Open fractures
IV antibiotics within an hour, tetanus, one photograph, a saline-soaked dressing and a splint. Then theatre on time.
A 30-year-old motorcyclist has a deformed lower leg with a 3 cm wound over the shin. Bone is visible. The foot is pink with a palpable dorsalis pedis pulse. He last had a tetanus injection at school.
What do you do in the first hour, and when must antibiotics be given?
- ABCDE firstLook for life-threatening injuries before the leg.
- IV antibiotics as soon as possibleWithin 1 hour of injury.
- TetanusBooster or immunoglobulin depending on status.
- Photograph, then coverSaline-soaked gauze and an occlusive dressing. Don't keep re-exposing it.
- Neurovascular checkBefore and after any manipulation.
- Realign and splintGross deformity, restore alignment, splint. Remove gross contamination only.
- Orthopaedics and plasticsDebridement within 12 hours (high-energy), 24 hours (low-energy), immediately if heavily contaminated or vascular injury.
- Pulseless or cold limb
- Compartment syndrome signs
- Heavy contamination (farm, sewage, water)
- Major bleeding
- Multiple injuries
- Vascular injury
- Compartment syndrome (can still occur with an open fracture)
- Nerve injury
- Tetanus
- Gas gangrene
- Other injuries
| Antibiotics | Within 1 hour of injury |
| Co-amoxiclav | 1.2 g IV every 8 hours |
| Cefazolin or cefuroxime alternative | Per local guidance |
| Gentamicin | Added for heavy contamination (Gustilo III), per local protocol |
| Debridement | Within 12 hours (high-energy), 24 hours (low-energy), immediate if marine, agricultural or sewage contamination or vascular injury |
| Soft tissue cover | Ideally within 72 hours |
Check every dose against a current drug reference and your hospital protocol.
On this page
Gustilo-Anderson classification
| Type | Wound | Notes |
|---|---|---|
| I | Under 1 cm, clean | Low energy |
| II | 1–10 cm, moderate soft tissue damage | No extensive stripping |
| IIIA | Over 10 cm or high energy, enough soft tissue to cover the bone | |
| IIIB | Extensive soft tissue loss, periosteal stripping, needs flap cover | |
| IIIC | Arterial injury needing repair |
Final classification is made in theatre after debridement.
Initial management
- Primary surveyATLS ABCDE. Stop bleeding with direct pressure.
- IV antibioticsAs soon as possible, within 1 hour.
- AnalgesiaIV opioid titrated.
- PhotographSo the wound doesn't need to be uncovered again.
- Clean and coverRemove obvious contamination. Saline-soaked gauze, occlusive film.
- Realign and splintCheck pulses and sensation before and after.
- TetanusAs per status.
- X-raysJoint above and below.
- Orthopaedics and plasticsJoint plan for theatre.
Don't wash the wound out in the emergency department. Thorough debridement belongs in theatre.
Vascular check
- Pulses, capillary refill, colour, temperature.
- Absent pulses: realign and recheck. Still absent: vascular surgeons immediately; CT angiography if it doesn't delay surgery.
- Ankle-brachial pressure index below 0.9 suggests arterial injury.
Tetanus
- Fully immunised within 10 years: nothing more.
- Over 10 years: booster.
- Not immunised or unknown, contaminated wound: booster plus tetanus immunoglobulin.
Investigations
| Test | Why |
|---|---|
| X-rays (two views, joint above and below) | Fracture pattern |
| FBC, group and save, clotting, U&E | Blood loss, theatre |
| CT angiogram | Suspected vascular injury |
| CT | Intra-articular fractures |
Treatment
See fractures and compartment syndrome.
Common mistakes
- Antibiotics delayed until theatre.
- Repeatedly lifting the dressing to show colleagues.
- Washing out the wound in the emergency department.
- Missing a vascular injury.
- Forgetting tetanus.
- Not checking for compartment syndrome because the fracture is "open".
Frequently asked questions
When should antibiotics be given for an open fracture?
As soon as possible, ideally within 1 hour of injury.
What is the Gustilo-Anderson classification?
A grading of open fractures by wound size, soft tissue damage and vascular injury: types I, II, IIIA, IIIB and IIIC.
How should an open fracture wound be dressed?
Photograph it, remove gross contamination, cover with saline-soaked gauze and an occlusive dressing, then leave it covered.
Can compartment syndrome happen with an open fracture?
Yes. An open wound does not reliably release compartment pressure.
Test yourself
Exam-style questions on this guide, from our two question banks. Choose an answer to see why each option is right or wrong.
1. A motorcyclist has an open tibial fracture with mud in the wound. Within what time should IV antibiotics be given?
Answer: Within 1 hour of injury. Early antibiotics reduce deep infection. Give within 1 hour of injury.
- Within 6 hours: Too late.
- After debridement in theatre: Too late.
