Injury, Int. J.

Care Injured 43 (2012) 891–897

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Injury
journal homepage: www.elsevier.com/locate/injury

The epidemiology of open fractures in adults. A 15-year review

Charles M. Court-Brown *, Kate E. Bugler, Nicholas D. Clement, Andrew D. Duckworth,
Margaret M. McQueen
Royal Infirmary of Edinburgh, Edinburgh EH16 4SA, United Kingdom

A R T I C L E I N F O A B S T R A C T

Article history: There is little information available about the epidemiology of open fractures. We examined 2386 open
Accepted 7 December 2011 fractures over a 15-year period analysing the incidence and severity of the fractures. The majority of open
fractures are low energy injuries with only 22.3% of open fractures being caused by road traffic accidents
Keywords: or falls from a height. The distribution curves of many open fractures are different to the overall fracture
Open fractures distribution curves with high-energy open fractures being commoner in younger males and low energy
Epidemiology open fractures in older females. The mode of injury and the different demographic characteristics
Lower extremity
between isolated and multiple open fractures are also discussed.
ß 2011 Elsevier Ltd. All rights reserved.

Introduction Materials and methods

Surgeons have had difficulty treating open fractures for several
millennia.1 In recent decades treatment has improved because of
improved surgical techniques, antibiotic use and more recently
because of improved soft tissue cover.2,3 However, these fractures
remain difficult to treat and they frequently result in considerable
morbidity for the patient and expense for the health system. Most
of the literature concerning open fractures has concentrated on the
management of high-energy fractures which have been treated in
Level 1 Trauma Centres, or their equivalent, in different countries.
The specialist nature of these hospitals means that they mainly
treat severe, high-energy injuries and they do not see the complete
range of open fractures. The other problem is that open fractures
are relatively uncommon with a recent study of fracture
epidemiology indicating that only 2.6% of 5271 fractures were
open.4 It has therefore been very difficult to document the
epidemiology of open fractures and there has been no previous
study of all open fractures in a large defined adult population.
We have analysed all in-patient and out-patient open fractures
in a defined adult population over a 15-year period. The study was
undertaken to investigate fracture epidemiology and to see which
fractures were associated with more severe injury. The modes of
injury were also examined and we have defined fracture incidence
distribution curves for most open fractures. We have also
examined the different demographic characteristics for patients
who present with isolated open fractures compared with multiple
open fractures.
* Corresponding author. Tel.: +44 0131 242 3516; fax: +44 0131 242 3467.
E-mail address: courtbrown@aol.com (C.M. Court-Brown).
Clinical information on all patients aged 15 years who
presented with open fractures on an in-patient or out-patient
basis to the Royal Infirmary of Edinburgh over the 15-year period
between 1995 and 2009 was collected and analysed. Clinical data
up to 2005 was collected prospectively with later data being
retrieved retrospectively from the hospital’s computerised data-
base. The Royal Infirmary of Edinburgh is the only hospital treating
orthopaedic trauma in the City of Edinburgh, Midlothian and East
Lothian. It also treats patients from adjacent areas and acts as a
secondary referral centre for complex fractures in the South East of
Scotland. However for the purpose of this study all patients
outwith the City of Edinburgh, Midlothian and East Lothian were
excluded from analysis although patients injured outside these
areas but resident in our catchment area were included. Paediatric
fractures, in children up to 12 years of age, are treated in a separate
paediatric hospital with 13- and 14-year-old patients being treated
in both the paediatric and adult hospitals. We have therefore
analysed the population aged 15 years. A review of the last
Census showed that the population 15 years in our catchment
area was 517,555.5
Basic epidemiological information was collected on all patients.
This included name, address, date of birth, gender, date of injury,
mode of injury, type of fracture, degree of soft tissue injury and
presence of other injuries. Information regarding the mode of
injury and presence of other injuries was unavailable in 71 (3.2%)
and 4 (0.05%) of patients respectively. The severity of the soft tissue
injury was assessed using Gustilo’s classification6,7 and informa-
tion about this was lacking in 7 (0.3%) of patients.
The severity of injury was assessed using the Injury Severity
Score (ISS)8 which was derived from the Abbreviated Injury Scale

