Ga'i (Fa'afu'a) Tatala, Tausiga o Ponaivi Fa'aalia, ma Ma'a¶

An open fracture (historically called a compound fracture) occurs whenever a broken bone communicates with the outside environment through a break in the skin and underlying soft tissues. While many open fractures present dramatically with a jagged white or blood-stained spear of bone visibly poking out through the skin, an open fracture also exists whenever a bone fragment pokes out at the moment of impact and immediately slips back underneath the skin, leaving only a small, dark, oozing puncture hole right over the fracture site.

Every open fracture is a time-critical orthopedic surgical emergency for three reasons: severe external and internal hemorrhage, direct bacterial contamination of the bone marrow cavity leading to deep bone infection (osteomyelitis) and non-union, and entrapment or kinking of the adjacent major artery and nerves threatening limb survival. Knowing how to control bleeding without pressing directly down on a sharp protruding bone shard, why you must never attempt to push an exposed bone end back under the skin, how to protect exposed bone from drying out with a sterile saline-moistened dressing, and how to perform a distal Pulse, Motor, and Sensation (PMS) check before and after splinting preserves both the limb and the patient's life.

Fai nei loa¶

1. Call your local emergency number immediately and request Advanced Life Support (ALS) paramedics. Dial 911 in the United States and Canada, 112 across the European Union, 999 in the United Kingdom, 000 in Australia, or check the directory of numera fa'afuase'i.
2. Control life-threatening external bleeding first without pushing down on the protruding bone. If bright red blood is spurting or pouring from the limb, apply a commercial windlass tourniquet 5 to 7 centimeters (2 to 3 inches) above (proximal to) the open fracture wound (never directly over the fracture site or over a joint). For steady venous or bone-marrow oozing, press sterile gauze pads firmly against the edges of the wound around the base of the bone or build a bulky doughnut/twin-roll ring pad around the protruding bone so you never grind the sharp bone end into nerves and arteries.
3. NEVER try to push a protruding bone fragment back inside the wound and NEVER scrub or pour antiseptics into the bone. Shoving a dirty bone end back beneath the skin drags soil, clothing fibers, and skin bacteria deep into the sterile medullary canal of the bone and risks slicing the adjacent artery or nerve in half.
4. Cover the exposed bone and open wound with a large sterile dressing moistened with sterile normal saline (0.9% sodium chloride) or a clean dry sterile trauma pad. Keeping exposed bone cortex and periosteum covered with a sterile saline-dampened pad (topped with a dry outer bandage) prevents the living outer bone cells from drying out and dying while blocking airborne bacteria.
5. Check distal circulation, sensation, and movement (the PMS check) below the fracture BEFORE and AFTER splinting. Gently feel for the distal pulse (radial pulse at the wrist or dorsalis pedis/posterior tibial pulse at the foot), check capillary refill and skin warmth/color in the fingers or toes, and ask if the person can feel light touch and wiggle their fingers or toes.
6. Immobilize the limb in the exact position found by splinting the joint above and the joint below the fracture, and keep the patient strictly NPO (nothing by mouth) and warm. Only if the lower limb is grossly angled AND the foot or hand below the break is cold, pale/bluish, and completely pulseless, and paramedics are more than 15 to 30 minutes away, should a trained responder apply gentle longitudinal traction to align the limb enough to restore blood flow.

