A foot fracture that has broken bone that is exposed to the environment is known as an “open fracture”. Open fractures of the foot are treated differently than closed fractures due to the risk of infection.
Open fractures can occur from tiny wounds with an underlying broken bone or from serious crush injuries that involve extensive skin and vascular damage with multiple bone fractures.
It’s important to understand how open fractures are treated.
In this article, we’ll discuss the management of open fractures of the foot in detail.
Let’s dive in…
What Causes Open Fractures?
Open fractures of the foot are often caused by high-velocity crush injuries. Open fractures can also occur from sporting injuries, falls from heights, and twisting injuries of the ankle/foot. Any injury that causes damage to the soft tissue structures with bone exposure is considered an open injury.
What Are the Types of Open Fractures?
Open fractures are classified into types. This helps identify the extent of the injury and helps your doctor decide how to treat the fracture.
If the open fracture is clean and with a foot wound that is less than 1cm long, it is considered a Type 1 fracture.
If the open fracture has a foot wound that is larger than 1cm it is considered a Type 2 fracture.
If the wound is large with extensive soft tissue/bone damage and possible arterial damage, it is considered a Type 3 fracture.
For a full list of open fracture types, check out this table published by K. Baldwin in the Journal of Children’s Orthopaedics.
How Common Are Open Fractures of the Foot?
Open fractures of the foot are rare. A study done by C. Court-Brown in Foot and Ankle International studied 530,000 adults over 23 years. In those 23 years, 348 open fractures were treated. Of those, 69% of open fractures occurred in the forefoot (1).
What Is the Most Common Open Fracture in the Foot?
Open phalanx fractures are the most common open fractures accounting for more than 45% of all open injuries (2). The “phalanx” is the toe bone in your foot. Toes are especially vulnerable to injury and are a common location for open fractures.
What Are the Symptoms of an Open Fracture in the Foot?
- Severe pain in the foot
- Foot swelling
- Presence of a wound with bone visible
- Burning/tingling pain or complete numbness of the foot
- Deformity of the foot (dislocation)
- Bleeding from the wound
- Inability to bear weight on the foot
- Blue/purple discoloration of the foot secondary to injury to the blood supply
What Should You Do if You Have an Open Fracture?
If you are involved in a traumatic injury, you should immediately stop moving your foot and sit down. If you have a crush injury with fractures in your foot, moving and bearing weight on your foot can make the injury worse.
You should use a bandage to apply direct pressure on the wound. This will help control bleeding. You or someone near you should call 911 right away. An ambulance will take you to the Emergency Room to be treated.
Avoid icing the open fracture. If the blood supply to your foot is disrupted from the injury, ice can further worsen the condition because ice constricts the blood vessels.
What Is the Treatment for an Open Fracture of the Foot?
Antibiotic Therapy for Open Fractures
Antibiotic therapy should be started as soon as a person is diagnosed with an open fracture. The earlier you can get to the hospital to receive antibiotics, the better.
All open fractures are contaminated, however antibiotic therapy can help prevent extensive infection.
Staphylococcus aureus is a common organism that is present in foot infections. As long as there is no allergy, Cephalosporin antibiotics are given for open fractures Type 1-3.
For open fractures with larger wounds that are extensively contaminated (Type 3 fractures), aminoglycoside antibiotics are generally added to cover gram-negative bacteria.
If the open injury occurred on a farm, there is a higher risk for Clostridium perfringens infection, so Penicillin G would be added to the antibiotic regimen in this case.
Antibiotics should be given immediately in the Emergency room, and are generally continued for 2-3 days after surgery if the open fracture requires surgical repair.
The ideal time that antibiotics should be given to prevent infection is less than 3 hours (3).
Tetanus and Open Fractures
Clostridium tetani is a gram-positive bacteria species that when present in the body can produce severe muscle contracture and pain.
This bacteria is present in the environment, in soil, and even in human and animal feces. When you sustain an open fracture, you are at higher risk of being infected with this bacteria due to the nature of the injury.
Anyone with an open fracture who has not had tetanus toxoid immunization in the past 5 years should be given a tetanus toxoid booster. If the wound is dirty, tetanus immune globulin should be given.
If it’s been greater than 10 years since you’ve had a tetanus immunization, both the toxoid and immune globulin should be given.
Check out CDC recommendations on tetanus protocol.
Management of Open Fractures
When you are in the emergency room, your doctor will obtain a history and do a whole-body physical exam.
Your doctor will check your vitals and order blood work to make sure there is no further damage to your body outside of your foot.
Your doctor will prescribe antibiotics and pain medication to help keep you comfortable. If there is a small wound with mild contamination, your doctor will gently clean the wound of any debris.
Radiographs of the foot will be ordered to assess the fracture.
If your doctor wants a more detailed view of your fracture, a CT scan will be ordered. A CT scan can help provide detailed images of the fracture pattern and cortical bone.
Your doctor will be looking to see if the foot fracture is non-displaced (broken but in proper alignment), displaced (broken and shifted), or comminuted (fracture fragment in more than two pieces).
