Open fractures and early antibiotic prophylaxis — Rapid

Synopsis

Identify every fracture communicating with a wound, give immediate network-approved intravenous prophylaxis, protect soft tissue and perfusion, and coordinate timely orthoplastic debridement, fixation and cover.

Any wound in the same limb segment as a fracture can communicate; document size, site, contamination and photographs before covering, without probing it in the emergency department.
Assess pulses, capillary refill and individual motor and sensory nerve function before and after alignment or splintage; hard vascular signs trigger immediate surgical escalation.
Give intravenous prophylaxis from the agreed open-fracture network protocol immediately, ideally within 1 hour of injury; record agent, dose and time and modify unusual contamination with microbiology advice.
Remove only gross loose surface contamination, photograph, cover with saline-soaked sterile gauze and an occlusive layer, then leave the dressing undisturbed until formal debridement unless clinically necessary.
Do not perform emergency-department mini-washouts, wound probing or primary closure; these contaminate tissue planes and compromise later assessment.
Realign gross deformity, splint and repeat neurovascular status; tetanus prevention follows UK immunisation guidance and does not replace antibiotic prophylaxis.
BOASt timing: immediate debridement for highly contaminated wounds or vascular compromise, within 12 hours for other high-energy fractures, and within 24 hours for lower-energy open fractures.
Plan debridement, skeletal stabilisation and definitive soft-tissue cover jointly through orthopaedic and plastic surgery; achieve cover at debridement or within 72 hours when not immediately possible.

Key red flags

Absent or deteriorating perfusion, hard vascular signs, uncontrolled bleeding or an ischaemic limb requires immediate combined orthopaedic and vascular intervention without delaying revascularisation for grading.

Gross agricultural, aquatic, sewage or heavily particulate contamination, compartment syndrome or a multiply injured unstable patient changes antimicrobial, debridement and damage-control priorities.

A pinhole wound near a fracture, degloving, skin under tension or exposed bone or tendon must be assumed to communicate until explored appropriately in theatre.

Investigation priorities

First-line orthogonal radiographsFirst stepFirst line

Define fracture, foreign material and joint involvement.

Preferred CT angiography when stablePreferred

Assess suspected arterial injury without hard signs requiring immediate operation.

Management branches

First hourProtect life, limb and wound

A fracture-associated wound is present or cannot confidently be shown not to communicate.

Perform CABCDE, control haemorrhage and record pulse, refill, temperature and named motor and sensory nerve findings before any realignment.
Administer the network-approved intravenous prophylactic agent immediately and ideally within one hour, recording the exact dose and time.
Photograph without probing, remove only loose gross contamination, apply saline-soaked sterile gauze with an occlusive cover and splint the realigned limb.
Contact the receiving orthoplastic service early and add vascular, microbiology or other specialty support for hard signs or unusual contamination.

Key medicines

Network open-fracture intravenous prophylaxisGive the exact intravenous agent and adult dose specified by the receiving trauma network immediately and ideally within 1 hour of injury; redose and stop at the protocol-defined operative or post-cover point.National guidance specifies timing rather than one universal drug; check severe allergy, renal function and unusual farm, water, sewage or bite contamination with microbiology and do not prolong prophylaxis as empirical infection treatment.

Tetanus-containing vaccine and human tetanus immunoglobulinWhen UKHSA wound guidance indicates active immunisation, give 0.5 mL of the appropriate tetanus-containing vaccine intramuscularly; when immunoglobulin is indicated for prevention, give 250 IU intramuscularly, increased to 500 IU if more than 24 hours have elapsed or heavy contamination is present.Tetanus measures do not replace open-fracture antibiotics or debridement; use a separate site for immunoglobulin and vaccine, verify immunisation and immune status, and seek specialist advice for treatment of suspected clinical tetanus.

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