Synopsis
Identify every fracture communicating with the external environment, prevent additional contamination, deliver antibiotics and alignment promptly, describe rather than prematurely grade the wound, and coordinate definitive debridement, fixation and coverage through orthoplastic care.
- Treat any wound in the same segment as a fracture as communicating until careful operative assessment establishes otherwise; visible bone is not required.
- Control haemorrhage with direct pressure, packing or the most distal effective tourniquet and never apply blind clamps inside the wound.
- Give the network's intravenous prophylactic antibiotic as soon as possible and ideally within one hour; record agent, weight-based dose, allergy check and exact time.
- Handle the wound only to remove gross loose contamination and obtain one policy-compliant photograph, then apply saline-soaked gauze and occlusive film; emergency-department mini-washouts are not indicated.
- Gently restore gross alignment, splint and repeat named neurovascular examination. Persistent dysvascularity after realignment activates immediate consultant-led revascularisation rather than serial observation.
- Describe size, site, contamination, tissue loss, degloving, circulation and neurology initially. Assign the definitive Gustilo-Anderson grade after formal debridement reveals the true soft-tissue injury.
- Debride immediately for agricultural, aquatic or sewage contamination or vascular compromise; within 12 hours for other solitary high-energy injuries; within 24 hours for other low-energy open fractures.
- Achieve definitive closure or cover at debridement where possible or within 72 hours; perform definitive internal fixation only when immediate definitive soft-tissue cover can follow.
Key red flags
Uncontrolled bleeding, a persistently dysvascular limb after realignment, expanding haematoma, bruit or neurological deterioration requires simultaneous resuscitation and NCEPOD-1 vascular and skeletal care.
Agricultural, aquatic or sewage contamination, compartment syndrome or ischaemia requires immediate debridement rather than waiting for a routine trauma list.
Tense compartments, escalating pain or passive-stretch pain may occur with an open wound; an open fracture does not decompress every compartment or exclude compartment syndrome.
Major tissue loss, degloving, exposed joint or tendon, periosteal stripping or a wound over a prosthesis requires early orthoplastic or relevant specialist planning even when the fracture itself appears simple.
Investigation priorities
Define the fracture and joint extension while the limb is protected.
Management branches
A fracture has any potentially communicating wound or major soft-tissue violation.
- Run ABCDE, control bleeding without blind clamping and document the entire limb, compartments, pulses and named nerves.
- Give network intravenous prophylaxis ideally within one hour and assess tetanus needs without waiting for radiographs.
- Photograph once, remove only gross loose debris, apply saline-soaked gauze and occlusive film and stop repeated wound handling.
- Realign and splint, repeat neurovascular findings and activate orthoplastic and vascular transfer pathways according to injury.