What is the initial management of an open tibia fracture in the Emergency Department (ED) before operating room (OR) intervention?

Initial ED Management of Open Tibia Fractures

Administer antibiotics as soon as possible—ideally within 3 hours of injury—using cefazolin (or clindamycin if penicillin-allergic) for all open tibia fractures, adding gram-negative coverage with an aminoglycoside or piperacillin-tazobactam for Gustilo-Anderson Type III (and possibly Type II) fractures. 1, 2

Immediate Antibiotic Administration

• Start antibiotics within 3 hours of injury to minimize deep infection risk; delays beyond 150 minutes significantly increase infection rates (20% vs 4%) 3, 4
• For Type I and II fractures: Use cefazolin 1-2g IV (or clindamycin 600-900mg IV if beta-lactam allergic) 1, 5
• For Type III fractures (and consider for Type II): Add gram-negative coverage with either an aminoglycoside (gentamicin) or piperacillin-tazobactam 1, 2
• Add penicillin if there is farm-related contamination or risk of clostridial infection 5
• Continue antibiotics for 48-72 hours maximum (or 24 hours after wound closure, whichever is shorter) unless proven infection exists 2, 5

Critical pitfall: Trauma activation, EMS arrival, and daytime presentation are associated with faster antibiotic delivery; walk-in patients and overnight arrivals often experience dangerous delays—be vigilant with these populations 6

Wound Management in the ED

• Apply sterile saline-moistened dressing to the open wound immediately—do not use additives like soap or antiseptics as they provide no benefit 1, 2
• Remove gross contamination gently but avoid aggressive manipulation that could worsen soft tissue injury 2, 4
• Do not use pulse lavage in the ED setting 1
• Photograph the wound for documentation, then cover it and avoid repeated unwrapping for multiple examinations 4

Fracture Stabilization and Tetanus Prophylaxis

• Immobilize the fracture with a well-padded splint to prevent further soft tissue damage and control pain 2
• Check tetanus immunization status and administer tetanus toxoid or tetanus immunoglobulin as indicated 2
• Align the limb to restore length and reduce gross deformity, but avoid multiple manipulation attempts 4

Surgical Timing Coordination

• Coordinate OR availability for débridement and irrigation ideally within 24 hours of injury, though the historical "6-hour rule" is not supported by current evidence when antibiotics are administered promptly 1, 2
• Earlier surgery (within 12 hours) does not reduce infection rates compared to surgery within 24 hours, provided antibiotics are given appropriately 4
• Some fractures may require more urgent attention based on specific injury patterns (e.g., vascular compromise, compartment syndrome) 1

Important nuance: The strength of evidence supports that antibiotic timing is more critical than surgical timing for infection prevention, allowing for better OR resource allocation and staffing 1

Documentation and Communication

• Document the Gustilo-Anderson classification (Type I, II, IIIA, IIIB, or IIIC) based on wound size, contamination, soft tissue injury, and vascular status 1, 2
• Note that the OTA Open Fracture Classification (OTA-OFC) may provide better interobserver agreement but Gustilo-Anderson remains the standard for antibiotic decision-making 1, 2
• Communicate clearly with the orthopedic surgery team regarding antibiotic administration timing and type 6
• Document patient risk factors: smoking, diabetes, obesity, alcohol use (>14 units/week), and ASA score, as these increase surgical site infection risk 2

What NOT to Do

• Do not obtain wound cultures in the ED to guide antibiotic selection—initial cultures do not correlate with eventual infecting organisms 5
• Do not delay antibiotics for imaging or orthopedic consultation 6, 3
• Do not perform extensive wound exploration in the ED—this should occur in the OR under sterile conditions 4
• Do not use topical antiseptics or additives in irrigation solutions 1