For the management of open fractures, consideration must first be given to the patient's general condition with appropriate emergency treatment of pain, haemorrhage and shock. The wound should be protected by a sterile dressing and left undisturbed until hospital treatment can be started. In the emergency department, the wound should be inspected and photographed, and then covered again until it can be treated in theatre.
Prophylactic antibiotics should be given regardless of the severity of the wound, usually benzylpenicillin and flucloxacillin. Addition of gentamicin or metronidazole to cover Gram negative organisms may be necessary if the wound is severe. Tetanus prophylaxis is important - toxoid for those previously immunised, otherwise human antiserum.
A medical history should identify when and where the injury occurred. Examination should assess the extent and type of soft tissue injury and the presence of any vascular or neurologic damage.
An open fracture is a surgical emergency. The probability of infection rapidly increases with time. A contaminated wound becomes an infected wound after 12 hours - more rapidly if the wound is extensive and severely contaminated.
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