Fracture assessment and open injuries

Major Fractures, Joint Dislocations & Acute Compartment Syndrome

Musculoskeletal trauma encompasses a wide spectrum of injuries ranging from closed extremity fractures to limb-threatening compartment syndromes and exsanguinating pelvic ring disruptions. A structured clinical approach prioritizing vascular integrity, neurological function, soft-tissue preservation, and time-critical reduction forms the foundation of Australian emergency and orthopaedic practice.

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Orthopaedic Principles: Assessment, Imaging & Open Fractures

The "Rule of Twos" in Radiography

When imaging suspected skeletal fractures, adhere to fundamental radiological principles:

1. Two Views: Always obtain at least two orthogonal projections (typically anteroposterior [AP] and lateral). A fracture visible on one view may be completely obscured on another.
2. Two Joints: Image the joint above and the joint below the fractured bone (e.g., in a tibial shaft fracture, obtain dedicated views of the knee and ankle to exclude associated dislocations or syndesmotic disruptions).
3. Two Limbs: In paediatric trauma, obtain comparison views of the uninjured contralateral extremity when assessing ambiguous growth plate (physeal) injuries.
4. Imaging: Document alignment and neurovascular findings before and after reduction. Persistent suspicion despite normal films requires an appropriate occult-fracture pathway. Suspected hip fracture needs urgent MRI, usually within 24 hours when available, or CT when appropriate; a two-week wait is unsafe.

Neurovascular Documentation

A comprehensive neurovascular examination of the extremity must be performed and documented prior to and immediately following any splinting, closed reduction, or procedural manipulation. Document palpable distal pulses, capillary refill time, motor function of peripheral nerves, and sensory distribution.

Open Fractures & Gustilo-Anderson Classification

An open (compound) fracture represents a direct communication between the fracture haematoma and the external environment, carrying substantial risk of osteomyelitis, deep surgical site infection, non-union, and chronic disability.

• Type I: Wound Characteristics: Clean puncture wound $< 1\text{ cm}$; Soft-Tissue Damage: Minimal contusion; clean; Skeletal Injury: Simple transverse / oblique fracture; Infection Risk: $1\%\text{ to }2\%$
• Type II: Wound Characteristics: Laceration $1\text{ to }10\text{ cm}$; Soft-Tissue Damage: Moderate soft-tissue stripping; Skeletal Injury: Moderate comminution; Infection Risk: $2\%\text{ to }7\%$
• Type IIIA: Wound Characteristics: Laceration $> 10\text{ cm}$; Soft-Tissue Damage: Extensive laceration; adequate periosteal cover; Skeletal Injury: High-energy, severe comminution; Infection Risk: $7\%\text{ to }12\%$
• Type IIIB: Wound Characteristics: Extensive soft-tissue defect; Soft-Tissue Damage: Severe stripping, bone exposed; requires flap cover; Skeletal Injury: High-energy comminution; periosteal stripping; Infection Risk: $10\%\text{ to }50\%$
• Type IIIC: Wound Characteristics: Any open fracture; Soft-Tissue Damage: Associated arterial injury requiring vascular repair; Skeletal Injury: High-energy injury; limb-threatening; Infection Risk: $25\%\text{ to }50\%$

Immediate Emergency Management of Open Fractures

• Wound documentation: A photograph can reduce repeated dressing removal if consent, an approved clinical device and secure record storage are used. Personal phones and informal messaging are inappropriate.

1. Gross Debris Removal: Gently brush away gross superficial foreign material (e.g., leaves, gravel), but never explore, probe, or irrigate the wound in the emergency department.
2. Do Not Reduce Exposed Bone: Do not push exposed bone ends back beneath the soft tissues in the emergency department, as this introduces superficial skin and environmental pathogens into the deep fascial planes.
3. Sterile Dressing & Splinting: Cover the wound with a sterile gauze dressing soaked in 0.9% sodium chloride, seal with an occlusive wrap, and immobilize the extremity in an appropriate rigid splint.
4. Tetanus Prophylaxis: Administer tetanus toxoid booster (and tetanus immunoglobulin if the wound is tetanus-prone and vaccination history is incomplete or unknown).

• Open fractures: Give appropriate IV antibiotics as soon as possible, ideally within one hour, and check tetanus status. Cover the wound with a sterile dressing, splint, document neurovascular findings and arrange orthopaedic debridement. Do not repeatedly explore or wash a wound in the emergency department.
  • All open fractures (Type I & II): Intravenous cefazolin ($2\text{ g}$ IV 8-hourly).
  • Type III / Severe contamination: Add intravenous gentamicin ($5\text{ mg/kg}$ IV once daily).
• Contaminated wounds: Water, soil, farm and bite exposure can require additional organism-specific cover. Use the local open-fracture protocol and microbiology advice; routine benzylpenicillin alone does not address every marine exposure.

1. Urgent Operative Debridement: Formal surgical debridement and irrigation in the operating theatre within 12 to 24 hours of injury (within 6 hours for severe gross marine/agricultural contamination, compartment syndrome, or Type IIIC arterial injury).

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Open-fracture reassessment

For an open tibial wound, antibiotics and sterile coverage are early actions while orthopaedic care is arranged. Record distal sensation, motor function, pulses and capillary refill before and after splinting. Wound size alone cannot determine the final Gustilo grade; operative assessment defines contamination, tissue loss and vascular injury. Reassess disproportionate pain or evolving numbness promptly. Neither a visible pulse nor an initially reassuring radiograph excludes compartment syndrome or associated neurovascular damage.

Primary references (checked 7 October 2026): NSW trauma pathway.