From Early Antibiotics to Fix and Flap: Current Evidence and Controversies in Open Fracture Management

Maulana Alhamdi Stivani; Teuku Nanta Aulia

doi:10.60084/ijcr.v4i2.431

Authors

Maulana Alhamdi Stivani Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh 23111, Indonesia
Teuku Nanta Aulia Faculty of Medicine, Universitas Syiah Kuala, Banda Aceh 23111, Indonesia

DOI:

https://doi.org/10.60084/ijcr.v4i2.431

Keywords:

Compound fracture, Fracture-related infection, Antibiotic prophylaxis, Wound debridement, Limb salvage

Abstract

Open fractures are severe orthopedic injuries associated with bacterial contamination, fracture-related infection (FRI), nonunion, and potential limb loss. Although established management principles are widely recognized, recent evidence has challenged traditional concepts such as the strict “six-hour rule” for debridement and emphasized the importance of coordinated multidisciplinary care. This narrative review summarizes current concepts and recent advances in open fracture management, focusing on initial assessment, infection prevention, surgical debridement, fracture stabilization, soft tissue reconstruction, and adjunctive local antibiotic strategies. The literature was searched through PubMed, Scopus, and Google Scholar, prioritizing publications from 2019 to 2025, while including seminal earlier studies when relevant. The final narrative synthesis included 21 articles, comprising clinical studies, systematic reviews, meta-analyses, clinical guidelines, and narrative or expert reviews. The reviewed evidence suggests that early intravenous antibiotic administration, adequate surgical debridement, stable mechanical fixation, and timely soft tissue coverage are interdependent components of modern open fracture care. The quality of debridement and early antibiotic delivery appear more consistently associated with infection prevention than strict adherence to a universal six-hour surgical threshold. The fix-and-flap approach may improve outcomes in selected high-grade injuries when appropriate expertise and resources are available. Adjunctive local antibiotic delivery shows potential in high-risk cases, but its indications, dosing, carrier selection, and long-term safety remain insufficiently standardized. Overall, contemporary open fracture management is best understood as a quality-driven and system-based strategy requiring early infection control, adequate stabilization, soft tissue reconstruction, and coordinated orthoplastic care.

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