Laau fa'ai'uga mo fa'alavelave fa'afuase'i mo gau ta'e¶

flowchart TD
    Start["Suspected Limb Fracture with Bleeding Skin Wound or Visible Protruding Bone"]
    CallEMS["Call Emergency Medical Services (ALS Paramedics) Immediately<br/>Put on nitrile gloves and cut clothing away to expose entire limb"]
    BleedCheck{"Is There Life-Threatening Arterial Spurting<br/>or Uncontrolled Pouring Blood?"}
    TourniquetStep["APPLY WINDLASS TOURNIQUET IMMEDIATELY<br/>1. Place tourniquet 5 to 7 cm (2 to 3 in) ABOVE the open fracture wound<br/>   (Never directly over the broken bone or over the knee/elbow joint)<br/>2. Tighten windlass until bright red bleeding stops completely<br/>3. Write exact time of application on tourniquet strap"]
    RingPadStep["CONTROL NON-ARTERIAL BLEEDING SAFELY<br/>1. DO NOT press directly down on top of protruding bone<br/>2. Press sterile gauze firmly around the soft-tissue edges beside the bone<br/>3. Build a bulky twin-roll or doughnut ring pad around protruding bone"]
    WoundCover["DRESS THE EXPOSED BONE & OPEN WOUND<br/>1. DO NOT push bone back inside; DO NOT scrub wound<br/>2. If gross loose gravel sits on skin beside wound, gently rinse with sterile saline only<br/>3. Cover exposed bone with sterile saline-moistened gauze + dry outer pad<br/>4. Wrap bandage snugly around ring pad without pushing bone inward"]
    PMSCheck1{"Perform First Distal Neurovascular (PMS) Check:<br/>Is the Hand/Foot Below the Break PULSELESS, Cold, and Pale/Blue?"}
    PulselessCheck{"Is the Limb Severely Angled/Twisted AND<br/>Is EMS Transport > 15 to 30 Minutes Away?"}
    GentleAlign["ISCHEMIC LIMB SALVAGE REALIGNMENT<br/>1. Support above and below fracture with both hands<br/>2. Apply smooth, gentle inline traction to untwist kinked artery<br/>3. STOP immediately if bone catches, severe resistance is felt, or bone starts retracting<br/>4. Re-check pulse immediately"]
    SplintAsFound["SPLINT IN EXACT POSITION FOUND<br/>1. Pad all gaps generously with soft towels or clothing<br/>2. Immobilize the joint ABOVE and the joint BELOW the open fracture<br/>3. Leave fingers or toes exposed to monitor color and warmth"]
    PMSCheck2["Perform Post-Splint PMS Check Every 10 to 15 Minutes<br/>Keep patient strictly NPO (nothing by mouth) and wrap in warm blankets"]

    Start --> CallEMS
    CallEMS --> BleedCheck
    BleedCheck -->|Yes: Arterial / Massive Bleed| TourniquetStep
    BleedCheck -->|No: Venous / Marrow Oozing| RingPadStep
    TourniquetStep --> WoundCover
    RingPadStep --> WoundCover
    WoundCover --> PMSCheck1
    PMSCheck1 -->|No: Pulse Present, Warm Pink Digits| SplintAsFound
    PMSCheck1 -->|Yes: Pulseless, Pale, Cold Hand/Foot| PulselessCheck
    PulselessCheck -->|Yes: Gross Angulation + Delayed EMS| GentleAlign
    PulselessCheck -->|No: EMS Near or Bone Locked| SplintAsFound
    GentleAlign --> SplintAsFound
    SplintAsFound --> PMSCheck2

O le fa'avasegaga a Gustilo-Anderson o gau gau: Aisea e o'o lava i se manu'a tu'i la'ititi i le malologa o se fa'alavelave fa'afuase'i.¶

Many people assume an open fracture only happens when 5 centimeters (2 inches) of white bone sticks out of a leg. In reality, orthopedic surgeons classify open fractures using the Gustilo-Anderson grading system into three major tiers, and Type I is the one most frequently missed by laypeople:

Anatomy and pathophysiology of an open bone injury¶

1. Why broken bones bleed so heavily (even without cutting a named artery)¶

Laypeople often forget that living human bone is not dry white chalk; it is a highly vascular organ supplied by high-flow nutrient arteries that enter the bone shaft and branch through a rich network of sinusoids inside the red and yellow bone marrow (medullary canal). * When a large long bone snaps open, blood pours out of both torn ends of the medullary canal as well as the shredded periosteum and surrounding muscle beds. * Even in a closed fracture, internal blood loss into the surrounding compartment is massive, and in an open fracture, blood loss often doubles because external skin tamponade is lost:

2. Aisea e tatau ai ona susu le Periosteum ma Cortical Ponaivi¶

O ponaivi ola uma lava e afifiina i se ga'o ga'o vascular e ta'ua o le periosteum, lea e feavea'i ai sela o le osteoprogenitor ma a'a toto ninii e faamalolo ai gau. * When a bone end protrudes through the skin into dry air, wind, or sun, the delicate periosteum and outer Haversian canals of the cortical bone desiccate (dry out) within 20 to 30 minutes. * Once cortical bone dries out, the osteocytes in that outer layer die (cortical osteonecrosis), turning the living bone tip into a dead piece of biological ivory (a sequestrum) that bacteria colonize easily and that the body cannot heal without surgical bone resection and grafting. * Covering exposed bone promptly with sterile gauze moistened with sterile 0.9% normal saline (or clean potable water if sterile saline is unavailable) preserves osteocyte viability until the patient reaches the operating room.

