Open Fractures — Field Management

An open fracture (also called a compound fracture) is a fracture where the bone has broken through the skin, or where there is a wound that communicates with the fractured bone. Open fractures are more serious than closed fractures for two specific reasons: the risk of serious infection in the bone (osteomyelitis), and the risk of significant blood loss from the wound and surrounding soft tissue damage.

Field management of an open fracture is more complex than a closed fracture — it involves wound management as well as immobilisation. The decisions made in the field affect both the immediate outcome (haemorrhage control) and long-term outcome (infection risk).

Why Open Fractures Are More Serious

Complication	Risk
Osteomyelitis (bone infection)	Bone is exposed to environmental bacteria; infection in bone is difficult to treat and can become chronic; may require surgical debridement and long courses of antibiotics
Vascular injury	The force that causes an open fracture frequently damages adjacent blood vessels
Nerve injury	Adjacent nerves may be damaged by the same mechanism
Soft tissue contamination	Soil, clothing, debris, and bacteria are driven into the wound
Compartment syndrome	Pressure buildup in muscle compartments — a limb-threatening emergency

Open fractures are classified by severity:

Grade	Description
Grade I	Small wound < 1cm; minimal contamination
Grade II	Wound 1–10cm; moderate contamination
Grade III	Wound > 10cm or significant contamination, devascularisation, or nerve damage

Grade I open fractures can sometimes be managed in a standard trauma centre within 6 hours. Grade III open fractures are limb-threatening emergencies requiring specialist surgical input.

First Aid Priority — Control Bleeding

Bleeding from an open fracture wound is the immediate life threat:

1. Apply direct pressure to the wound with the cleanest available material.
2. Do not attempt to push exposed bone back under the skin — this worsens contamination and injury.
3. Do not attempt to clean the wound in the field — rinsing with clean water (not antiseptic) is acceptable for heavily contaminated wounds, but extensive cleaning should wait for hospital.
4. If bleeding cannot be controlled with pressure and the fracture is in a limb: apply a tourniquet 5–7cm above the wound.

Wound Coverage — The Infection Risk Decision

The wound covering in the field aims to reduce further contamination:

1. Rinse gross contamination with clean water — if the wound is heavily contaminated with soil or debris, gently rinse with clean water or sterile saline if available; do not scrub.
2. Cover the wound with the cleanest material available:
   • Sterile dressing if available
   • A clean plastic bag or cling film can create a barrier in the absence of formal dressings
   • Moistened dressing — a slightly damp clean cloth reduces desiccation of exposed tissue
3. Do not apply iodine or strong antiseptics directly to open bone — these cause tissue damage and are not recommended for open fracture management.
4. Do not repeatedly uncover the wound to check — every exposure is another contamination opportunity.

⚠️ Once the wound is covered, leave it. The principle of "cover it and leave it for the surgeons" is sound field medicine. Hospital wound assessment under sterile conditions will reveal what needs attention; field wound exploration achieves nothing useful and introduces additional contamination.

Immobilisation of Open Fractures

The fracture must be immobilised, as with a closed fracture. Additional considerations:

1. Do not attempt to reduce (straighten) the fracture — this is more important with open fractures where reduction could move contaminated debris deeper.
2. Splint in the position found — padding around the wound.
3. Ensure the covering dressing is not disturbed or displaced by the splint material — secure the splint around and away from the wound area.
4. Apply splint loosely enough that swelling can occur without the splint becoming a tourniquet.

Neurovascular Assessment

For all fractures, but especially open fractures, check distal neurovascular status:

Check	How	Concern
Pulse	Palpate at the wrist (radial) or foot (dorsalis pedis)	Absent pulse = vascular emergency
Sensation	Ask if they can feel you touching their fingers or toes	Absent or reduced sensation = nerve damage
Movement	Can they move their fingers or toes?	Absent movement = nerve damage
Colour	Pink or pale/blue	Pale or blue below fracture = vascular compromise
Temperature	Warm or cold compared to the other limb	Cold = reduced blood supply

Check before and after splinting. If vascular compromise exists, this is a surgical emergency.

Compartment Syndrome — Recognise and Alert

Compartment syndrome can develop in any significant fracture (open or closed) and is a limb-threatening emergency:

Signs:

• Severe, increasing pain out of proportion to the injury
• Pain on passive stretching of muscles in the compartment (moving the fingers or toes)
• Extreme tightness or tenseness of the muscle compartment
• Numbness and tingling distally

Field action: Cannot be treated in the field; immediately alert emergency services; document time of onset of these signs.

Compartment syndrome requires fasciotomy (surgical incision to release pressure) within hours of onset.

Calling 999 — What to Communicate

When calling emergency services for an open fracture:

• That the fracture is open (skin broken, possible bone exposure)
• The location of the fracture
• Whether pulses are present in the limb distally
• What bleeding control has been applied (direct pressure or tourniquet + time)
• Any other injuries
• Your exact location

Grade the contamination if possible — heavily contaminated (soil, mud, dirty water) changes how urgently the wound needs surgical management.

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Quick Reference

Priority	Action
1	Control bleeding — direct pressure or tourniquet
2	Cover wound — clean material; rinse gross contamination only
3	Immobilise — splint in position found; do not straighten
4	Neurovascular check — pulse, sensation, movement, colour
5	Call 999 — state open fracture; distal pulse status
Do not	Push bone back; apply antiseptic to exposed bone; repeatedly uncover
Tourniquet	If bleeding uncontrolled from limb fracture — apply + note time
Compartment syndrome	Pain out of proportion + tight compartment → alert emergency services immediately