skip to main content

Open midfoot fracture — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

ModerateAnkle and FootOpen midfoot fractureMSRA

A 38-year-old carpenter attends an urgent treatment centre 25 minutes after a circular-saw injury to his right foot. He has received analgesia and his tetanus immunisation is up to date. There is a 6 cm contaminated laceration over the dorsomedial midfoot with exposed cuneiform bone and deformity. Bleeding is controlled. Dorsalis pedis and posterior tibial pulses are palpable, toe capillary refill is normal, and sensation is intact. He has no drug allergies. What is the most appropriate immediate management?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: C — Apply a saline-soaked occlusive dressing without irrigating, give intravenous prophylactic antibiotics immediately and arrange urgent transfer to an orthoplastic centre.

Explanation lettering: B = shown as A · D = shown as B · E = shown as C · C = shown as D · A = shown as E

This is an open midfoot fracture: exposed cuneiform bone establishes communication between fracture and the external environment. NICE advises against irrigating open fractures involving the hindfoot or midfoot before wound excision, including in the emergency department, because definitive wound excision should be undertaken by the orthoplastic team. A saline-soaked dressing with an occlusive layer reduces desiccation and further contamination. Intravenous prophylactic antibiotics should be given immediately; in pre-hospital care they should be administered as soon as possible, preferably within 1 hour, without delaying transfer. Open midfoot fractures require transfer within the trauma network to a major trauma centre or specialist centre able to provide orthoplastic care. A is incorrect because irrigation and oral antibiotics are inappropriate initial measures. B is attractive because it includes IV antibiotics, but a dry dressing, local imaging that may delay transfer, and transfer merely to the nearest ED do not reflect the required pathway. C adds antiseptic cleansing and an inappropriate outpatient pathway. D includes the correct dressing and antibiotic route but manipulation of exposed bone is not indicated without vascular compromise and risks further contamination and tissue injury.

Reference: NICE NG37: Fractures (complex): assessment and management — Recommendations (Published 17 February 2016; last updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations