What are the guidelines for open fracture management based on British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) recommendations?

Open Fracture Management Based on BAPRAS Guidelines

Note: The provided evidence does not contain specific BAPRAS (British Association of Plastic, Reconstructive and Aesthetic Surgeons) guidelines. However, I will provide comprehensive open fracture management based on the highest quality available guidelines, which align with international best practices that BAPRAS would reference.

Initial Management and Antibiotics

Administer systemic antibiotics as early as possible—ideally within 3 hours of injury—using cefazolin or clindamycin for all open fractures, with mandatory addition of gram-negative coverage (aminoglycoside or piperacillin-tazobactam) for Gustilo-Anderson Type III and possibly Type II fractures. 1

Antibiotic Protocol by Fracture Type:

• Type I and II fractures: Cefazolin 2g IV (or clindamycin 900mg IV if penicillin-allergic) 1
• Type III fractures (and possibly Type II): Add gram-negative coverage with piperacillin-tazobactam (preferred) or aminoglycoside (gentamicin) 1
• Duration: Continue antibiotics for 24-72 hours maximum after wound closure, not beyond 72 hours post-injury unless proven infection exists 1, 2
• Avoid: Routine vancomycin or gentamicin addition does not improve outcomes and should not be routinely added 1, 2

Local Antibiotic Adjuncts:

• Consider vancomycin powder, tobramycin-impregnated beads, or gentamicin-coated implants as beneficial adjuncts, particularly for Type III fractures with bone loss 1, 2

Surgical Timing

Perform débridement and irrigation as soon as reasonably possible, ideally within 24 hours of injury—the historical "6-hour rule" is not supported by current evidence. 1

• Prioritize operating room readiness and appropriate staffing over arbitrary time cutoffs 1
• Certain fractures (e.g., tongue-type calcaneus) may require more urgent intervention 1
• Delays beyond 24 hours increase infection risk and should be avoided when possible 1

Wound Management

Initial Irrigation:

Use simple normal saline without additives (no soap, no antiseptics) for wound irrigation—additives provide no additional benefit. 1

Débridement Principles:

• Perform thorough surgical débridement and trimming of devitalized tissue 1
• Reassess wound viability and contamination intraoperatively 1, 3
• Do not primarily close contaminated or extensively damaged wounds 3

Fracture Fixation Strategy

Definitive fixation with primary wound closure may be performed at initial débridement in selected patients with favorable soft tissue conditions; otherwise, use temporizing external fixation. 1

Decision Algorithm:

• Simple injury patterns (minimal contamination, adequate soft tissue): Consider primary definitive fixation and closure 4, 5
• Substantial contamination, bone loss, or extensive soft tissue damage: Perform temporary external fixation and staged closure 4, 5
• External fixation remains a viable and appropriate option for severe open fractures 1

Soft Tissue Coverage

Achieve definitive soft tissue coverage within 7 days of injury, ideally within 72 hours, to reduce fracture-related infection risk. 1, 4, 5

Coverage Options:

• Primary closure for simple wounds with adequate soft tissue 4
• Local or free flaps for extensive soft tissue loss 3, 6
• Temporary wound coverage (e.g., negative pressure wound therapy) until definitive closure 4

Negative Pressure Wound Therapy (NPWT)

After open fracture fixation, NPWT does not decrease wound complications or amputations compared to standard sealed dressings and should not be routinely used. 1

• Exception: Consider NPWT for high-risk surgical incisions after closed reduction (pilon, plateau, calcaneus fractures) where it may reduce revision surgery risk 1
• Cost-benefit ratio has not been fully established 1

Additional Preventive Measures

Tetanus Prophylaxis:

• Verify immunization status and administer tetanus immune globulin and/or vaccination per protocol 1

Wound Documentation:

• Photograph wounds before covering with sterile dressings 5
• Document neurovascular status and compartment syndrome risk 1, 5

Fracture Immobilization:

• Splint and realign fractures in the emergency department 1, 5
• Cover wounds with sterile wet dressings until surgical intervention 1

Common Pitfalls to Avoid

• Delaying antibiotics beyond 3 hours significantly increases deep infection risk 1, 7
• Using irrigation additives (soap, antiseptics) provides no benefit over saline alone 1
• Routinely adding vancomycin or gentamicin to standard prophylaxis does not improve outcomes 1
• Delaying soft tissue coverage beyond 7 days increases infection and nonunion rates 1, 4
• Using NPWT routinely for open fractures increases costs without proven benefit 1
• Adhering rigidly to the "6-hour rule" when operating room conditions are suboptimal 1

Risk Factors Requiring Counseling

• Smoking and diabetes increase SSI risk 1
• Significant alcohol use (>14 units/week) increases postoperative infection risk 1
• Obesity may increase SSI risk 1
• Race and socioeconomic status show minimal evidence of affecting SSI risk 1