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The laceration associated with an open fracture should not be closed in
the ED, even if the fracture is nondisplaced.
Patients with an open fracture should receive antibiotics as soon as
possible to minimize risk of infection.
Compartment syndrome associated with a fracture can occur in the
forearm, hand, leg, or foot, with the leg being the most common
location.
Fractures associated with compartment syndrome do not need to be
severe.
Pain out of proportion to the injury or increasing pain after analgesics,
especially with passive extension, is one of the earliest signs of
compartment syndrome.
Compartment syndrome may present shortly after the fracture is
sustained, or may occur after reduction and casting. Therefore,
neurovascular status must always be checked in the injured extremity
after casting.
Fasciotomy should be considered when clinical symptoms of
compartment syndrome are present and/or when compartment
pressures measured in the injured extremity are within 30 mm Hg of the
patient’s diastolic blood pressure or the mean arterial pressure.

Current Evidence
A fracture is considered to be “open” when the injury results in disruption of the
skin and underlying soft tissues overlying the fracture, thus providing a
communication between the fracture and the outside environment. The organisms
found to be contaminating an open fracture at the time of presentation do not
necessarily represent the microbes that will eventually cause infection; therefore,
wound cultures are of minimal utility. Most open fracture infections are caused by
gram-negative rods and gram-positive staphylococci; however, clinicians should
be mindful of a rising frequency of infections caused by methicillin-resistant
Staphylococcus aureus (MRSA). While there is consensus supporting the timing

of antibiotic administration to minimize risk of infection, there are variable
recommendations on the optimal regimen.
Children with compartment syndrome may present with only one associated
sign or symptom, with pain being the most common presentation. In one study of
compartment syndrome with tibial shaft fractures, adolescents (14 years and