3. The "Golden 1-to-3-Hour Window" for Intravenous Antibiotics¶

Clinical orthopedic studies demonstrate that the single most important medical factor in preventing chronic osteomyelitis (deep bone infection) after an open fracture is how fast intravenous broad-spectrum antibiotics reach the fracture hematoma. * When IV cefazolin (plus gram-negative coverage for Grade III or penicillin/metronidazole for farmyard/soil clostridial contamination) is started within 60 minutes (and no later than 3 hours) of injury, deep bone infection rates drop by more than 60 percent. * That is why even a minor-looking Grade I open fracture (a tiny 5-millimeter bleeding hole over a broken ankle or wrist) must go immediately to a hospital emergency department by ambulance rather than waiting until the next morning.

Step-by-step technique: Managing an open fracture in the field¶

Step 1: Expose the entire limb safely¶

1. Put on medical nitrile gloves.
2. Cut clothing away with trauma shears or scissors: Never try to pull a pant leg or tight jacket sleeve off over a broken limb. Pulling clothing drags dirty fabric across the exposed bone and levers the jagged fracture ends against the adjacent artery and nerve. Cut straight up the seam of the trouser leg or sleeve to expose the entire limb from the hip/shoulder down to the toes/fingers.
3. Remove rings, watches, bracelets, and shoes immediately (if safe): Swelling travels rapidly down an injured arm or leg. A wedding ring or wristwatch left on a fractured arm becomes an unyielding metal tourniquet within 30 minutes, causing finger necrosis. Slip rings and watches off immediately before the fingers swell.

Step 2: Control bleeding around protruding bone (The Ring-Pad & Tourniquet Protocol)¶

1. If there is life-threatening arterial bleeding (bright red blood spurting with each heartbeat or rapidly pooling on the ground):
2. Do not waste time trying to press delicately around a bone shard while a femoral, popliteal, or brachial artery bleeds out.
3. Fa'aaoga loa se mata'ivili fa'atau tourniquet (e pei o le CAT po'o le SOFTT-W) 5 i le 7 senitimita (2 i le 3 inisi) latalata (luga/latalata i le fatu) i le manu'a gau matala.
4. Tulafono Autu o le Tulaga o le Tourniquet mo Ga'i: Aua ne'i nonoa sa'o i luga o le ponaivi o lo'o i luga pe sa'o i luga o le mea gau (i le fa'amauina o le fusi e olo ai le ponaivi gau i totonu o le alatoto), ma aua ne'i tu'u sa'o i luga o le tulivae po'o le sooga tulilima. Afai o le gau tatala o loʻo i le vae pito i lalo (tibia) ma latalata tele i le tulivae, tuʻu le taamilosaga i luga aʻe o le tulivae i luga o le ogavae pito i lalo. Fa'amau le ipu matagi se'ia uma le toto mumu sesega, loka le kilipa, ma tusi le taimi i luga o le fusi.
5. Afai o lo'o tumau pea le tafetotoi o le vena po'o le ga'o-povi e aunoa ma le puna alatoto:
6. Aua ne'i oomi fa'alalo i le pito i luga o se pito ponaivi o lo'o fa'aoso.
7. Nai lo lena, tu'u pepa kasa mama i tafatafa o matau o le pa'u manu'a i lalo tonu o le ponaivi ma oomi mau i le aano vaivai i tafatafa o le ponaivi.
8. Fausia se Twin-Roll poʻo le Donut Ring Pad (e pei lava o le faʻamautuina o se mea ua tutu'i): ave ni ta'aiga mafiafia se lua o le kausa ta'avale (pe gaugau se fusi tafatolu po'o se solo mama i totonu o se mama mafiafia) ma tu'u i itu uma o le ponaivi o lo'o oso a'e maualuga atu nai lo le pito o le ponaivi. O le mama mama e puipuia ai le pito o ponaivi mai le pa'i pe tulei i totonu pe a e afifiina le ofu pito i fafo.