0020–1383/$ – see front matter ß 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.injury.2011.12.007
892 C.M. Court-Brown et al. / Injury, Int. J. Care Injured 43 (2012) 891–897
(AIS)9 of each fracture. There is some debate about the relevant AIS
for open fractures as opposed to closed fractures but in this
analysis we have used an AIS of 3 for all long bone fractures, 2 for all
carpal, hindfoot, midfoot and metatarsal fractures and 1 for all
finger and toe phalangeal fractures. An AIS score of 1 was given for
all Gustilo Type I and II fractures and a score of 2 was given for all
Gustilo Type III fractures. Thus an isolated Gustilo Type I open
finger fracture was given a total AIS of 2 whereas a Gustilo Type IIIb
open tibial fracture was given an AIS of 13. The ISS was computed
by adding the squares of the three highest AIS scores in each
patient.
Each severe musculoskeletal injury was analysed to provide a
musculo-skeletal index (MSI). All fractures and severe soft tissue
injuries, such as ligamentous disruptions, dislocations, nerve
damage, vascular damage and tendon injuries were given a score
of 1 and the total used to provide an assessment of the degree of
musculo-skeletal injury. Minor joint sprains and soft tissue injuries
were excluded from analysis.
Results
In the 15 years of the study 2386 open fractures were treated
giving an incidence of 30.7/105/year. They occurred in 2206
patients with 2079 (94.2%) presenting with a single open fracture
and a further 127 (5.8%) presenting with between 2 and 7 open
fractures. The average age was 45.5 years. Analysis shows that
69.1% of the fractures occurred in males with an average age of 40.8
years and 30.9% occurred in females with an average age of 56.0
years. In males 10.2% of the fractures occurred in patients aged 65
years and 2.1% in patients aged 80 years. The equivalent figures
for females were 42.9% and 18.6%, respectively.
The overall fracture incidence distribution curves for open
fractures are shown in Fig. 1. This shows that in adult males the
highest incidence of open fractures occurs between 15–19 years
and that there is an almost linear decline with increasing age. The
incidence of open fractures in males aged 15–19 years was 54.5/
105/year compared to 23.3/105/year in the 90+ age group. In
females there is a unimodal distribution rising from 9.2/105/year in
the 15–19-year group to 14.6/105/year in the 50–59-year group.
Thereafter there is a rapid rise in incidence to 53.0/105/year in the
80–89-year group.
We calculated the fracture incidence curves for most of the
open fractures. There were insufficient fracture numbers to
calculate curves for open fractures of the scapula, proximal radius,
radial diaphysis, carpus and proximal femur. Fig. 2 shows the
previously published fracture incidence distribution curves for all
fractures10 and Table 1 shows a comparison of the open fracture
incidence distribution curves with the overall fracture curves.
Table 1 also shows the fracture distribution curves for the modes of
injury that cause open fractures.
Fig. 1. The fracture incidence distribution curves for male and female open
fractures. In this figure fracture incidence is expressed as n/105/year.
The prevalences, average ages and percentages of patients aged
65 and 80 years for each fracture type are shown in Table 2
which indicates that almost half of all open fractures involve the
fingers and that open fractures of the fingers, tibia and fibula, distal
radius, toes and ankle accounted for about three quarters of all
open fractures. Table 2 also shows that a number of open fractures
are very rare with 10 of the open fractures averaging less than 1 per
year in a very busy trauma unit. In 15 years there were no open
proximal radial fractures.
The severity of the different open fractures is shown in Table 3.
The prevalence of isolated open fractures together with the Gustilo
grade has been use to define the severity of the fracture and the ISS
and MSI have been use to define the overall injury suffered by the
patient. Overall 75.9% of patients had an isolated open fracture
with no other musculo-skeletal injury with 81.3% of open upper
limb fractures being isolated compared with 62.8% of lower limb
fractures. Overall 26.8% of open fractures were Gustilo Type III with
18.6% of upper limb fractures being Gustilo Type III compared with
42.6% of lower limb fractures. The overall average ISS was 7.2 with
the average ISS of patients with upper and lower limb fractures
being 5.1 and 11.1, respectively. Overall 7.2% of patients presented
with an ISS 16 with 2.5% and 13.8% of patients with upper and
lower limb open fractures having an ISS 16. Table 3 also shows
the principal modes of injury for each fracture.
Table 4 shows the epidemiology and factors determining
fracture severity for each mode of injury. There are differences
between open upper and lower limb fractures. Road traffic
accidents caused 34.1% of lower limb open fractures but only
6.5% of upper limb open fractures. The commonest cause of open
upper limb fractures was crush injuries which were responsible for
39.5% of upper limb fractures compared with 13.5% of lower limb
fractures. Falls from a standing height caused 18.0% of open upper
limb fractures and 22.1% of open lower limb fractures. Table 4 also
shows the commonest types of fracture resulting from each mode
of injury. Table 5 shows a comparison of the epidemiology of
patients who present with isolated open fractures compared with
those that present with multiple open fractures.
Discussion
This is the first comprehensive analysis of a large number of
open fractures in a defined population. There have been studies
detailing the presentation and treatment of patients with open
fractures but they have mainly involved high-energy open
fractures which present to specialist trauma centres. This fact,
together with the relative scarcity of open fractures, means that
useful epidemiological information is difficult to obtain. In
particular there has been very little data published regarding
low-energy open fractures or on open fractures in the elderly and
when one considers that in this study only 22.3% of open fractures
were caused by road traffic accidents or falls from a height and that
20.3% of the fractures occurred in the 65-year group it is obvious
that further information about low-energy open fractures and
open fractures in the elderly is required.
Fracture distribution
Fig. 1 shows the fracture incidence distribution curves for open
fractures. They are different from the overall fracture curves in
which there is a bimodal distribution in young and older males and
a unimodal distribution affecting older females.9 In open fractures
it is evident that it is younger males who are most affected and it
can be seen from Table 4 that it is younger males who tend to
sustain open fractures as a result of sport, falls from a height, road
traffic accidents and direct blows or assaults. In road traffic
accidents and falls from a height the average ages of males with
 C.M. Court-Brown et al. / Injury, Int. J. Care Injured 43 (2012) 891–897 893

