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fractures
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NICE Pathways bring together everything NICE says on a topic in an interactive

flowchart. NICE Pathways are interactive and designed to be used online.

They are updated regularly as new NICE guidance is published. To view the latest
version of this NICE Pathway see:

http://pathways.nice.org.uk/pathways/trauma
NICE Pathway last updated: 29 August 2019

This document contains a single flowchart and uses numbering to link the boxes to the
associated recommendations.

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1 Person with open fracture in hospital

No additional information

2 Antibiotics and dressings

In the emergency department, administer prophylactic intravenous antibiotics immediately to

people with open fractures if not already given.

Consider a saline-soaked dressing covered with an occlusive layer (if not already applied) for
open fractures in the emergency department before debridement.

Do not irrigate open fractures of the long bones, hindfoot or midfoot in the emergency
department before debridement.

3 Debridement, fixation and cover in hospital

Surgery to achieve debridement, fixation and cover of open fractures of the long bone, hindfoot
or midfoot should be performed concurrently by consultants in orthopaedic and plastic surgery
(a combined orthoplastic approach).

Perform debridement:

immediately for highly contaminated open fractures

within 12 hours of injury for high-energy open fractures (likely Gustilo-Anderson
classification type IIIA or type IIIB) that are not highly contaminated
within 24 hours of injury for all other open fractures.

Perform fixation and definitive soft tissue cover:

at the same time as debridement if the next orthoplastic list allows this within the time to
debridement recommended above, or
within 72 hours of injury if definitive soft tissue cover cannot be performed at the time of
debridement.

When internal fixation is used, perform definitive soft tissue cover at the same time.

Consider negative pressure wound therapy after debridement if immediate definitive soft tissue

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cover has not been performed.

NICE has published a medtech innovation briefing on Galaxy UNYCO for temporary
stabilisation of lower limb fractures.

Quality standards

The following quality statement is relevant to this part of the interactive flowchart.

3. Open fractures

4 Limb salvage in hospital

Perform emergency amputation when:

a limb is the source of uncontrollable life-threatening bleeding, or

a limb is salvageable but attempted preservation would pose an unacceptable risk to the
person's life, or
a limb is deemed unsalvageable after orthoplastic assessment.

Include the person and their family members or carers (as appropriate) in a full discussion of the
options if this is possible.

Base the decision whether to perform limb salvage or delayed primary amputation on
multidisciplinary assessment involving an orthopaedic surgeon, a plastic surgeon, a
rehabilitation specialist and the person and their family members or carers (as appropriate).

When indicated, perform the delayed primary amputation within 72 hours of injury.

Do not base the decision whether to perform limb salvage or amputation on an injury severity
tool score.

5 Pain relief in hospital

For people with suspected open fractures, use intravenous morphine as the first-line analgesic
and adjust the dose as needed to achieve adequate pain relief.

If intravenous access has not been established, consider the intranasal route for atomised
delivery of diamorphine or ketamine1.

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Consider ketamine in analgesic doses as a second-line agent.

6 Photographic documentation in hospital

All trusts receiving patients with open fractures must have information governance policies in
place that enable staff to take and use photographs of open fracture wounds for clinical
decision-making 24 hours a day. Protocols must also cover the handling and storage of
photographic images of open fracture wounds.

Consider photographing open fracture wounds when they are first exposed for clinical care
before debridement and at other key stages of management.

Keep any photographs of open fracture wounds in the patient's records.

7 Documentation

See Trauma/fractures in hospital /documentation

1
At the time of publication (February 2016), neither intranasal diamorphine or intranasal ketamine had a UK
marketing authorisation for this indication. The prescriber should follow relevant professional guidance, taking full
responsibility for the decision. Informed consent should be obtained and documented. See the General Medical
Council's Prescribing guidance: prescribing unlicensed medicines for further information.

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Glossary

ASIA

American Spinal Injury Association

BIS

Bispectral Index

Delayed primary amputation

amputation when there is time to delay decision but reconstructive surgery is not involved in the
decision

EEG

electroencephalography

eFAST

extended focused assessment with sonography for trauma

FAST

focused assessment with sonography for trauma

RSI

rapid sequence induction

TARN

trauma audit and research network

MRC

Medical Research Council

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MTC

major trauma centre

MTCs

major trauma centres

NSAIDs

non-steroidal anti-inflammatory drugs

PACS

picture archiving and communication system

Sources

Major trauma: assessment and initial management (2016) NICE guideline NG39

Fractures (complex): assessment and management (2016 updated 2017) NICE guideline NG37

Your responsibility

Guidelines

The recommendations in this guideline represent the view of NICE, arrived at after careful
consideration of the evidence available. When exercising their judgement, professionals and
practitioners are expected to take this guideline fully into account, alongside the individual
needs, preferences and values of their patients or the people using their service. It is not
mandatory to apply the recommendations, and the guideline does not override the responsibility
to make decisions appropriate to the circumstances of the individual, in consultation with them
and their families and carers or guardian.

Local commissioners and providers of healthcare have a responsibility to enable the guideline
to be applied when individual professionals and people using services wish to use it. They
should do so in the context of local and national priorities for funding and developing services,

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and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to
advance equality of opportunity and to reduce health inequalities. Nothing in this guideline
should be interpreted in a way that would be inconsistent with complying with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Technology appraisals

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, health
professionals are expected to take these recommendations fully into account, alongside the
individual needs, preferences and values of their patients. The application of the
recommendations in this interactive flowchart is at the discretion of health professionals and
their individual patients and do not override the responsibility of healthcare professionals to
make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or their carer or guardian.

Commissioners and/or providers have a responsibility to provide the funding required to enable
the recommendations to be applied when individual health professionals and their patients wish
to use it, in accordance with the NHS Constitution. They should do so in light of their duties to
have due regard to the need to eliminate unlawful discrimination, to advance equality of
opportunity and to reduce health inequalities.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

Medical technologies guidance, diagnostics guidance and interventional procedures

guidance

The recommendations in this interactive flowchart represent the view of NICE, arrived at after
careful consideration of the evidence available. When exercising their judgement, healthcare
professionals are expected to take these recommendations fully into account. However, the
interactive flowchart does not override the individual responsibility of healthcare professionals to

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make decisions appropriate to the circumstances of the individual patient, in consultation with
the patient and/or guardian or carer.

Commissioners and/or providers have a responsibility to implement the recommendations, in

their local context, in light of their duties to have due regard to the need to eliminate unlawful
discrimination, advance equality of opportunity, and foster good relations. Nothing in this
interactive flowchart should be interpreted in a way that would be inconsistent with compliance
with those duties.

Commissioners and providers have a responsibility to promote an environmentally sustainable

health and care system and should assess and reduce the environmental impact of
implementing NICE recommendations wherever possible.

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