In the emergency department, how should I manage a severe open fracture—including initial airway, breathing, circulation stabilization, tetanus prophylaxis, broad‑spectrum antibiotics, and dressing—and what criteria determine whether to attempt limb salvage or proceed with primary amputation?

Management of Severe Open Fractures and Amputated Limbs in the Emergency Department

Initial Stabilization and Resuscitation

Prioritize "life over limb"—if definitive limb salvage would increase mortality risk, pursue damage-control measures or immediate amputation. 1

ABC Assessment and Hemodynamic Status

• Evaluate overall systemic injury burden and patient physiology to determine if limb salvage is advisable 1
• Assess for hemorrhagic shock, associated organ injuries (brain, thorax, abdomen, pelvis, spinal cord), respiratory failure, and coagulopathy 1
• In hemodynamically unstable patients with severe limb trauma complicated by vascular injury or mangled extremity, apply a damage control strategy 1
• In hemodynamically stable patients, limb salvage is recommended 1

Immediate Medical Management

• Administer intravenous antibiotics as soon as possible for open fractures to reduce early infection rates 1, 2
• Continue antibiotic prophylaxis for a maximum duration of 48-72 hours (unless proven infection exists) 1
• Provide tetanus prophylaxis immediately 2, 3
• Photograph the wound, then apply sterile dressing and splint the limb 3

Decision Algorithm: Limb Salvage vs. Primary Amputation

Factors Favoring Limb Salvage

In hemodynamically stable patients without life-threatening injuries, pursue limb salvage when surgically feasible. 1

• Psychological outcomes and quality of life remain superior when limb reimplantation is successful 1
• Delayed amputations have functional outcomes equivalent to immediate amputations, so there is no obstacle to continued limb rescue if surgically feasible 1

Absolute Indications for Primary Amputation

Consider primary amputation when the following clinical situations are present:

• Complete traumatic amputation 1
• Large loss of substance making skin coverage impossible and/or major infectious risks 1
• Multiple fractures with bone loss or ischemic vascular lesions 1
• Uncontrollable hemorrhagic shock despite resuscitation, where continued salvage attempts would increase mortality 1
• Associated pelvic fractures or multiple traumatic amputations (increased mortality and pulmonary embolism risk) 1

Relative Factors (Should NOT Be Used in Isolation)

• Absent plantar sensation at presentation should NOT be a major factor in treatment pathway decisions 1
• Documented major nerve (tibial) transection should NOT be a major factor in deciding between salvage and amputation 1
• Recovery of sensitivity occurs in 67% of patients at two years, even with initial nerve damage 1
• MESS score >7-8 and MESI score >20 have traditionally guided amputation decisions, but recent evidence shows these scores should not be considered in isolation 1, 4, 5
• Cold ischemia >6 hours increases reimplantation failure risk but should be considered a relative rather than independent criterion 1

Surgical Strategy Based on Patient Stability

For Hemodynamically Stable Patients

• Proceed with early appropriate care and definitive osteosynthesis if feasible within 24-36 hours 1
• Thoroughly irrigate and debride the open fracture wound 2
• Achieve wound closure ideally within 72 hours 3

For Hemodynamically Unstable or "Borderline" Patients

Apply Damage Control Orthopaedic Surgery (DCO) strategy:

• Perform temporary stabilization with external fixators (preferred over skeletal traction) when definitive osteosynthesis is not anticipated within 24-36 hours 1
• This approach significantly reduces operative delays, blood loss, and respiratory complications 1
• Once clinical status stabilizes (typically 36-48 hours), schedule safe definitive orthopaedic surgery as early as possible, ideally within the first two weeks 1

Daily Reassessment Parameters

Frequently reassess the following to identify optimal timing for definitive surgery:

• Hemodynamic status 1
• Respiratory function 1
• Acid-base status 1
• Coagulation function 1

Multidisciplinary Rehabilitation and Psychosocial Support

All patients sustaining severe limb trauma must be evaluated for psychosocial risk factors (PTSD, anxiety, low self-efficacy), as these are the greatest determinants of functional outcomes. 1

• Implement multidisciplinary rehabilitation including physical therapy, occupational therapy, and behavioral health interventions to improve both psychological and functional outcomes 1
• Low self-efficacy is associated with worse functional outcomes and increased prosthetic management costs 1

Key Clinical Pearls

• No single gravity criterion requires amputation—management should be based on cumulative injury burden, patient preferences, and surgeon expertise 1
• Amputation (whether initial or secondary) has additional functional benefits if performed distal to the knee 1
• Limb salvage patients require more interventions and rehospitalizations, while amputation offers shorter rehabilitation and fewer surgeries 1
• Ultimately, equivalent functional results are possible with both options when appropriately selected 1