Fig. 2. Previously published fracture distribution curves for all fractures.10 See Table 1.

open fractures were 36.3 and 36.2 years, respectively. In the overall
male fracture distribution curve there is a marked decline in
middle age which is not seen in open fractures and Fig. 1 shows
that there is an almost linear decline in incidence with increasing
age.
In females the open fracture incidence distribution curve is
similar to the overall fracture distribution curve but there is one
significant difference. The overall female distribution curve shows
a marked rise in incidence in the 50–59-year group, in the post-
menopausal period. In open fractures this increase occurs one
decade later and is therefore probably not just related to
osteoporosis but to increasing overall patient frailty which affects
the soft tissues as well as bone. In addition the ability to avoid
dangerous situations is compromised in older patients.11
Fig. 2 shows the fracture distribution curves that have been
shown to define all fractures9 and Table 1 shows a comparison of
the curves for all fractures with those of open fractures. In the open
fractures which are commonly caused by higher energy injuries,
such as fractures of the pelvis, femoral diaphysis, distal femur,
patella, proximal tibia, distal humerus and proximal ulna the
distribution changes to one which highlights the increased
frequency of open fractures in younger patients. Thus the
distribution curve for femoral diaphyseal fractures changes from
a type A curve, highlighting the fact that many older women
894 C.M. Court-Brown et al. / Injury, Int. J. Care Injured 43 (2012) 891–897

Table 1
The distribution curves of open fractures compared with those, previously obtained, for all fractures. The distribution curves for the different modes of injury are also shown.
Diagrams of the different curves are shown in Fig. 2.

Upper limb Axial skeleton and upper limb

All fractures Open fractures All fractures Open fractures

Fracture incidence distribution curves

Clavicle G C Pelvis E C
Proximal humerus F H Femoral diaphysis A B
Humeral diaphysis H F Distal femur E A
Distal humerus E G Patella F A
Proximal ulna F H Proximal tibia H A
Ulna diaphysis H D Tibia and fibular diaphyses A A
Radius and ulna diaphyses A G Distal tibia D D
Distal radius and ulna A E Ankle A E
Metacarpus B A Talus C C
Finger phalanges B A Calcaneus G G
Midfoot C B
Metacarpus A A
Toe phalanges C C
Modes of injury (open fractures)
Crush injuries A Direct blows or assaults B
Falls from standing height F Falls from height C
Road traffic accidents G Falls down stairs F
Cutting injuries B Sport C

present with closed femoral fractures, to a type B curve which
shows that open femoral fractures are predominantly seen in
young men. Other fractures such as those of the distal femur,
patella and proximal ulna change from a curve showing a unimodal
distribution affecting older patients to a to a bimodal distribution
where younger patients are affected more commonly.
In lower energy open fractures it can be seen that there are a
number of changes as more elderly patients are affected. Thus,
fractures of the metacarpals and finger phalanges covert from a
unimodal curve affecting younger patients to a bimodal curve
where elderly females are also affected. In both distal radial and
ankle fractures there is a change from a type A curve in all
fractures to a type E curve in open fractures emphasising the
frequency of open fractures in elderly females and further
analysis shows that 37.3% of open distal radial fractures and
20.8% of open ankle fractures occur in females 80 years. There
are a number of fractures in which the distribution curve does
not change. These tend to be fractures which mainly occur in
young patients anyway. There was no change in the curves for
the different foot fractures although whilst closed talar fractures
affect both young males and females the open talar fracture is the
province of young males!

Table 2
The basic epidemiological data for the open fractures treated between 1995 and 2007.

All patients Males Females

n % Age (year) 65 year (%) 80 year (%) n % n %

Finger phalanges 1090 45.7 43.9 13.4 4.2 858 52.0 232 31.5
Tibia and fibula 267 11.2 43.3 18.0 6.7 179 10.9 88 11.9
Distal radius 184 7.7 67.0 67.4 30.4 43 2.6 141 19.1
Toe phalanges 170 7.1 41.9 11.8 1.8 112 6.8 58 7.9
Ankle 126 5.3 56.7 42.9 14.3 54 3.3 72 9.8
Metacarpus 104 4.4 34.8 7.7 4.8 94 5.7 10 1.4
Proximal ulna 51 2.1 47.9 29.4 7.8 35 2.1 16 2.2
Metatarsus 49 2.1 42.2 14.3 8.2 39 2.4 10 1.4
Patella 46 1.9 36.5 10.9 4.3 33 2.0 13 1.8
Radius and ulna 44 1.8 40.9 20.5 6.8 39 2.4 14 1.9
Femoral diaphysis 43 1.8 31.8 4.7 2.3 33 2.0 10 1.4
Distal tibia 31 1.3 48.1 22.6 3.2 18 1.1 13 1.8
Proximal tibia 29 1.2 47.7 24.1 10.3 17 1.0 12 1.6
Distal femur 25 1.0 40.6 20.0 12.0 12 0.7 13 1.8
Ulna diaphysis 25 1.0 43.2 16.0 0 17 1.0 8 1.1
Calcaneus 18 0.8 43.7 22.2 0 14 0.8 4 0.5
Distal humerus 18 0.8 48.5 33.3 11.1 14 0.8 4 0.5
Humeral diaphysis 16 0.7 51.3 37.5 12.5 12 0.7 4 0.5
Proximal humerus 12 0.5 56.0 25.0 8.3 6 0.4 6 0.8
Clavicle 9 0.4 44.0 11.1 11.1 7 0.4 2 0.3
Pelvis 7 0.3 40.9 14.3 0 6 0.4 1 0.1
Talus 6 0.3 31.3 0 0 5 0.3 1 0.1
Radial diaphysis 5 0.2 44.0 20.0 0 4 0.2 1 0.1
Midfoot 5 0.2 28.2 0 0 5 0.3 0 0
Scapula 2 0.08 29.5 0 0 2 0.1 0 0
Proximal radius/ulna 2 0.08 71.0 50.0 50.0 1 0.06 1 0.1
Proximal femur 1 0.04 45.0 0 0 1 0.06 0 0
Carpus 1 0.04 20.0 0 0 1 0.06 0 0
Proximal radius 0 0 0 0 0 0 0 0 0
Total 2386 100 45.5 20.3 7.2 1649 100 737 100
 C.M. Court-Brown et al. / Injury, Int. J. Care Injured 43 (2012) 891–897 895

