The timing of treatment for broken bones in the legs and arms that also have open wounds

Key messages

We are uncertain whether the different timings of treatments (antibiotics, wound cleaning and whether to do all the surgery in one operation or more) might affect how well people recover from open long bone fractures. We found very few studies, and they did not provide reliable evidence.

What is an open fracture?

Some broken bones include open skin wounds around the break. These are called open fractures and are most common in high impact injuries such as road traffic accidents or falls from a height. In this review, we were interested in the treatment of open fractures of long bones (in the thigh, shin, lower leg, upper arm and forearms). These fractures can be very serious injuries. Because of the open wound, people are at serious risk of infection. A 'deep infection' involves the bone and will require further surgery; it may be limb-threatening and affect long-term recovery.

What are the treatments?

- Antibiotics (to fight infection) may be started early (within an hour of injury) or later; they may be given for a short time (until the wound is surgically closed) or a longer time.

- Debridement: surgically removing any dirt, foreign objects, or dead and damaged tissue from inside the wound: this may be done early (within 12 hours of injury) or later.

- Treatment also includes surgery to fix the bone and close the wound (this may involve moving skin or muscle, or both, from another body area to cover the wound). All stages (debridement, fixing the bone, wound closure) may be completed during a single operation or in multiple operations. If this is done in multiple operations, the wound may be closed early (within 72 hours of injury) or later.

What did we do?

We searched for studies that compared one or more of these treatments for adults who had broken bones with open skin wounds. We wanted to find out the benefits and harms of these different treatments. If we found similar studies, of the same treatments, we combined the findings from the studies to see if we could find out if some treatment resulted in better outcomes.

What did we find?

We found three studies with 613 adults, who had 617 open fractures. Most fractures were in men, and the average age was 30 to 34 years. In two studies, the open fractures were in the shin bone (a common place for this type of injury because there is not much skin and muscle between the bone and skin surface). In the other study, injuries were in arms and legs.

One study compared giving antibiotics for 24 hours (short course) with five days of antibiotics (long course). It is unclear if these treatment times had an effect on the number of people who developed superficial infections within 14 days. Superficial infections are in the skin around the wound, but not deep enough to affect the bone; they may occur early in the recovery period and can be easily treated with antibiotics only.

Two studies compared closing the wound immediately after fixing the bone with a delay to closing the wound. It is unclear if timing of wound closure had an effect on the number of people who developed deep infections, superficial infections, or had delayed bone union (when the broken parts of the bone heal together more slowly than expected) or non-union (when the bone does not heal).

None of the studies looked at how well a person can move their injured arm or leg, or the health-related quality of life of people six to 12 months after treatment.

We found no studies that compared starting antibiotics immediately or later, whether wound cleaning started within 12 hours of the injury or later, or whether the different stages of treatment happened at the same time or separately.

Are we confident in what we found?

We are not very confident in these findings because:

- we only had information from one small study about how long antibiotics are given, and from two studies about when the wound is closed;

- the studies were not well reported, and one was only reported in a short summary;

- all of the findings included the possibility of benefit (for example, fewer infections with a short course of antibiotics) as well as the possibility of harm (for example, more infections with a short course of antibiotics).

How up to date is this review?

The evidence is up to date to February 2021.

Authors' conclusions: 

We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.

Read the full abstract...

Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes.


To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs.

Search strategy: 

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies.

Selection criteria: 

We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery.

Data collection and analysis: 

We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes.

Main results: 

We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement.

Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis)

One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes.

Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis)

Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes.