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Open tibial shaft fracture — MRCEM SBA MCQ

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EasyTraumaOpen tibial shaft fractureMRCEM SBA

A 36-year-old cyclist is brought to a trauma unit after a collision with a car. He is haemodynamically stable. His left lower leg is deformed, with a 4 cm wound over the tibial shaft through which bone is visible. Distal pulses, sensation and movement are intact. The limb has been supported, and the wound has been photographed and covered with a saline-soaked dressing and occlusive layer. He has received analgesia but no antibiotics. Radiographs are pending. This hospital has no orthoplastic service. What is the most appropriate next management plan?

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

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Correct answer: E — Give IV antibiotics now and arrange urgent transfer for combined orthoplastic care.

Visible bone through a wound over the deformed tibial shaft establishes a suspected open long-bone fracture without waiting for radiographs. Because no prophylaxis has been given, IV antibiotics are required immediately in the ED. The wound is already appropriately covered; definitive wound excision, fixation and soft-tissue cover require combined orthopaedic and plastic surgical care, which this hospital cannot provide. Arrange transfer to an orthoplastic centre while continuing limb and neurovascular reassessment. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations)) A is tempting because irrigation is useful for many contaminated wounds, but NICE advises against irrigating open long-bone fractures in the ED before wound excision. B unnecessarily delays antibiotics for imaging: the open fracture is clinically apparent. C would address hard signs of vascular injury, but this patient has an intact distal neurovascular examination. D recognises the need for surgery but separates local fixation from the combined orthoplastic approach without a stated reason for emergency surgery before transfer. ([nice.org.uk](https://www.nice.org.uk/guidance/ng37/chapter/recommendations))

Reference: NICE NG37: Fractures (complex): assessment and management — recommendations 1.2.20–1.2.22 (Last updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations NICE NG37: Fractures (complex): assessment and management — recommendations 1.1.12 and 1.2.27 (Last updated 23 November 2022) — https://www.nice.org.uk/guidance/ng37/chapter/recommendations