Your doctor will identify the fracture site and determine whether the fracture needs to be stabilized immediately.
For instance, in the case of a dislocated toe fracture or even an ankle fracture, your doctor can reduce the deformity using closed reduction and splint the fracture in the proper position.
Closed reduction of a fracture can help realign the fracture fragments and prevent vascular injury.
Check out this video by Larry Mellick on how a closed reduction of the ankle is performed.
Closed reduction whenever possible with splinting is helpful until your doctor can take you into the operating room. The closed reduction provides stability to the fracture site and prevents further damage from occurring.
If the open fracture is minor, you may be discharged with close monitoring with your foot doctor afterward.
You will need to see your foot doctor in the office every 1-3 weeks to ensure appropriate fracture healing and wound healing.
Surgery for Open Fractures
Open fractures that are extensively contaminated require surgery.
Your surgeon will remove all the dead dirty tissue that is present at the fracture site. Your surgeon will irrigate the fracture site using normal saline solution via a pulse irrigator. This is effective in helping clean the open fracture site.
If there are fractures present that need to be stabilized your doctor will stabilize these fractures using surgical pins or an external fixator.
An external fixator uses pins and rods in the bone to help stabilize the fracture. The pins and rods connect to a stabilizing structure outside of the body. An external fixator is a good choice if the fracture site is infected.
Once the infection is treated and the fracture site is stable, your doctor will return to the operating room at a later date and stabilize the fracture using plates and screws if needed.
If there is extensive soft tissue damage, your doctor may use skin grafts/muscle flaps.
If there is arterial damage, a vascular surgeon may be consulted for repair.
If a fracture is repaired, you will need to stay off of your foot for a minimum of 6-8 weeks in a splint/cast until the bone heals. The bone could take longer to heal depending on the fracture, and the person’s medical history. Full recovery can take anywhere from 6 months to 1 year.
Sometimes, there is extensive damage to the foot with no chance of repair. In this case, your doctor may recommend amputating the affected portion of the foot.
Open fracture treatment involves a team approach and involves a Podiatrist/Orthopedic surgeon, Vascular Surgeon, Infectious Disease physician, Plastic Surgeon, and wound care team.
What Happens if an Open Fracture Is Not Treated?
If an open fracture is not treated, there is a high chance of bone infection. Bone infections may require IV antibiotics and can result in amputation. Untreated open fractures can also cause chronic pain and arthritis due to the fracture healing improperly.
Conclusion
In conclusion, open fractures of the foot are very serious injuries and should be taken as such. If you sustain an injury to the foot and suspect that you may have an open fracture, it’s important to go to the emergency department immediately. Treating open fractures quickly can help optimize positive outcomes.
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References
- Court-Brown C, Honeyman C, Bugler K, McQueen M. The spectrum of open fractures of the foot in adults. Foot Ankle Int. 2013 Mar;34(3):323-8.https://pubmed.ncbi.nlm.nih.gov/23520288/#:~:text=Conclusions%3A%20Open%20foot%20fractures%20are,of%20the%20midfoot%20and%20hindfoot.
- Sop JL, Sop A. Open Fracture Management. 2021 Aug 14. In: StatPearls Treasure Island (FL): StatPearls Publishing; 2022 Jan–.https://pubmed.ncbi.nlm.nih.gov/28846249/
- Cross WW 3rd, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop. 2008 Oct;42(4):377-86. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2740354/
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- Penn-Barwell, J. G., Murray, C. K., & Wenke, J. C. (2012). Early antibiotics and debridement independently reduce infection in an open fracture model. The Journal of Bone and Joint Surgery. British volume, 94(1), 107-112.https://online.boneandjoint.org.uk/doi/full/10.1302/0301-620X.94B1.27026
- Sexton, S. E. (2014). Open fractures of the foot and ankle. Clinics in Podiatric Medicine and Surgery, 31(4), 461-486.https://www.podiatric.theclinics.com/article/S0891-8422(14)00047-0/fulltext
- Bartow‐McKenney, C., Hannigan, G. D., Horwinski, J., Hesketh, P., Horan, A. D., Mehta, S., & Grice, E. A. (2018). The microbiota of traumatic, open fracture wounds is associated with mechanism of injury. Wound Repair and Regeneration, 26(2), 127-135.https://onlinelibrary.wiley.com/doi/abs/10.1111/wrr.12642
- Rosario Saccomanno, D. P. M., & Kalmar, M. S. (2020). Management of an open crush fracture to the foot from a lawnmower injury: A case report.http://faoj.org/wp-content/uploads/2021/01/FAOJ_13.4.14.pdf
- Hong, C. C., Nashi, N., Kuan, W. S., Teh, J. W. D., & Tan, K. J. (2015). Forklift-related crush injuries of the foot and ankle. Foot & Ankle International, 36(7), 806-811.https://journals.sagepub.com/doi/abs/10.1177/1071100715576486
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