Laasaga 3: Tulafono fa'aleaga manu'a ma le La'ei Susū-Plus-Mago¶

1. Ae faapefea pe a pipii le palapala, mutia, po o le iliili i le ponaivi o loo oso mai?
2. Aua le olo, pipii, pe fufulu le ponaivi i kasi po'o tamatamailima. O le fufuluina e le masini e aveese ai le periosteum ma'ale'ale ma tulei atili ai le palapala i totonu o le ga'o ponaivi fa'alilolilo.
3. Afai e iai sau fagu po'o se taga mama 0.9% masani masima (po'o mama vai inu fagu inu), e mafai ona e sasaa lemu se vai e maualalo le mamafa i luga o le manu'a e fa'afefea ai le iliili ma'ale'ale po'o le palapala a'o le'i tu'u lou ofu i luga.
4. Aua ne'i sasaa le hydrogen peroxyide, pa'u 'ava malosi, povidone-iodine (Betadine), chlorhexidine, po'o le fasimoli fale i totonu o se gau matala. O nei vaila'au fa'ama'i e o'ona i osteoblasts ma sela maso ma fa'aleagaina ai le fa'asao masani a le aano i fa'ama'i.
5. Fa'aoga le La'ei Ga'i Tatala Lua-Layer:
6. ** Laega 1 (I luga o le Ponaivi):** Fa'ata'atia le mafiafia pepa kausa mafiafia ua fa'asūsū i le masima masani fa'amama fa'alelei i luga o le ponaivi matala ma manu'a. (Afai e leai sau saline mama, fa'aaoga se mea mama mamago e le o pipi'i i le manua; aua ne'i fa'aogaina ni polo fulafula po'o ni fasipepa e sasaa ai le ga'o i totonu o le ponaivi.)
7. ** Layer 2 (Outer Protective Cover):** Tu'u se ta'i mafiafia mamago abdominal (ABD) po'o se fa'alava tele-fa'aleaga i luga o le susu i totonu ma le ta'amilosaga mama, ona afifi lelei lea i le vae e taofi ai le fusi e aunoa ma le tuleia o le ponaivi i totonu.

Laasaga 4: Fa'afefea ona fai le Su'ega Neurovascular Distal (PMS/CMS).¶

Soo se taimi lava e te suʻesuʻeina ai se gau (** ae e te leʻi paʻi i ai pe faʻamaʻi, ** i le taimi lava e uma ai ** e te nonoa le faʻamalama, ma ** 10 uma i le 15 minute ** seia oʻo ina ave e fomaʻi), e tatau ona e siaki ma faʻamau le PMS triad (Pulse/Perfusion, Motor function, ma Sensation i lalo) i le gau.

Step 5: Splinting an open fracture safely (and when to realign a pulseless limb)¶

