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Open fractures
Antibiotics within the hour, photograph, dress, splint — and don't poke the wound. Treat the patient before the limb (ATLS), then follow the BOAST bundle: early IV antibiotics, tetanus, a photo and sealed saline dressing, splintage, neurovascular checks, and a joint orthopaedic–plastics plan. Built for revision, not live patient decisions.
Settle them, and check the basics
life before limbRed flags — what each should make you think
Don't repeatedly lift the dressing to look at the wound. Take one good photograph, then keep it sealed: every look adds contamination. The photo lets everyone (ortho, plastics, theatre) see the wound without re-exposing it.
The BOAST bundle in ED
- ℞IV antibiotics ASAP
- TTetanus status
- 📷Photograph the wound
- 🩹Saline-soaked dressing
- 🦴Realign and splint
- ☎Ortho + plastics
Understand the injury
classify · time itGustilo–Anderson classification (finalised in theatre)
- Type I — wound under 1 cm, clean, low energy
- Type II — wound 1–10 cm, moderate soft-tissue damage
- Type IIIA — high energy or extensive soft-tissue damage, but bone can be covered
- Type IIIB — periosteal stripping, needs flap cover
- Type IIIC — arterial injury needing repair
BOAST timings for surgery
- Immediately — gross contamination (agricultural, aquatic, sewage) or vascular compromise (revascularisation within 3–4 h of injury; consider shunt)
- Within 12 h — high-energy open fractures (not grossly contaminated)
- Within 24 h — other low-energy open fractures
- Debridement and fixation by consultant orthopaedic and plastic surgeons together, ideally at a specialist centre
Work A–E — assess and act as you go
The diagnoses you must not miss
tap to open eachWhat points toward it, what would rule it in, and how to manage it.
Pulselessness, pallor, expanding haematoma, pulsatile bleeding, bruit/thrill. Knee dislocation and supracondylar fractures are high risk.
Clinical hard signs; ABPI below 0.9 → CT angiogram.
Realign and recheck pulses. Hard signs → vascular surgery immediately; revascularisation within 3–4 h.
Escalating pain, pain on passive stretch, tense compartments; open fractures can still develop it.
Clinical ± compartment pressures.
Release dressings to skin, urgent consultant review, fasciotomy. See the compartment syndrome page.
Soil, faeces, marine or freshwater contamination.
History and inspection.
Immediate surgical debridement; broaden antibiotics per local policy (e.g. add cover for anaerobes/water organisms).
Shock, other injuries, pelvic or femoral fractures.
Primary survey, FAST, trauma CT.
Haemorrhage control, MHP, trauma team; the limb waits.
Investigate — what to order, when, and what it tells you
test with a question in mindX-rays
CT
Bloods
Vascular
How the plan comes together
disposition · handoverortho admission
All open fractures are admitted. Plan theatre within BOAST timings; ortho-plastics review.
theatre now
Vascular injury, gross contamination, compartment syndrome, or haemorrhage.
Hand over: time of injury, antibiotic time, tetanus, photo taken, NV status before/after splinting.
Treat the patient before the limb. Then antibiotics within the hour, tetanus, one photograph, a sealed saline dressing, splintage, and neurovascular checks before and after. Nicely done getting here.
Clerking template
copy or downloadOpen fractures — documentation structure
A structure and prompt list to help you document and think systematically. It is not a completeness check and cannot guarantee nothing is missed — use your trust's own proforma, your seniors, and your clinical judgement.
Test yourself
active recallCover the answer, say it out loud, then reveal. Retrieval beats re-reading.
0 / 10 knownFrequently asked questions
quick answersWhat are the red flags for open fractures?
- Pulseless, cold, pale limb — think vascular injury — immediate surgery
- Pain out of proportion, tense compartments — think compartment syndrome
- Farmyard, sewage or water contamination — think gross contamination — surgery now
- Multiply injured, shocked — think ATLS — life before limb
- Wound near a joint — think open joint injury
- Crush or high-energy mechanism — think extensive soft-tissue damage
What is the initial management of open fractures?
- IV antibiotics ASAP — ideally within 1 h of injury, per local protocol (e.g. co-amoxiclav or cefuroxime; clindamycin if penicillin allergic)
- Tetanus status — give booster ± immunoglobulin per guidance
- Photograph the wound — then remove gross contamination only, no ED irrigation
- Saline-soaked dressing — covered with an occlusive film
- Realign and splint — check neurovascular status before and after, and document
- Ortho + plastics — joint plan; urgent if vascular injury or gross contamination
Always alongside senior support and your local guideline.
What diagnoses must you not miss in open fractures?
- Vascular injury — hard signs
- Compartment syndrome — pain out of proportion
- Gross contamination — farm · sewage · water
- Major haemorrhage / multiple injuries — ATLS
Open each one in the must-not-miss section for what points toward it, how to rule it in, and how to manage it.
What investigations should a junior doctor order for open fractures?
- X-rays — Two views, including the joints above and below.
- CT — Intra-articular, complex or multiply injured (trauma CT).
- Bloods — FBC, U&E, clotting, group and save/crossmatch, CK if crush.
- Vascular — If pulses reduced or high-risk injury.
Admit or discharge: how is the plan decided for open fractures?
- Ortho admission — All open fractures are admitted. Plan theatre within BOAST timings; ortho-plastics review.
- Theatre now — Vascular injury, gross contamination, compartment syndrome, or haemorrhage.
Is there a clerking template for open fractures?
Yes — there is a free clerking template for open fractures on this page, structured as presenting complaint, red flags asked, history, examination (A–E), investigations, differentials, plan and escalation. You can copy it or download it as a Word document. Jump to the template.
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