Table 3
The severity of injury associated with each open fracture type. See text for details. The principal modes of injury for each fracture type are shown.

Fracture severity Injury severity score Soft tissues Principal modes of injury

Isolated fracture (%) MSI Average ISS ISS 16 Gustilo type III (%)

Finger phalanges 84.5 1.3 2.9 0.5 24.9 55.4% crush, 31.5% cut
Tibia and fibula 71.9 1.7 13.5 15.3 44.6 46.1% rta
Distal radius 78.3 1.3 10.9 6.5 2.2 71.2% fall
Toe phalanges 67.6 1.8 3.3 3.5 17.1 45.3% crush
Ankle 86.5 1.3 12.6 5.5 47.6 54.8% fall
Metacarpus 45.2 1.7 5.7 1.9 10.6 55.8% direct blow or assault
Proximal ulna 82.3 1.5 11.3 5.9 13.7 43.1% fall
Metatarsus 22.4 3.6 7.6 0 57.1 40.8% crush, 36.7% rta
Patella 58.7 1.9 9.1 19.5 30.4 58.7% rta
Radius and ulna 86.4 1.2 10.8 6.8 4.5 43.2% fall, 25% rta
Femoral diaphysis 37.2 2.7 18.1 39.5 65.1 53.5% rta
Distal tibia 83.9 1.4 13.1 12.9 45.2 51.6% fall height
Proximal tibia 48.3 2.1 14.3 20.7 58.6 51.7% rta
Distal femur 25.0 2.7 18.6 40.0 72.0 80.0% rta
Ulna diaphysis 76.0 1.5 12.0 8.0 16.0 28.0% fall. 28.0% direct blow or assault
Calcaneus 22.2 2.7 15.0 50.0 77.8 72.2% fall height
Distal humerus 72.2 1.5 13.6 11.1 44.4 33.3% fall, 33.3% rta
Humeral diaphysis 62.5 1.8 17.5 37.5 18.7 50% rta
Proximal humerus 91.6 1.1 10.2 0 8.3 41.7% fall, 33.3% rta
Clavicle 77.8 1.7 6.4 11.1 0 33.3% fall
Pelvis 57.1 2.0 19.0 42.9 0 42.8% fall height
Talus 50.0 3.0 10.2 33.3 50.0 50% rta
Radial diaphysis 40.0 1.6 12.4 20.0 20.0 40% fall
Midfoot 20.0 5.8 14.0 40.0 80.0 40% rta, 40% fall height
Scapula 100.0 1.0 13.0 50.0 0 50% direct blow/assault, 50% fall height
Proximal radius/ulna 50.0 2.0 25.5 50.0 0 50% fall, 50% fall height
Proximal femur 0 2.0 10.0 0 0 100% rta
Carpus 0 6.0 8.0 0 0 100% cut
Total 75.9 1.5 7.2 6,5 26.8

A review of the fracture distribution curves for the different modes from a standing height and falls down stairs mainly affect older
of injury (Table 1) shows what one might expect. Open fractures patients. Bimodal distributions are seen in crushing injuries and road
caused by cutting injuries, direct blows or assaults, falls from a height traffic accidents where males show a bimodal distribution and
or sport affect younger patients whereas fractures caused by falls females show a unimodal distribution affecting older females.