- Within 24 hours: Too late.
- Only if fever develops: Prophylaxis is essential.
2. An open tibial fracture has a 12 cm wound with extensive soft-tissue loss and periosteal stripping needing a flap. Which Gustilo type is this?
Answer: IIIB. IIIB fractures need soft-tissue reconstruction (a flap). The final grade is set in theatre.
- IIIC: Needs arterial repair.
- I: Under 1 cm.
- IIIA: Bone can still be covered with soft tissue.
- II: 1–10 cm, no extensive stripping.
3. What should be done to an open fracture wound in the emergency department?
Answer: Remove debris, photograph, cover. Remove only obvious debris, photograph, cover and splint. Formal debridement happens in theatre.
- Apply antiseptic and close: No.
- Suture the wound: Never close before debridement.
- Leave the wound open to air: Increases contamination.
- Formal washout with litres of saline: Done in theatre.
4. An open tibial fracture has a 12 cm wound with extensive soft-tissue loss and periosteal stripping requiring a flap, but no arterial injury. What is its Gustilo–Anderson grade?
Answer: IIIB. Gustilo–Anderson: I — wound < 1 cm, clean; II — 1–10 cm, moderate soft-tissue damage; IIIA — extensive damage but adequate soft-tissue coverage; IIIB — extensive loss with periosteal stripping needing flap coverage; IIIC — arterial injury requiring repair. Infection and amputation risk rise with grade. Management: antibiotics within 1 h, debridement, stabilisation, early soft-tissue cover (within 72 h).
- I: Grade I wounds are under 1 cm and clean.
- II: Grade II wounds are 1–10 cm with moderate damage.
- IIIC: IIIC requires an arterial injury needing repair.
5. A 25-year-old motorcyclist has an open tibial fracture with a 6 cm wound contaminated with soil. What should be given in the emergency department?
Answer: IV antibiotics, tetanus, splint. Open fractures carry a high risk of infection. Give IV antibiotics (e.g. co-amoxiclav or cefuroxime per local policy) within 1 hour, check tetanus status, remove gross contamination, photograph the wound, cover with saline-soaked gauze and splint. Formal debridement is done in theatre urgently (immediately if highly contaminated, within 12–24 hours otherwise). Do not close or irrigate extensively in the ED.
- Suture the wound in the ED: Closing a contaminated open fracture wound in ED traps soil and bacteria and leads to deep infection; it is debrided in theatre.
- Wash out in ED, leave open: Irrigation is done in theatre; keep covered.
- Antibiotics only in theatre: Delaying antibiotics until theatre increases infection; they should be given within an hour of injury.
6. How does tetanus toxin cause spastic paralysis?
Answer: Blocks glycine and GABA release. Tetanospasmin travels back along motor axons to the spinal cord and cleaves proteins needed to release GABA and glycine from Renshaw and other inhibitory interneurones. Unopposed motor activity causes trismus, risus sardonicus, opisthotonus and spasms. Botulinum toxin, in contrast, blocks acetylcholine release, causing flaccid paralysis.
- Blocks acetylcholine release: That is botulinum toxin (flaccid).
- Destroys anterior horn cells: Polio.
- Blocks acetylcholine receptors: Myasthenia gravis.
- Activates muscle sodium channels: Not the mechanism.
7. A man presents 2 hours after a deep wound contaminated with soil. He had a full primary course of tetanus vaccine but his last booster was 12 years ago. What is the correct tetanus prophylaxis?
Answer: Toxoid booster and wound care. For tetanus-prone wounds, give a booster if the last dose was over 10 years ago (some guidance: over 5 years for dirty wounds), together with thorough wound cleaning and debridement. Human tetanus immunoglobulin is added for high-risk wounds or incomplete/unknown immunisation. Toxoid and immunoglobulin are given at different sites.
- No action needed: Booster is overdue.
- Antibiotics alone: Do not prevent toxin effects.
- Immunoglobulin alone: Vaccine is also needed.
- Repeat the full primary course: Not needed after a full primary course.
References and dose sources
- BOA standards for trauma (BOASTs), including open fractures
- NICE NG39 — major trauma
- NICE NG37 — fractures (complex)
- Co-amoxiclav (amoxicillin with clavulanic acid) dosing: Drugs.com: Amoxicillin/clavulanate dosage (see also our co-amoxiclav (amoxicillin with clavulanic acid) dose page)
- Clindamycin dosing: Drugs.com: Clindamycin dosage (see also our clindamycin dose page)
- Morphine dosing: Drugs.com: Morphine dosage (see also our morphine dose page)
- Tetanus toxoid and immunoglobulin dosing: Drugs.com: Tetanus toxoid dosage (see also our tetanus toxoid and immunoglobulin dose page)
International guidance is linked where it reflects good practice. Where your hospital’s protocol differs, follow your hospital.