregnated beads and definitive wound closure within one week of injury.

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Open fracture complications4

  • Patients with open fractures are at risk of complications of acute wound infection and osteomyelitis. Infection can result in non-union of the fracture and chronic osteomyelitis. It can also possibly result in the need for amputation.

  • There is also a risk of tetanus infection.

  • Infection rates vary but remain as high as 20% in severe cases. This risk depends on the degree of associated soft-tissue injury and the initial management of the patient. Infections may be caused by bacteria that contaminate the wound at the time of injury or by hospital-acquired pathogens.

  • Complications other than infection, failure of skeletal fixation and non-union of fracture will depend on the location and extent of soft-tissue damage.

  • Both neurovascular injury and compartment syndrome can occur.

Further reading and references

  1. Kim PH, Leopold SS; In brief: Gustilo-Anderson classification. [corrected]. Clin Orthop Relat Res. 2012 Nov;470(11):3270-4. doi: 10.1007/s11999-012-2376-6. Epub 2012 May 9.
  2. Trompeter AJ, Knight R, Parsons N, et al; The Orthopaedic Trauma Society classification of open fractures. Bone Joint J. 2020 Nov;102-B(11):1469-1474. doi: 10.1302/0301-620X.102B11.BJJ-2020-0825.R1.
  3. Sop JL, Sop A; Open Fracture Management.
  4. Omeroglu H; Basic principles of fracture treatment in children. Eklem Hastalik Cerrahisi. 2018 Apr;29(1):52-7. doi: 10.5606/ehc.2018.58165.

Article history

The information on this page is written and peer reviewed by qualified clinicians.

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