Open Fracture Management

Use trauma principles first. Expose the entire injured limb, document motor, sensory, pulse, and perfusion findings before and after any reduction or splinting, and assess for associated injuries. Plain radiographs should include the injured bone and adjacent joints; radiographic soft-tissue gas or foreign bodies support an open injury. CT may define articular involvement in stable patients, and CT angiography can identify vascular injury when pulses are absent. PubMedPubMedOpen Fracture Management - StatPearls - NCBI Bookshelf - NIH

After gross contamination is addressed only as needed for temporary protection, cover the wound with a saline-soaked sterile dressing and occlusive layer, immobilize in a well-padded splint, and minimize repeated wound inspection. NICE advises against emergency department irrigation of open long-bone, hindfoot, or midfoot fractures before operative wound excision. PubMedPubMedFractures (complex): assessment and management - NCBI - NIH

Attempt immediate reduction when fracture displacement is thought to compromise vascular flow. Persistent hard signs of vascular injury—absent palpable pulse, continued blood loss, or expanding hematoma—require immediate surgical exploration; do not rely on capillary refill or Doppler signal to exclude vascular injury, and do not delay revascularization for angiography. PubMedPubMedFractures (complex): assessment and management - NCBI - NIH

Cefazolin-based prophylaxis is the usual foundation because staphylococci are common fracture-related infection pathogens. A recent OTA review recommends antibiotics within 60 minutes before surgery and continuation for up to 24 hours after surgery; it notes that type III open fractures may benefit from brief gram-negative expansion. PubMedPubMedOpen fractures: evidence-based best practices - PMC

For Gustilo types I and II, gram-positive coverage with cefazolin or cefuroxime is recommended in the supplied open-fracture review. For type III injuries, add gram-negative coverage; gentamicin is a commonly used option. Add high-dose penicillin for farmyard, fecal, or suspected clostridial contamination; clindamycin is an alternative for true penicillin allergy. PubMedPubMedOpen Fracture Management - StatPearls - NCBI Bookshelf - NIH

The supplied sources do not provide a current U.S. society-endorsed dose regimen for cefazolin, gentamicin, or penicillin in this setting. Use local trauma/antimicrobial stewardship protocols, renal function, allergy history, injury contamination, and planned repeat operations to select agents and duration. Routine prolonged systemic therapy without evidence of established infection is not supported by the cited contemporary review. PubMedPubMedOpen fractures: evidence-based best practices - PMC

Perform meticulous operative wound excision of nonviable and contaminated tissue. Debridement should evaluate skin, subcutaneous tissue, fascia, muscle, and bone; remove necrotic tissue and foreign material while preserving viable structures. Repeat debridement may be required until all nonviable tissue is removed. PubMedPubMedOpen fractures: evidence-based best practices - PMC

The timing of debridement should be individualized. Contemporary evidence from the FLOW cohort found no significant difference in reoperation between early and later debridement after adjustment for injury severity, undermining a rigid 6-hour cutoff. However, highly contaminated injuries, vascular injury, and suspected compartment syndrome require immediate operative management. NICE recommends wound excision immediately for highly contaminated injuries, within 12 hours for high-energy type IIIA/IIIB injuries that are not highly contaminated, and within 24 hours for other open fractures. PubMed+1PubMedOpen fractures: evidence-based best practices - PMCPubMedFractures (complex): assessment and management - NCBI - NIH

Use copious normal saline for operative irrigation. In the FLOW trial, reoperation rates did not differ by high, low, or very-low irrigation pressure, whereas castile soap was associated with more reoperations than normal saline. PubMedPubMedOpen fractures: evidence-based best practices - PMC

Choose fixation based on physiology, contamination, fracture pattern, soft-tissue injury, and access to reconstruction. External fixation is useful for damage control, severe soft-tissue injury, vascular injury, and staged management. Definitive internal fixation is commonly appropriate for many Gustilo I, II, and IIIA injuries after adequate debridement; type IIIB/IIIC injuries often require staged fixation coordinated with flap coverage. PubMedPubMedOpen fractures: evidence-based best practices - PMC

Definitive soft-tissue coverage protects exposed bone, tendon, vessels, and implants while reducing fracture-related infection risk. Early coverage—preferably within 3 to 5 days in the cited OTA review—reduces deep infection and nonunion; delay beyond 7 days has been associated with increased complications. PubMedPubMedOpen fractures: evidence-based best practices - PMC

NICE recommends concurrent orthopaedic and plastic surgery management for open long-bone, hindfoot, and midfoot fractures. Perform definitive fixation and soft-tissue coverage at wound excision when feasible; otherwise provide definitive cover within 72 hours of injury. When internal fixation is used, definitive soft-tissue coverage should occur at the same time. PubMedPubMedFractures (complex): assessment and management - NCBI - NIH

Negative-pressure wound therapy may be a useful temporary dressing but should not be interpreted as permission to defer definitive coverage. The updated NICE recommendation is to use a temporary dressing that prevents desiccation and minimizes dressing changes; it does not endorse a specific dressing type. PubMedPubMedFractures (complex): assessment and management - NCBI - NIH

Repeat and document neurovascular examinations, especially after reduction, splinting, external fixation, or changes in swelling. For tibial fractures, clinical surveillance for compartment syndrome should continue through 48 hours after injury or fixation; use continuous pressure monitoring when symptoms are not reliable because of unconsciousness or regional anesthesia. PubMedPubMedFractures (complex): assessment and management - NCBI - NIH

Fracture-related infection risk increases with diabetes, peripheral vascular disease, smoking, malnutrition, obesity, and immunosuppression. Identify modifiable host risks and optimize nutrition, smoking cessation, and glycemic control where possible. PubMedPubMedOpen fractures: evidence-based best practices - PMC

Open fractures can progress to infection, nonunion, malunion, osteomyelitis, vascular compromise, compartment syndrome, and limb loss. Persistent wound drainage, progressive pain, systemic illness, recurrent swelling, loss of fixation, or failure of radiographic progression should prompt reassessment for infection, inadequate stability, occult devitalized tissue, or insufficient coverage. PubMed+1PubMedOpen fractures: evidence-based best practices - PMCPubMedOpen Fracture Management - StatPearls - NCBI Bookshelf - NIH