Open Fracture Management — ABOS Oral Boards Preparation
What examiners expect and how to prepare
Clinical Scenario
A 22-year-old right-hand-dominant male is brought to the trauma bay after a high-speed motorcycle collision. He was wearing a helmet but no lower extremity protection. He is hemodynamically stable. ATLS primary survey is intact. On secondary survey, the right leg has a 6 cm wound over the anterior tibia with exposed bone visible, gross contamination with road debris, and active bleeding controlled with direct pressure. The foot is warm with palpable dorsalis pedis pulse but diminished posterior tibial pulse. Sensation is intact in all distributions. Compartments are soft. There is significant soft tissue stripping with periosteal exposure extending beyond the wound margins.
AP and lateral radiographs reveal a comminuted tibial shaft fracture with a butterfly fragment and approximately 2 cm of bone loss at the fracture site. The fibula is fractured at the same level. There is no proximal or distal articular involvement.
After IV antibiotics (cefazolin and gentamicin) in the emergency department and tetanus prophylaxis, you performed emergent irrigation and debridement in the operating room within 90 minutes of arrival. The wound was extended, all devitalized tissue debrided, and the wound was irrigated with 9 liters of low-pressure normal saline. The fracture was temporarily stabilized with a spanning external fixator. The wound was left open with a negative pressure wound therapy dressing. Definitive soft tissue coverage with a free flap was performed at 5 days, and conversion to an intramedullary nail was done at 2 weeks.
What Examiners Look For
- Data gathering: ATLS first — vascular status, compartment assessment, and systemic injury screening before focusing on the open fracture.
- Diagnosis: Classify the open fracture accurately. Describe the wound, degree of contamination, periosteal stripping, and bone loss systematically.
- Treatment plan: Antibiotic protocol by Gustilo type — know the standard regimens and timing. When do you add penicillin for farm/soil contamination?
- Technical skill: Describe your debridement principles — what tissue is debrided, how do you assess muscle viability (color, capacity, contractility, consistency, bleeding)?
- Indications: Why temporary external fixation before definitive nailing? What is the timing rationale for staged reconstruction?
- Complications: What if the wound develops infection after flap coverage? How do you manage a segmental bone defect — Masquelet, bone transport, or acute shortening?
- Outcomes: Discuss the Gustilo IIIB and IIIC salvage-versus-amputation decision. What factors guide this discussion with the patient?
Common Pitfalls
- Naming specific antibiotic trials by author or publication year — state the protocol, not the paper.
- Performing high-pressure lavage — current evidence favors low-pressure irrigation. Know why.
- Rushing to definitive fixation without addressing soft tissue — staged management is the standard for severe open fractures.
- Forgetting tetanus prophylaxis — simple but commonly omitted in the oral exam.
- Not discussing the vascular injury workup when pulses are diminished — ABI, CTA, or vascular surgery consultation.
Key Classifications
Related Scenarios
Free — takes 3 minutes