Table 4
The epidemiological data for each mode of injury. The ‘Other’ category contains 14 high-energy fractures from blast injuries, gunshots and aeroplane and train crashes. In this
Table fracture incidence is expressed as n/106/year. The main fracture types caused by the different modes of injury are also shown.

Mode of injury Numbers, prevalence and Age (years) Gender Injury severity Fracture types
incidence

n % n/106/year Average age 65 year (%) 80 year (%) M/F ISS ISS16 MSI Gustilo
(years) (%) type III (%)

Crush 728 30.5 93.8 44.4 9.9 3.0 77/23 3.1 0.3 1.3 24.3 83.0% Finger phalanges
10.6% Toe phalanges
2.7% Metatarsus
Fall 461 19.3 59.4 64.4 60.9 24.1 35/65 8.8 0.5 1.1 14.1 28.4% Distal radius
15.2% Finger phalanges
15.0% Ankle
Rta 379 15.9 48.8 40.0 14.0 4.2 69/31 14.0 26.1 2.5 50.7 32.5% Tibia and fibula
9.0% Finger phalanges
7.1% Patella
Cut 261 10.9 33.6 44.4 11.1 1.9 88/12 3.5 0 1.5 34.9 83.5% Finger phalanges
9.6% Toe phalanges
2.3% Metacarpus
Direct blow 197 8.3 25.4 35.2 5.1 2.4 87/13 5.1 0.5 1.2 9.6 38.1% Finger phalanges
29.4% Metacarpus
7.1% Tibia and fibula
Fall height 154 6.5 19.8 37.2 7.1 1.3 77/23 14.5 28.6 2.3 40.9 18.2% Tibia and fibula
15.6% Distal radius
10.4% Distal tibia
Sport 85 3.6 10.9 29.2 1.2 0 82/18 7.0 0 1.2 14.1 35.3% Finger phalanges
21.2% Tibia and fibula
8.2% Ankle
Fall stairs 31 1.3 4.9 62.3 54.8 25.8 32/68 10.3 3.2 1.2 9.7 29.0% Distal radius
22.6% Ankle
19.4% Tibia and fibula
Other 14 0.6 1.8 31.2 0 0 79/21 6.8 0 2.9 42.8 35.7% Finger phalanges
35.7% Metacarpus
14.3% Forearm
Total 2386 100 307.3 45.8 20.3 7.2 69/31 7.2 6.4 1.5 26.8
896 C.M. Court-Brown et al. / Injury, Int. J. Care Injured 43 (2012) 891–897

Table 5
The epidemiology of isolated open fractures compared with multiple open fractures.
Separate epidemiological data is given for patients who presented with 2, 3 and 4–7
open fractures.
injuries and will be discussed in the next section. A number of open
fractures are extremely uncommon and will rarely be seen outside
major trauma hospitals.

