Apley’s System of Orthopaedics and Fractures 9th ed

 All open fractures, must be assumed to be

contaminated; it is important to try to prevent
them from becoming infected. The four
essentials are:
◦ Antibiotic prophylaxis.
◦ Urgent wound and fracture debridement.
◦ Stabilization of the fracture.
◦ Early definitive wound cover.
 The wound should be kept covered until the
patient reaches the operating theatre. In most
cases co-amoxiclav or cefuroxime (or
clindamycin if penicillin allergy is an issue) is
given as soon as possible, often in the
Accident and Emergency department.
 At the time of debridement, gentamicin is
added to a second dose of the first antibiotic.
 The following principles must be observed:
◦ Wound excision
◦ Removal of devitalized tissue
◦ Wound cleansing
 Stabilizing the fracture is important in reducing
the likelihood of infection and assisting recovery
of the soft tissues. The method of fixation
depends on the degree of contamination, length
of time from injury to operation and amount of
soft-tissue damage.
 If there is no obvious contamination and
definitive wound cover can be achieved at the
time of debridement, open fractures of all grades
can be treated as for a closed injury; internal or
external fixation may be appropriate depending
on the individual characteristics of the fracture
and wound.
 A small, uncontaminated wound in a Grade I or II
fracture may (after debridement) be sutured,
provided this can be done without tension.
 In the more severe grades of injury, immediate
fracture stabilization and wound cover using
split-skin grafts, local or distant flaps is ideal,
provided both orthopaedic and plastic surgeons
are satisfied that a clean, viable wound has been
achieved after debridement. In the absence of
this combined approach at the time of
debridement, the fracture is stabilized and the
wound left open and dressed with an impervious
dressing.