Compound Fractures



Fracture with break in skin communicating with fracture haematoma or fracture

- contamination with micro-organisms

- coupled with damage to ST and vascular supply

- leads to increased risk in infection and healing problems


Gustillo Classification


Grade I

- low velocity / wound < 1cm

- minimal contamination & minimal tissue injury


Grade II

- wound > 1cm

- moderate contamination / moderate tissue Injury


Grade IIIA


High velocity injury

- segmental

- comminuted

- suggests extensive injury or loss of soft tissue

- damage to periosteum


DPC possible


Automatic Grade III

- shotgun wound

- high velocity gunshot wound

- segmental fracture with displacement

- diaphyseal segmental loss

- wound occurring in a farmyard / highly contaminated environment

- crushing force from a fast-moving vehicle


Grade IIIB


High velocity injury

After debridement needs skin flap / graft


Grade IIIC


Needed vascular repair to save limb


Infection Rate


I:      0-2%

II:     2-7%

IIIA:  7%

IIIB:  10-50%

IIIC:  25-50% with 50% or more amputation






Prevent infection

Manage the wound

Stabilise the fracture

Enable healing




EMST / ATLS Principles


Assess Limb

- vascular

- neurology

- skin defect / contamination

- photos



- irrigate wound

- apply betadine dressing

- stabilise with POP if possible

- appropriate antibiotics / tetanus

- early OT for irrigation / debridement / stabilisation





- grade 1: first generation cephalosporin

- grade 2: add gentamicin

- farmyard / heavily contaminate add penicillin (clostridium / gas gangrene)


Patzakis JBJS Am 1974

- prospective, randomised controlled trial

- infection with preoperative cephalothin was 2.3% 

- infection 13.9% without antibiotic



- studies finding of initial swab correlating with infecting organism has been discredited

- no real correlation between road-side organisms & subsequent infection

- subsequent infection are typically hospital acquired



- increased rate of gram negative infection in Grade II

- hence add aminoglycoside if Grade II

- add penicillin if soil contamination

- no evidence any other combination is better



- delay > 3 hours increases infection risk

- 48 - 72 hours post injury

- 48 - 72 hours post each procedure


Wound Management




Gustilo JBJSA 1987

- infection higher if < 10L washout


Anglen 1984

- pulse lavage 100 x effective than bulb




Must remove all non viable tissue

- remove cortical bone with no ST covering


Timing of wound closure


Do so when wound is clean


No evidence of increased infection with primary closure

- may prevent secondary contamination

- risk of clostridial myonecrosis


DPC (delayed primary closure)

- prevent anaerobic conditions in wound

- facilitates drainage

- allows second debridement

- can seal the wound via vacuum dressing


Fracture Stabilisation



- prevent soft tissue from further injury

- facilitates host response to bacteria despite presence of implants

- allows mobilisation and functional rehab



- IMN best for I, II, IIIA and B

- 10% deep infection in type III B

- best to plate in type IIIC before revascularisation




Reamed v unreamed

- no difference in infection rate


IMN v External fixator

- reduced risk of revision surgery, malunion and superficial infection with IM nail

- no difference in infection rate or union


External fixator

- heavily contaminated wound

- non amenable to nail (i.e. very distal)

- vascular injury


Soft Tissue Reconstruction




Proximal tibia - local pedicle gastrocnemius flap

Middle third - soleus flap

Distal third - free muscle flap (rectus / gracilis / lat dorsi)




Gopal et al JBJS Br 2000

- early < 72 hours v late > 72 hours

- 6% v 29% deep infection

- did not use antibiotic beads