Number of open fractures

Fracture severity
1 >1 2 3 4–7

Patient numbers 2079 127 94 22 11 Tables 2 and 3 show that a number of very uncommon open
Prevalence (%) 94.2 5.8 4.3 1.0 0.5 fractures present with a high ISS and MSI and a high prevalence of
Incidence (n/106/year) 267.7 16.4 12.1 2.8 1.4 Gustilo III fractures. Examples are open fractures of the talus and
Gender (%) 68/32 74/26 77/23 68/32 82/18
midfoot. These fractures are usually caused by high-energy injury
Average age (years) 45.9 43.0 44.8 41.1 38.9
65 years (%) 21.3 13.7 16.0 9.1 9.1 injuries and it seems likely that a number of open fractures are rare
80 years (%) 7.6 4.9 6.4 4.6 0 because they are often fatal. There were no open spinal fractures
Gustilo III (%) 22.4 56.4 41.5 72.7 88.7 and only 2 open scapular fractures. Presumably the chest damage
Average ISS 6.7 10.0 8.9 13.3 9.7 associated with many open scapular fractures often precludes
ISS 16 4.0 23.1 36.4 0 11.3
survival. The same is probably true of many open pelvic fractures.
MSI 1.2 3.4 2.7 3.9 5.4
Non-hand/forefoot 42.2 30.9 32.4 39.4 13.2 Tables 2 and 3 show that open pelvic fractures are relatively rare
fractures (%) with an incidence of 0.9/105/year. We were somewhat surprised
that there were no Gustilo III open pelvic fractures in our study and
that none of the open pelvic fractures occurred as a result of road
Fracture types traffic accidents although there were 4 pelvic fractures caused by
road traffic accidents between 1988 and 1994. There is no doubt
Tables 2 and 3 show the epidemiology and severity of the that road safety has improved in recent years but it is important to
different open fractures. Table 2 shows that open fractures of the point out that, as yet, the United Kingdom has no organised trauma
fingers, tibia and fibular diaphyses, distal radius, toes and ankle system, as is seen in the USA and other European countries, and it
account for about 75% of the all the open fractures that will present may be that many patients with severe open pelvic fractures do not
to orthopaedic surgeons. Open finger fractures are by far the survive to get to hospital.
commonest open fracture with an incidence of 14.0/105/year. They Open lower limb fractures tend to be more severe than open
tend to be isolated low-energy injuries. Their average MSI of 1.3 is, upper limb fractures. The overall ISS and MSI for upper limb fractures
together with the distal radius and ankle fractures, the lowest seen were 5.1 and 1.3, respectively compared with 11.1 and 1.9 for open
in the commoner open fractures and only 0.05% of the patients had lower limb fractures. Table 3 shows that open fractures of the
an ISS 16. Tibial diaphyseal fractures have an overall incidence of femoral diaphysis, distal femur, patella, proximal tibia, tibial
3.4/105/year and tend to occur in younger males. However, their diaphysis, distal tibia, talus and calcaneus tend to be associated
type A distribution curve indicates that open tibial fractures will with the highest ISS and MSI and the highest prevalence of Gustilo III
also be seen in older females and, in fact, 39.8% of females who fractures and it also shows that the majority of these are caused by
presented with open tibial fractures were 65 years. Surgeons road traffic accidents or falls from a height. The highest prevalence of
have always found Gustilo type III open tibial fractures difficult to Gustilo III fractures is seen in fractures of the hindfoot and midfoot
treat and Table 3 shows that about 45% of patients had Gustilo type although the incidence of these fractures is only 0.4/105/year.
III open tibial fractures. Further analysis showed that 51.3% of the Analysis of the mode of injury shows that only 9.6% of open
Gustilo Type III fractures were Gustilo IIIa, 45.4% were IIIb and 3.4% upper limb fractures were caused by road traffic accidents or falls
were IIIc. Gustilo Type III open fractures have a type A distribution from a height compared with 46.6% of open lower limb fractures.
curve with the average male and female ages being 35.7 and 57.3 However open distal humeral and humeral diaphyseal fractures
years, respectively. The importance of open fractures in the elderly tend to be associated with a higher ISS and MSI and a higher
is highlighted by the fact that 9.3% of all Gustilo IIIb open tibial prevalence of Gustilo III fractures than other open upper limb
fractures occurred in patients aged 65 years and that 80% were fractures despite the fact that over 33% of these fractures occurred
female. in patients aged 65 years. Overall 58.8% of these fractures were
