Open fractures

Objectives

Open fractures require timely multidisciplinary management and significant morbidity can
occur as a result of infection. This guideline applies to all long bone, hind foot and mid-foot
open fractures. This guideline does not apply to open fractures of the hand, wrist, forefoot or
digit.

Management in the ED

• Do not irrigate
• Photograph open fracture wounds when they are first exposed, before debridement (Keep in patient record, in line with information governance policy)
• Assess nerve and nerve function. Document the following using MRC grading system where applicable:
  • Time of assessment
  • Sensation
  • Motor function (using MRC grades 0-5)
  • Pulses (if not accessible document how circulation has been assessed)
  • Reassessment of the above (especially after reduction/splintage) 
• Re-align and splint the limb
• Cover with a saline-soaked dressing covered with an occlusive layer
• Give 1.5g cefuroxime within 60 minutes (& metronidazole 500mg if contused/dirty/acquatic)
• Give 500IU tetanus immunoglobulin if wound contaminated with soil/manure or has extensive devitalised tissue. Check tetanus status for all other patients.
• Involve orthopaedics and plastics/transfer to MTC.
• Extend the WBCT to include the limbs and provide angiography where clinically indicated
• Manage compartment syndrome in line with separate guidelines.

Emergency amputation

Perform an emergency amputation in the following three scenarios:

1. The limb is the source of uncontrollable life threatening haemorrhage
2. The limb is salvageable but attempted preservation would pose an unacceptable risk to life
3. The limb is deemed unsalvageable after review by a consultant orthopaedic and plastic surgeon

Debridement, fixation and definitive cover

• All the above should be performed concurrently by an orthopaedic and plastics consultant
• Debridement should occur in the following timescales:
  • IMMEDIATELY if highly contaminated (agricultural, aquatic, sewage) or vascular compromise
  • WITHIN 12 HOURS OF INJURY if high energy
  • WITHIN 24 HOURS OF INJURY if low energy 
• Perform fixation and definitive soft tissue cover at the same time as debridement. If this is not possible then consider negative pressure wound therapy and perform internal fixation and soft tissue cover WITHIN 72 HOURS of injury
• Internal fixation and definitive soft tissue cover should usually occur at the same time

Limb salvage or delayed primary amputation

Do not base this decision on an injury severity tool score. If indicated a delayed primary amputation should occur within 72 hours of the injury and after assessments and discussions involving the patient, family, carers, an orthopaedic surgeon, plastic surgeon and rehabilitation specialist.