TTL tip 23: Open fractures

Open fracture management starts in the resus room. Early antibiotics, careful neurovascular assessment, realignment and coordinated wound care are key priorities for the trauma team. A little preparation before anyone removes the dressing can also prevent repeated examinations and unnecessary wound handling.

1. Give IV antibiotics early, ideally within one hour of injury. Follow your local trauma network antibiotic guideline.
2. Assess and document neurovascular status, repeating the examination after realignment and splinting.
3. Realign and splint the limb, with appropriate analgesia.
4. Remove gross contamination, but avoid mini-washouts in resus. Formal wound debridement belongs in theatre.
5. Plan before removing the prehospital dressing. Have the relevant clinicians, camera and replacement dressing ready. Aim for one coordinated assessment: remove gross contamination, photograph the wound using the approved system, then apply saline-soaked gauze covered with an occlusive film. Avoid repeated exposure and unnecessary handling.
   1. Caveat – Coordinate the first wound assessment wherever possible, but do not delay urgent assessment or treatment while waiting for everyone to attend.
6. See TTL Tip 14 for associated vascular injury.
7. Check tetanus status. Assess the wound and vaccination history, and provide tetanus prophylaxis according to current guidance.
8. Get the specialist plan moving early. Involve the orthoplastic team and arrange transfer where needed. Flag agricultural, aquatic or sewage contamination and any vascular compromise immediately, as these require immediate operative management.

For further detail, see the BOAST guidance on open fractures.