With significant trauma, resuscitation and stabilization efforts are paramount. Type IIIa injuries have severe crushing soft tissue damage, type IIIb have a significant loss of tissue coverage, and type IIIc have significant loss of tissue with an associated vascular injury. Type III fractures are high-velocity injuries have wounds greater than 10 cm. Type II fractures are low to moderate energy injuries with wounds that are greater than 1 cm with moderate soft tissue and muscle damage. Gustilo-Anderson type I open fractures is a low energy injury with wounds less than 1 cm with minimal soft tissue damage. The wound should be examined thoroughly and characterized according to the Gustilo-Anderson classification system for open fractures as this will dictate initial treatment. The movement and neurovascular status of all involved limbs should be assessed to ascertain whether or not there is a possible nerve or vascular injury associated with the fracture. It should be noted that the wound may not lie directly over the fracture site. Once the patient has been stabilized, open fractures should be addressed emergently. These injuries are associated with symptoms of pain, deformity, swelling, and a wound that may be bleeding. The initial focus should be on assessing the status of the patient's airway, breathing, and circulation, and resuscitation measures should be implemented as necessary. The patient should be adequately undressed to evaluate for other significant, life-threatening injuries per advanced trauma life support protocol. Patients with open fractures have a reported history of trauma that is most commonly high velocity in nature. Open phalanx fractures are the most common open fractures accounting for more than 45% of all open injuries. The most common long bone fracture is the tibia and fibula at 11.2%. The highest incidence of open fractures in males is between ages 15 and 19 years at 54.5 per 100,000 persons per year, whereas the highest occurrence in females is at 53.0 per 100,000 persons per year between the ages of 80 and 89 years. The overall average age of occurrence is 45.5 years, but in general, the incidence declines in males and increases in females with age. The overwhelming majority of open fractures occur singularly, but patients may have more than one at a time. Crush injuries are the most prevalently associated with open, lower extremity fractures causing 39.5% of these cases. Motor vehicle accidents are the most common cause of open, lower extremity fractures and are responsible for 34.1% of these injuries. A 15-year review of epidemiologic factors of open fractures in adults, reports the incidence was 30.7 per 100,000 persons per year.
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