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Highly contaminated open tibial shaft fracture — MRCEM SBA MCQ

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HardTraumaHighly contaminated open tibial shaft fractureMRCEM SBA

A 31-year-old farm worker arrives at a major trauma centre 50 minutes after his leg was trapped beneath a tractor in a slurry-filled ditch. He is haemodynamically stable, with no other apparent injury. Radiographs show a displaced tibial shaft fracture. A large wound over the fracture contains visible soil and slurry. His foot is warm, with intact distal pulses, sensation and movement. No antibiotics have been given. Orthopaedic and plastic surgery consultants and an operating theatre are available now; the next scheduled orthoplastic list is in 8 hours. Which management plan is most appropriate?

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

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Correct answer: A — Give intravenous antibiotics now, cover the wound without emergency-department irrigation, and arrange immediate orthoplastic wound excision.

This is an open long-bone fracture with **heavy, visible agricultural contamination**. The decisive distinction is contamination, not simply the fracture’s high-energy mechanism: NICE recommends *immediate* wound excision for highly contaminated open fractures. Intravenous prophylactic antibiotics are due immediately because none have been given. Before surgery, the emergency department should cover the wound rather than irrigate it. Wound excision, fixation and cover should be planned through a combined orthopaedic and plastic surgery approach. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations)) **B** is tempting because a high-energy open fracture that is *not* highly contaminated may undergo wound excision within 12 hours; visible soil and slurry make that timetable inappropriate here. **C** applies the 24-hour window for other open fractures and likewise misses the contamination exception. **D** correctly prioritises surgery but adds emergency-department irrigation, which NICE advises against before wound excision. **E** recognises the urgency but substitutes orthopaedic-only surgery for the recommended combined orthoplastic approach; both specialties are available now. Intact distal perfusion does not reduce the urgency created by heavy contamination. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations))

Reference: NICE NG37: Fractures (complex): assessment and management — recommendations (Last updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations NICE NG37: Fractures (complex): assessment and management — wound excision, fixation and cover (Last updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations NICE NG37: Full guideline — open fractures (2016) — https://www.nice.org.uk/guidance/ng37/evidence/full-guideline-pdf-2359957649