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[Conditions](https://durgical.com/en/conditions/) · [Surgery and trauma](https://durgical.com/en/conditions/)

# Open fracture

A broken bone that connects with a wound in the skin. Germs can reach the bone, so it needs antibiotics, tetanus cover and surgical cleaning fast.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Tibia](https://durgical.com/en/anatomy/tibia/)
- [Fibula](https://durgical.com/en/anatomy/fibula/)
- [Skin](https://durgical.com/en/anatomy/skin/)
- [Crural fascia](https://durgical.com/en/anatomy/crural-fascia/)
- [Anterior tibial artery](https://durgical.com/en/anatomy/anterior-tibial-artery/)
- [Posterior tibial artery](https://durgical.com/en/anatomy/posterior-tibial-artery/)
- [Fibular artery](https://durgical.com/en/anatomy/fibular-artery/)
- [Tibial nerve](https://durgical.com/en/anatomy/tibial-nerve/)
- [Common fibular nerve](https://durgical.com/en/anatomy/common-fibular-nerve/)
- [Tibialis anterior](https://durgical.com/en/anatomy/tibialis-anterior-muscle/)
- [Femur](https://durgical.com/en/anatomy/femur/)

## Why it happens

- [What delays healing: infection, diabetes, nutrition, glucocorticoids, poor blood flow](https://durgical.com/en/general-pathology/what-delays-healing-infection-diabetes-nutrition-glucocorticoids-poor-blood-flow/)
- [Bone tissue: cells, compact and spongy bone](https://durgical.com/en/histology/bone-tissue-cells-compact-and-spongy-bone/)
- [Ossification, growth plate and bone remodeling](https://durgical.com/en/histology/ossification-growth-plate-and-bone-remodeling/)

## What it is

A fracture in which the bone or the fracture haematoma communicates with the outside through a break in the skin and soft tissues. The [tibia](https://durgical.com/en/anatomy/tibia/) is the long bone most often involved because so much of it lies just under the skin. It is an orthopaedic emergency because of the risk of infection, poor healing and loss of the limb.

## Who gets it

Open fractures follow high-energy trauma and are common in young adult men. In Colombia and the rest of Latin America, motorcycle crashes are the leading cause of open tibial fractures seen in emergency departments, followed by falls, run-over pedestrians and gunshot wounds.

## Causes

- High-energy blunt trauma: motorcycle and car crashes, run-over pedestrians
- Falls from height and crush injuries
- Gunshot wounds
- Low-energy falls in people with fragile skin or bone (older adults)
- Bone spike piercing the skin from the inside out

## Risk factors

- Motorcycle riding without protective gear
- Farm, construction or water-contaminated injuries (heavy contamination)
- Smoking and diabetes (worse infection and healing)
- Delay to antibiotics or to surgical debridement
- Peripheral arterial disease or associated vascular injury

## Pathophysiology

The skin wound lets bacteria into the fracture site, while crushed muscle, stripped periosteum and damaged vessels leave dead tissue with poor blood supply. This devitalised tissue is an ideal medium for infection and impairs bone healing. The larger the soft-tissue damage and contamination, the higher the risk of deep infection, non-union and amputation.

## Classification

- Gustilo-Anderson type I: clean wound smaller than 1 cm, low energy
- Type II: wound 1–10 cm without extensive soft-tissue damage
- Type IIIA: extensive soft-tissue injury but bone can still be covered
- Type IIIB: periosteal stripping and bone exposure needing flap coverage
- Type IIIC: arterial injury requiring repair, regardless of wound size
- Final grade is assigned in the operating room after debridement

## Symptoms and signs

- Wound over or near a deformed, painful limb
- Bone visible in the wound, or bleeding with fat droplets
- Swelling, bruising and inability to bear weight
- Abnormal movement or grating at the fracture site

## Red flags

- Absent or weak distal pulses, cold or pale foot (vascular injury, Gustilo IIIC)
- Pain out of proportion, pain on passive stretch or tense calf (compartment syndrome; an open wound does not rule it out)
- Heavy contamination with soil, farm material or water
- Haemorrhagic shock or other life-threatening injuries
- Fever, spreading redness, foul discharge or crepitus in the days after injury

## Diagnosis

**Clinical**
Diagnosis is clinical: any wound near a fracture is assumed to be open until proven otherwise. After the ATLS primary survey, document the wound, contamination, distal pulses, capillary refill, sensation and motor function, and photograph the wound so the dressing does not need to be repeatedly lifted.

**Tests**
Blood count, group and crossmatch, coagulation tests and baseline [kidney](https://durgical.com/en/anatomy/kidney/) function in major trauma; ankle-brachial index when pulses are abnormal; compartment pressure measurement when the examination is unclear.

**Imaging**
Plain radiographs in two planes including the joint above and below. CT for intra-articular extension. CT angiography or angiography when a vascular injury is suspected.

## Differential diagnosis

- Closed fracture with a nearby superficial abrasion or skin tear not reaching the bone
- Open joint injury (traumatic arthrotomy) without fracture
- Isolated soft-tissue laceration
- Degloving injury

## Goal of treatment

Prevent infection, stabilise the fracture, restore blood flow and soft-tissue cover early, and get the bone to heal with a functional limb.

## Treatment

**Acute**
Early intravenous antibiotics, ideally within the first hour: a first-generation cephalosporin for all grades, with added gram-negative cover for type III, and anaerobic cover for farm or heavily soiled wounds.

**Acute**
Tetanus prophylaxis according to vaccination history: tetanus toxoid-containing vaccine, plus tetanus immune globulin for dirty wounds in people not fully vaccinated.

**Acute**
Initial care: control bleeding with direct pressure, remove gross contamination, cover the wound with a sterile saline-moistened dressing, realign and splint the limb, and recheck pulses after each manoeuvre.

**Surgical**
Urgent operative debridement and irrigation of all dead and contaminated tissue, repeated as needed, then stabilisation with external fixation or intramedullary nailing.

**Surgical**
Early definitive soft-tissue coverage (closure, [skin](https://durgical.com/en/anatomy/skin/) graft or local or free flap) in a combined orthopaedic-plastic approach; vascular repair for type IIIC.

**Follow-up**
Nursing priorities: neurovascular checks of the limb, compartment syndrome surveillance, timing of antibiotic doses, wound and pin-site care, pain control and thromboprophylaxis.

## Complications

- Deep infection and chronic osteomyelitis
- Delayed union and non-union
- Compartment syndrome
- Vascular injury and limb loss (amputation)
- Tetanus and necrotising soft-tissue infection
- Fat embolism and venous thromboembolism

## Prognosis

Type I and II injuries usually heal well with prompt treatment. Infection and non-union rise sharply in type III injuries, and type IIIC carries the highest amputation rate. Early antibiotics, thorough debridement and early soft-tissue cover are the factors most linked to good outcomes.

## Prevention

- Road safety for motorcyclists: protective gear and speed control
- Workplace safety measures
- Up-to-date tetanus vaccination

## Test yourself

Think of the answer, then tap the question to see it.

## Which Gustilo-Anderson type is defined by an arterial injury needing repair?

Type IIIC, whatever the size of the wound.

## What is the most time-critical drug intervention in an open fracture?

Intravenous antibiotics as early as possible, ideally within the first hour, together with tetanus prophylaxis.

## Does an open wound rule out compartment syndrome in a tibial fracture?

No. Compartment syndrome can still occur, so pain on passive stretch and tense compartments must be monitored.

## What surgical step is essential before definitive fixation of an open fracture?

Thorough operative debridement and irrigation of all dead and contaminated tissue.

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## Related conditions

- [Tibial shaft fracture](https://durgical.com/en/conditions/tibial-shaft-fracture/)
- [Acute compartment syndrome](https://durgical.com/en/conditions/acute-compartment-syndrome/)
- [Osteomyelitis](https://durgical.com/en/conditions/osteomyelitis/)
- [Tetanus](https://durgical.com/en/conditions/tetanus/)
- [Major trauma (polytrauma): ATLS primary survey](https://durgical.com/en/conditions/major-trauma-atls-primary-survey/)
- [Popliteal Artery Injury](https://durgical.com/en/conditions/popliteal-artery-injury/)
- [Fat embolism syndrome](https://durgical.com/en/conditions/fat-embolism-syndrome/)
- [Necrotizing soft tissue infection (necrotizing fasciitis, gas gangrene)](https://durgical.com/en/conditions/necrotizing-soft-tissue-infection/)
- [Hypovolaemic shock](https://durgical.com/en/conditions/hypovolaemic-shock/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Open Fractures - OrthoInfo - AAOS](https://www.orthoinfo.org/en/diseases--conditions/open-fractures/) (American Academy of Orthopaedic Surgeons (OrthoInfo), 2026); [Clinical Guidance for Wound Management to Prevent Tetanus](https://www.cdc.gov/tetanus/hcp/clinical-guidance/index.html) (Centers for Disease Control and Prevention (CDC), 2024).

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Source: https://durgical.com/en/conditions/open-fracture/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/open-fracture/