Open Fractures & Mangled Extremities
Initial assessment, antibiotic selection, and management.
Updated: 05/04/2025
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⚠️ Aggressive intervention or amputation without orthopedic consultation is strongly discouraged.
💊Antibiotic Table (within 1 hour)
▼| Type | Agent | Duration |
|---|---|---|
| I–II | Cefazolin 2g Q8h | 24h |
| III (no contam.) | Ceftriaxone 2g Q24h | 48h or 24h after closure |
| III + soil/fecal | Ceftriaxone 2g Q24 + Metronidazole 500mg Q8h | 48h or 24h after closure |
| III + standing water | Pip/tazo 4.5g Q8h | 48h or 24h after closure |
⚠️
PCN/ceph allergy: I–II → Clindamycin 900mg Q8. III → Levofloxacin 500mg Q24 ± Metronidazole. MRSA risk → add Vancomycin 15mg/kg Q12 per Ortho.
📋Initial Actions
▼- Document neurovascular status of limb
- Antibiotics + tetanus within 1 hour
- Cover with Betadine-soaked gauze — do NOT close in ED
- IP consult AND call Ortho (<30 min bedside)
- Order skeletal films of the injury site plus the joints above and below
- Do not probe open joints — Orthopedics only
- Examine vagina and rectum when pelvic injury is possible
- VTE prophylaxis per VTE CPG from time of admission
📊Gustilo Classification
▼- Grade I: clean wound <1 cm
- Grade II: extensive soft-tissue laceration (>10 cm), damage or loss, or segmental fracture; includes farm injuries and any fracture requiring vascular repair
- Grade III: extensive laceration — three subtypes by periosteal coverage, soft-tissue loss/stripping, and arterial injury
ℹ️
Mangled extremity: injury involving at least three of four anatomic systems — soft tissue, bone, nerves, and/or vessels.
- Status
- AHS Official Protocol
- Source
- Open-Fractures_and_Mangled_Extremities-Updated-8_2024.docx
- Last reviewed / updated
- 05/04/2025