Thorough neurovascular exam: Any fracture high enough injury to break the skin should be thoroughly examined to determine if intervening neurovascular structures are injured.

Skin examination: Skin overlying every fracture should be evaluated for dermal violation.

If a wound violating the dermis is present, it should be considered an open fracture until deemed otherwise.

Concomitant injuries should be ruled out.

Timing: Intravenous antibiotics should be given when an open fracture is suspected.

Cefazolin: Weight-based cefazolin should be given to every patient with open fracture unless the patient has a known allergy.

Gram-negative coverage: Guidelines are currently debated. In severe open fractures, an aminoglycoside in weight-based dosing is given (e.g., gentamicin); some hospitals have moved on to fluoroquinolones, because of the better side effect profiles, or piperacillin-tazobactam; for severe open fractures (described as Gustilo IIIA-C), be aware of your hospital’s policy.

Penicillin: Given for farm, barnyard, and heavily contaminated injuries.

Fluoroquinolones: Usually given for injuries occurring in standing water.