As a human being, I never want to see anyone get injured, but as a medical professional, if no one ever did, I would be out of a job! So sometimes, injuries are fun to see, as it presents a challenge for determining the best option for treatment. About a week ago a patient came into the Emergency Room with a Type II Gustillo Anderson fracture of the 1st, 2nd, and 3rd toes after a car jack slipped and landed onto his foot. (Hopefully, you’ll understand what all that means by the conclusion of today’s Blog) It wasn’t much fun for the patient, and I felt bad for the guy as he was a really nice man, but getting to treat his injury was fun!
An open fracture is any fracture that is accompanied by a break in the skin in the area of the boney fracture. The broken bone does not necessarily need to be protruding from the skin, but it often will be. These types of injuries are not exclusive to the lower extremity, but when found there are typically associated with high-energy injuries. Meaning any injury where there is a strong force or impaction as would be the case in falls from a height or motor vehicle accidents for example, or in the case of this patient, direct force to the foot from the car jack.
There are two main ways to look at an open fracture: was the break in the skin caused by something from the outside penetrating inward, or was the break in the skin caused by a bone from inside the body pushing outward? In terms of treatment and managing the fracture site, the answer to this makes little difference, but if the break in the skin was caused by something outside (like a nail or bullet) penetrating inward, you would want to consider whether the patient has an updated tetanus vaccination and what bacteria are commonly associated with the type of object that has penetrated the skin.
If you haven’t picked up on it yet, in the medical profession we love to classify things! Some of our classification systems make little sense, but it gives us a way to communicate with our colleagues in a succinct manner. For open fractures, the classification system used most often is the Gustillo and Anderson Classification. It evaluates open fractures based on soft tissue coverage and injury to blood vessels, muscles, and/or nerves. The classification is as follows:
Type I: An open fracture less than 1cm in size with little soft tissue involvement and no crush of the bone.
Type II: An open fracture that is greater than 1cm in size with minimal soft tissue damage.
Type III: An open fracture that is greater than 5cm in size with extensive soft tissue damage including damage to muscle, nerve, and blood vessels.
Open fractures are typically surgical emergencies from a Podiatric Medicine standpoint, meaning we would like to take the patient to the Operating Room within the first 24 hours. Type III injuries would be taken to the operating room sooner than a Type I injury. The goal in taking these patients for a surgical procedure is to clean out the soft tissue eliminating as much dirt and bacteria as possible, to reduce/realign the fracture fragments into their correct “pre-injury” position, and to close the skin if possible preventing further infection. If all the goals of surgical intervention are met, it will help decrease the risk of further tissue damage as well as decrease swelling, pain, and bacterial spread, getting the patient on the road to recovery!
If we revisit the patient I saw in the ER last week, we can recall that he had a Gustillo-Anderson Type II injury. If we refer to the classification system, we know that the open part of the injury along the digits was larger than 1cm with minimal soft tissue damage. His injury was an “outside to in” type injury, but luckily, the car jack did not break through his shoe, thus there was no foreign body present. He was given a broad-spectrum antibiotic (to cover the most common types of bacteria) and was taken to the OR the following day. One of the bones in the big toe suffered a crush injury and had very little soft tissue coverage, meaning it was in many small pieces and would have been difficult to approximate the skin edges, thus the bone was removed. The bones within the 2nd and 3rd toes had one fracture line each, so they were reduced and the soft tissue coverage over them was adequate, thus they were closed.
Open fractures are not something we see on a daily basis, and certainly can be detrimental to the patient depending on the severity of the injury, but they do provide a welcomed challenge to the Podiatric Surgeon!