Open Fractures of the Lower Limb

Two major British surgical associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have worked together to create updated multi-disciplinary standards for the treatment of open fractures of the lower limb

The recommendations are summarised as:

Standards for Practice Audit:

1. Intravenous antibiotics are administered as soon as possible, ideally within 3 hours of injury: Co-amoxiclav (1.2g) or Cefuroxime (1.5g) 8 hourly and are continued until wound debridement. Clindamycin 600mg, 6 hourly if penicillin allergy

2. The vascular and neurological status of the limb is assessed systematically and repeated at intervals, particularly after reduction of fractures or the application of splints

3. Vascular impairment requires immediate surgery and restoration of the circulation using shunts, ideally within 3-4 hours, with a maximum acceptable delay of 6 hours of warm ischaemia

4. Compartment syndrome also requires immediate surgery, with 4 compartment decompression via 2 incisions

5. Urgent surgery is also needed in some multiply injured patients with open fractures or if the wound is heavily contaminated by marine, agricultural or sewage matter.

6. A combined plan for the management of both the soft tissues and bone is formulated by the plastic and orthopaedic surgical teams and clearly documented

7. The wound is handled only to remove gross contamination and to allow photography, then covered in saline-soaked gauze and an impermeable film to prevent desiccation

8. The limb, including the knee and ankle, is splinted

9. Centres that cannot provide combined plastic and orthopaedic surgical care for severe open tibial fractures have protocols in place for the early transfer of the patient to an appropriate specialist centre

10. The primary surgical treatment (wound excision and fracture stabilisation) of severe open tibial fractures only takes place in a non-specialist centre if the patient cannot be transferred safely

11. The wound, soft tissue and bone excision (debridement) is performed by senior plastic and orthopaedic surgeons working together on scheduled trauma operating lists within normal working hours and within 24 hours of the injury unless there is marine, agricultural or sewage contamination. The 6 hour rule does not apply for solitary open fractures. Co-amoxiclav (1.2g) and Gentamicin (1.5mg/kg) are administered at wound excision and continued for 72 hours or definitive wound closure, which ever is sooner

12. If definitive skeletal and soft tissue reconstruction is not to be undertaken in a single stage, then vacuum foam dressing or an antibiotic bead pouch is applied until definitive surgery.

13. Definitive skeletal stabilisation and wound cover are achieved within 72hours and should not exceed 7 days.

14. Vacuum foam dressings are not used for definitive wound management in open fractures.

15. The wound in open tibial fractures in children is treated in the same way as adults

The full guidelines are available here