OR2.15 | Open Fracture Infection Prevention — Summary & Reflection

KEY TAKEAWAYS

Open fractures are defined by skin breach communicating with the fracture, regardless of whether bone is visible. The Gustilo-Anderson classification (Grade I: <1 cm clean; Grade II: 1-10 cm moderate contamination; Grade IIIA: >10 cm or high-energy, adequate coverage; Grade IIIB: periosteal stripping, requires flap; Grade IIIC: arterial injury requiring repair) guides management and predicts infection risk. The immediate priorities are: neurovascular assessment of the distal limb (absent pulse or ABI <0.9 = vascular emergency); antibiotics within 1 hour (Grade I/II = cefazolin; Grade III = cefazolin + gentamicin; farm/soil = add penicillin for clostridial cover); tetanus prophylaxis based on immunisation history; and a single sterile dressing over the wound. Surgical debridement should be performed as early as feasible (the fixed 6-hour rule is obsolete); Grade I can be closed primarily, Grade II reassessed at 48 hours, Grade III never closed primarily. CT angiography is the investigation of choice for suspected arterial injury. Compartment pressure >30 mmHg (or delta P <30 mmHg) mandates fasciotomy. Emergency-department wound swabs are unreliable for antibiotic guidance and should not be routinely taken.

REFLECT

A motorcyclist presents at 3 AM with a Grade IIIB open tibial fracture. The on-call registrar suggests waiting until the morning consultant list to perform debridement 'properly'. Antibiotics were given within 45 minutes. The wound is covered with a sterile moist dressing. Is the registrar's decision defensible with current evidence? What factors determine whether delayed debridement is safe versus harmful in this specific scenario? And how would your counselling of the patient about infection risk and the possibility of requiring a flap change depending on whether debridement is performed now versus in 8 hours?