Open fracture sepsis prevention — FFICM MCQ

Correct answer: E — Give intravenous antibiotics and cover the wound with sterile saline-soaked dressing

The correct answer is E, give intravenous antibiotics and cover the wound with sterile saline-soaked dressing. In an open, heavily contaminated fracture, the priority before transfer to the orthoplastic centre is to reduce infection risk without disturbing tissues that require formal surgical debridement. NICE guidance on complex fractures recommends immediate prophylactic intravenous antibiotics in the emergency department for open fractures, alongside a saline-soaked dressing covered with an occlusive layer, with definitive wound handling deferred to theatre. This combination controls bacterial load while protecting exposed bone and soft tissue during transfer, and does not compromise the subsequent debridement and skeletal stabilisation performed jointly by orthopaedic and plastic surgical teams. Why the other options are wrong: B. Delay antibiotics until theatre swabs are taken: delaying prophylactic antibiotics increases infection and osteomyelitis risk; antibiotics must be given as soon as possible in the emergency department, not withheld for microbiological sampling. D. Close the wound primarily in the emergency department: primary closure traps contaminated tissue and devitalised material, promoting deep infection and compartment syndrome; open fractures require formal debridement in theatre before any closure decision. A. Apply a tight circumferential dressing: a tight or circumferential dressing risks compressing the limb, compromising already tenuous perfusion, and can precipitate or mask compartment syndrome despite currently present distal pulses. C. Use oral antibiotics after discharge: oral therapy has inadequate bioavailability and timing for surgical prophylaxis in contaminated open fractures; intravenous antibiotics are required immediately, not as an outpatient measure after discharge. Key point: In contaminated open fractures, give immediate intravenous antibiotics and a saline-soaked occlusive dressing, leaving debridement and definitive wound management to the orthoplastic theatre team.

Reference: NICE Guideline NG37, Fractures (complex): assessment and management (2016, updated), recommendations 1.2.21 to 1.2.22 on saline-soaked dressings and immediate prophylactic intravenous antibiotics for open fractures, www.nice.org.uk/guidance/ng37