1. Golden Rule of Open Fracture Splinting: Splint the limb in the exact position found whenever a distal pulse is present.
2. Never try to straighten an angled open fracture just to make it fit neatly into a straight board splint. Straightening an open fracture pulls the contaminated bone end back under the skin.
3. Instead, use moldable splints (such as a padded SAM malleable aluminum splint, vacuum splint, pillow splint, or folded blankets/cardboard) molded to match the angle of the limb, and pad all hollow spaces generously with soft towels or clothing.
4. Immobilize the joint ABOVE and the joint BELOW the break: For an open lower-leg (tibia) fracture, the splint must immobilize both the ankle and the knee. For an open forearm fracture, immobilize both the wrist and the elbow.
5. Never tie a splint strap directly over the open fracture wound or protruding bone. Tie straps above and below the wound dressing, and leave the tips of the fingers or toes exposed so you can check PMS every 10 minutes.
6. The Single Exception: What if the hand or foot below the break is completely PULSELESS, cold, and pale/blue?
7. Occasionally, a severe ankle fracture-dislocation, tibial shaft fracture, or supracondylar elbow fracture twists at a 90-degree angle and kinks the main artery shut like a bent garden hose, threatening rapid death of the foot or hand and bursting of the tight stretched skin flap over the bone.
8. If EMS paramedics are only 5 to 10 minutes away: Leave the limb supported on pillows and let the arriving ALS paramedics administer intravenous analgesia and perform gentle inline realignment.
9. If the distal limb is completely pulseless, pale, and cold AND you are in a remote location or EMS transport is delayed (> 15 to 30 minutes): International trauma guidelines (ATLS, PHTLS, Wilderness Medical Society, UK NICE) authorize one gentle attempt at longitudinal inline traction realignment to un-kink the artery:
   1. Have one person steady the limb above the fracture while you hold the limb below the fracture with both hands.
   2. Apply smooth, gentle, steady inline traction (pulling gently along the long axis of the bone) while slowly easing the grossly twisted limb back toward a more natural anatomical line.
   3. STOP IMMEDIATELY if you feel mechanical bony resistance/locking, if pain becomes intolerable, or if you see a protruding bone end starting to slip back beneath the skin.
   4. Splint in that position and re-check the distal pulse immediately. (If a pulse was present before you put a splint on, and disappeared after you tied the splint, loosen the splint straps immediately.)

Step 6: What if a loose piece of bone has fallen completely out of the wound onto the ground?¶

I gau matala matala maualuga (fana, pasika pasika, po'o masini falegaosimea), atonu o lo'o taatia i luga o le auala po'o lavalava i tafatafa o le tagata manua se vaega o le ponaivi o le tino. * Aua ne'i tia'i se fasi ponaivi ua ta'e, ma aua ne'i toe taumafai e toe utu i totonu o le manu'a. * E pei lava o le faasaoina o se tamatamailima motusia i se tipi'esea tiga, afifi le fasiga o ponaivi mavaevae i le kaisa mama ua fa'asūsū i le masima masani masima, fa'amau i totonu o se taga palasitika mama e le susu, fa'amama lelei (i luga o se pusa malulu e tu'ueseese i se ie pupuni ina ia aua ne'i malo), ma tu'u sa'o i foma'i ina ia mafai e foma'i tipitipi ona siaki le fa'aletonu pe fa'aoga mo le fa'apipi'i o ponaivi.

O le tausiga vave o se gau gau e puipuia ai le le atoatoa o le tino ma le ponaivi. Mafaufau e ave se fesoasoani muamua faʻamaonia, Taofi le toto, poʻo le vao e tali muamua atu i lau Koluse Mumu poʻo Red Crescent sosaiete, St John Ambulance, poʻo le American College of Surgeons.

Fesili e fai soo¶

Punavai ua siaki¶

• American College of Surgeons (ACS, United States): Advanced Trauma Life Support (ATLS) Student Course Manual: Musculoskeletal Trauma, Open Fractures, and Neurovascular Assessment.
• British Orthopedic Association (BOA) & British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS, United Kingdom): BOAST Guidelines: Audit Standards for Trauma: Open Fractures.
• National Institute for Health and Care Excellence (NICE, United Kingdom): Taʻiala NG37: Faʻalavelave (Faʻalavelave): Iloiloga ma le Puleaina o Gagana Tatala i Faiga Faʻapitoa ma Falemai.
• American Academy of Orthopedic Surgeons (AAOS) & Orthopedic Trauma Association (OTA, United States): Clinical Practice Guideline on Prevention of Surgical Site Infection After Major Extremity Trauma.
• ** Wilderness Medical Society (WMS, United States):** Clinical Practice Guidelines for the Basic Management of Open and Angulated Fractures in Austere Environments.

Taiala fa'atatau¶

• Ga'i ponaivi, gau, ma fa'asalaina fesoasoani muamua
• Puleaina malosi o le toto ma toleni
• Manu'a manu'a ma iloa fa'ama'i vaega
• Ua se'e le tauau, tuli tuli, ma le le gaioi sooga
• Fa'asalaina ma fa'apipi'i fa'amautu mea mai fafo
• Numera o fa'alavelave fa'afuase'i ma fe'au fa'ava-o-malo