Open distal radial fractures have an incidence of 2.4/105/year caused by road traffic accidents or falls from a height and it seems
and tend to occur in older patients. Table 2 shows that they have likely that these fractures occur in the fitter elderly.
the highest average age of all open fracture types and >30% occur Table 4 shows that falls from a standing height are the second
in patients 80 years. Only 2% presented with Gustilo type III commonest cause of open fractures. It also shows that 60% of the
fractures and almost 80% were isolated injuries with only 6.5% of patients are 65 years and that they had an average age of 60.6
patients presenting with an ISS 16. Table 3 shows that as with years. However the 61% of patients who had open upper limb
closed fractures open fractures of the toe phalanges usually occur fractures had an average age of 66.8 years compared with the 39%
in younger patients. They have an incidence of 2.2/105/year and who had open lower limb fractures who had an average age of 58.9
only 17.1% were associated with severe soft tissue injuries. The years. Open fractures following falls tend to be isolated and not
average ISS is low and the higher MSI is because open toe fractures particularly severe. Only 0.7% of patients who had an open fall-
are often multiple. Open ankle fractures have an incidence of 1.6/ related upper limb fracture had an ISS 16 and the average MSI
105/year and have a have a similar epidemiology to open distal was 1.2. Similar values were seen in open lower fractures where
radial fractures although fewer patients  80 years presented with 1.1% had an ISS 16 and the average MSI was 1.1. There was
ankle fractures. The other major difference between open distal however a difference in the prevalence of Gustilo III open fractures
radial and ankle fractures is that 47.6% of the open ankle fractures which occurred in 3.2% of open upper limb fractures and 31.1% of
were Gustilo type III. However, 86.7% of the Gustilo type III open open lower limb fractures.
ankle fractures were IIIa in severity and simply associated with a
large medially located open wound, usually associated with a Multiple open fractures
dislocation.
Tables 2 and 3 also provide epidemiological details for other less One hundred and twenty-seven (5.8%) of patients presented
common open fractures. A number of these tend to be high-energy with multiple open fractures. Table 5 shows that these patients
 C.M. Court-Brown et al. / Injury, Int. J. Care Injured 43 (2012) 891–897
tend to be more seriously injured and that they present with a
higher ISS and MSI and a prevalence of Gustilo III fractures. They
also tend to be younger. However it should be noted that 77 (62.2%)
of these patients presented with multiple hand or forefoot open
fractures usually as a result of crushing or cutting injuries. This is
the reason why Table 5 shows that patients who present with more
than 3 open fractures tend to less severely injured but to have a
high average MSI and a high prevalence of Gustilo III injuries. Only
13.2% of open fractures in this group did not involve the hand or
forefoot.
Of the high-energy open lower limb fractures that have already
been listed the highest prevalence of multiple open fractures was
seen in the talus (50%), distal femur (44%), calcaneus (33.3%),
patella (23.9%), proximal tibia (20.7%) and femoral diaphysis (14%).
Despite the high prevalence of multiple open fractures in the femur
and hindfoot it is interesting that the prevalence in tibial
diaphyseal and distal tibial fractures was only 6.4% and 3.2%,
respectively. In the upper limb 12.5% of patients with humeral
diaphyseal fractures, 9.1% of patients with distal humeral fractures
and 3% of patients with distal radial fractures presented with
multiple open fractures again illustrating the greater severity of
open lower limb fractures.
We believe that this paper will help quantify the problem of
open fractures. The fracture incidence figures in Table 4 can be
used to predict how many open fractures may be seen in a specific
community. Thus in the United Kingdom road traffic accidents will
cause about 2,500 open fractures per year in patients aged 15
years of which about 810 will be open tibial fractures. Falls will
cause about 3000 open fractures each year of which about 860 will
be distal radial fractures. We believe that our data will be similar to
897
that of other developed countries although we accept that it will be
less relevant in countries with different social conditions.
Conflict of interest statement
All authors declare that no conflicts of interest this paper.
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