What is the first step in managing an open fracture?

First Priority in Open Fracture Management: Stop Bleeding (Answer C)

If an open fracture is associated with severe bleeding, controlling hemorrhage takes absolute priority before any other intervention, including antibiotics, pain control, or debridement. 1

Immediate Management Algorithm

Step 1: Control Life-Threatening Bleeding

• Severe external bleeding from an open fracture must be stopped first using direct pressure or tourniquet application for extremity bleeding not controlled by direct pressure 1
• Long-bone fractures and open fractures can cause substantial and possibly life-threatening blood loss that supersedes all other interventions 1
• If the fractured extremity appears blue, purple, or pale (indicating poor perfusion), activate emergency services immediately while controlling bleeding 1

Step 2: Antibiotic Administration (Within 3 Hours)

• Once bleeding is controlled, antibiotics should be started as soon as possible after injury, ideally within 3 hours, as delays beyond this timeframe significantly increase infection risk 2, 3
• For Gustilo-Anderson type I and II fractures, use first- or second-generation cephalosporin (e.g., cefazolin) 2
• For type III fractures, combine cephalosporin with an aminoglycoside for enhanced gram-negative coverage 2
• Tetanus prophylaxis should be administered concurrently 4

Step 3: Wound Coverage and Splinting

• Cover the open wound with a clean dressing to reduce contamination and infection risk 1
• Splint the fractured extremity to reduce pain, prevent further injury, and facilitate transport 1
• Photograph the wound before covering 5

Step 4: Pain Control

• Address pain management after life-threatening bleeding is controlled and antibiotics are initiated
• Pain control facilitates patient cooperation during transport and subsequent interventions

Step 5: Surgical Debridement

• Definitive surgical debridement should occur after initial stabilization 6, 5
• While early debridement is important, timing within 12 hours does not affect infection rates if antibiotics are administered promptly 3
• Soft tissue coverage should ideally occur within 72 hours to reduce fracture-related infection risk 6, 5

Critical Pitfalls to Avoid

• Never delay hemorrhage control to administer antibiotics or perform other interventions when severe bleeding is present 1
• Do not delay antibiotic administration beyond 3 hours post-injury once bleeding is controlled 2, 3
• Avoid attempting to straighten deformed fractures unless necessary for safe transport 1
• Do not use antiseptics or soap additives for wound irrigation—simple saline is sufficient 2