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Open calcaneal fracture — MSRA MCQ

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HardAnkle and FootOpen calcaneal fractureMSRA

You are providing pre-hospital medical care for a 36-year-old man who has fallen from a ladder at a construction site 30 minutes ago. He has severe hindfoot pain and cannot stand. There is a 4 cm laceration over the medial heel; the wound communicates with a displaced calcaneal fracture visible through the wound. There is minor particulate contamination but no uncontrolled bleeding. Dorsalis pedis pulse is palpable, capillary refill is 2 seconds and sensation is intact. He is haemodynamically stable and has no apparent head, chest, abdominal or other limb injury. The nearest emergency department is 12 minutes away, whereas the regional major trauma centre with orthoplastic services is 45 minutes away. There is no local trauma-network protocol requiring interim treatment at the nearer hospital. What is the most appropriate management now?

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

Reveal the answer and explanation

Correct answer: B — Apply a saline-soaked occlusive dressing without wound irrigation, give prophylactic intravenous antibiotics immediately and transfer directly to the major trauma centre

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

This is an open hindfoot fracture: the medial heel wound communicates with a calcaneal fracture. The intact pulses and normal capillary refill do not reduce the need for urgent orthoplastic management; they only make an associated major vascular injury less likely. NICE advises that open fractures involving the hindfoot or midfoot should not be irrigated before formal wound excision, because irrigation may disseminate contamination. A saline-soaked dressing with an occlusive layer is appropriate to reduce desiccation and further contamination. Prophylactic intravenous antibiotics should be administered as soon as possible, preferably within 1 hour of injury, without delaying transfer. Where a long bone, hindfoot or midfoot is involved, direct transfer to a major trauma centre or specialist centre capable of orthoplastic care is recommended unless the regional trauma pathway requires interim trauma-unit treatment. A is wrong because bedside irrigation is contraindicated. C substitutes oral treatment and an inappropriate destination for immediate intravenous prophylaxis and specialist assessment. D creates avoidable delay for imaging that will not alter initial management. E is attractive because the wound is contaminated, but formal wound excision should be undertaken by the orthoplastic team rather than through pre-hospital exploration or debridement.

Reference: NICE NG37: Fractures (complex): assessment and management (Updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/Recommendations NICE NG37: Fractures (complex): assessment and management (Updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/Recommendations