What is the most appropriate next step for a patient with a suspected open fracture, stable vital signs, and an open wound with devitalized tissue and dirt, after falling 3 meters onto their right leg?

Most Appropriate Next Step: Antibiotics

For this patient with an open fracture (devitalized tissue and dirt in wound), antibiotics should be administered immediately as the most appropriate next step, ideally within 3 hours of injury to minimize infection risk. 1, 2, 3

Rationale for Prioritizing Antibiotics

This is a contaminated wound (Class III) requiring therapeutic antibiotic therapy, not just prophylaxis. 1 The presence of devitalized tissue and dirt indicates significant contamination, making early antibiotic administration critical before any surgical intervention. 1

Timing is critical: Delaying antibiotic administration beyond 3 hours post-injury significantly increases infection risk. 2, 3 The patient's vital signs are stable (BP 112/70, HR 99, RR 22, SpO2 95%), allowing time for immediate antibiotic administration before proceeding to the operating room. 1

Recommended Antibiotic Regimen

For this open fracture with contamination:

• Start with a first-generation cephalosporin (cefazolin) to cover Staphylococcus aureus, streptococci, and aerobic gram-negative bacilli 1, 2, 3
• Add an aminoglycoside (gentamicin) if this appears to be a Gustilo-Anderson type III fracture based on the extent of soft tissue damage and contamination 1, 2, 3
• Consider adding penicillin given the gross contamination with dirt to cover anaerobic organisms including Clostridium species 2, 4

Duration should be 3 days for type I/II fractures or up to 72 hours for type III fractures, but no more than 24 hours after wound closure. 1, 2

Why Not the Other Options First?

Surgical debridement (Option C) is absolutely necessary and should follow immediately after antibiotic administration, but antibiotics must be started first to achieve tissue levels before incision. 1, 4 The guideline explicitly states antibiotics should be given "as soon as possible after injury" and within 60 minutes before surgical incision. 1

External fixator (Option B) and urgent internal fixation (Option D) are both components of definitive fracture management but occur after initial antibiotic administration and surgical debridement. 1, 4 The splint already provides temporary stabilization. 1

Complete Management Sequence

After immediate antibiotic administration, the algorithmic approach should be:

1. Antibiotics started immediately (already discussed above) 1, 2
2. Surgical debridement with thorough irrigation and removal of devitalized tissue 1, 4, 5
3. Fracture stabilization (external fixator for severe contamination, or internal fixation if appropriate) 1, 4
4. Soft tissue coverage within 72 hours to reduce infection risk 1, 6
5. Consider local antibiotic delivery systems (antibiotic-impregnated beads) as adjuncts for severe type III fractures 1, 2, 4

Critical Pitfalls to Avoid

• Do not delay antibiotics waiting for surgical debridement—infection risk increases significantly after 3 hours 2, 3
• Do not use wound cultures obtained immediately post-injury to direct antibiotic choice, as initial pathogens don't correlate with infecting organisms 3
• Do not forget tetanus prophylaxis based on immunization status 1
• Do not perform primary wound closure in contaminated wounds—delayed closure within 3-7 days is preferred 4