OT notes · Orthopaedics

Debridement of open fracture

Usual anaesthesia
Spinal for lower limb, general or brachial plexus block for upper limb
Position
Supine, limb elevated on bumps
Setting
emergency

Operative note template for debridement and irrigation of an open long-bone fracture, with a filled example for a Gustilo-Anderson type IIIA open tibial shaft fracture stabilised with a temporary monolateral external fixator under spinal anaesthesia.

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Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • wound and deep bone infection
  • need for repeat debridement (second look)
  • need for flap or skin graft cover later
  • delayed union or non-union
  • pin-site infection and pin loosening with external fixator
  • further surgery to change to internal fixation
  • nerve or vessel injury
  • amputation if the limb cannot be saved

Pre-operative details for this operation

  1. Mechanism and time of injuryroad traffic accident / fall / crush / farm injury; date and clock time of injury
  2. Place of contaminationRoadFarm or soilSewage or faecalStanding waterIndoor, cleandecides antibiotic choice
  3. Bone and fracture patternside, bone, level, pattern (transverse / comminuted / segmental / bone loss) from X-ray with joints above and below
  4. First antibiotic in casualtydrug, dose, clock time; interval from injury
  5. Tetanus prophylaxisGivenAlready immunisedNot given (reason)
  6. Distal neurovascular status before surgerydorsalis pedis and posterior tibial pulses, capillary refill, sensation and toe movement; compartment tense or soft
  7. Time from injury to debridementhours
  8. Implants availableexternal fixator set, Schanz pins, rods, clamps; or nail / plate if primary fixation planned

Anaesthesia and position

  1. AnaesthesiaSpinalGeneralRegional block
  2. PositionSupine, limb elevated on bumps
  3. TourniquetApplied, not inflatedInflated (pressure, inflation and deflation times, reason)Not applieddebridement is done with the tourniquet deflated so that bleeding edges can be seen
  4. C-arm (image intensifier)UsedNot used

Operative findings

  1. Gustilo-Anderson grade (re-graded after debridement)IIIIIIAIIIBIIIC
  2. Woundsite, length x width in cm, direction, skin loss, degloving, flaps
  3. ContaminationNone or minimalSurface, not ground inEmbedded in bone or deep tissuetype of material found (mud, grass, grease, clothing)
  4. Musclecompartments involved; dead muscle by the four Cs (colour, consistency, contractility, circulation)
  5. Periosteal stripping and bonelength stripped, loose fragments, bone loss in cm
  6. Tendons, nerves and vessels seen in the woundintact / cut / repaired

Procedure (steps)

  1. Wound wash and skin preparationantiseptic used; wide draping of the whole limb
  2. Wound extensiondirection and length of the surgical extension
  3. Skin edge excisiontrimmed back to bleeding edge; approximate width removed
  4. Subcutaneous fat and fasciacontaminated and devitalised fat excised; fascia opened
  5. Muscle debridementwhich muscles, how much removed; based on the four Cs
  6. TendonsIntact, cleanedCut ends trimmed to viable tendon
  7. Bone endsdelivered and cleaned; avascular fragments removed (number, size); canal cleaned with rongeur or saw, not curetted
  8. Foreign bodies removedwhat was removed
  9. IrrigationGravity flowLow-pressure lavageBulb syringefluid (normal saline), volume in litres, additives none
  10. Re-drape, change gloves, gowns and instruments before fixationDoneNot done
  11. Fracture stabilisationMonolateral external fixatorJoint-spanning external fixatorIntramedullary nailPlateSlab onlynumber and site of pins, pins kept out of the zone of injury, reduction checked on C-arm
  12. CulturesNot sentSent (reason)

Closure, drains and dressing

  1. Surgical extensionClosedLeft opensuture used
  2. Traumatic woundClosed loosely without tensionClosed over drainLeft openif open, why
  3. DressingSterile moist dressingNegative pressure wound therapy (NPWT)Antibiotic bead pouchexposed bone, tendon or nerve covered and kept moist
  4. Pin-site dressingcompressive gauze wrap around each pin
  5. Splintslab or foot plate to keep ankle at neutral if needed
  6. Distal neurovascular status at end

Specimens and implants

  1. Debrided tissueDiscardedSent for HPESent for culture
  2. External fixatormake, type (monolateral / monotube / ring), number of Schanz pins with diameter and length, rods, clamps; lot/batch numbers; stickers pasted in file
  3. Internal implant if usednail or plate: make, size, lot/batch, sticker

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Distal neurovascular chartingpulses, capillary refill, sensation and movement every hour for 6 hours, then 4-hourly
  2. Watch for compartment syndromepain out of proportion, pain on passive stretch; inform at once
  3. Limb elevationon pillows
  4. Antibioticsdrug, dose, interval and stop date according to the Gustilo grade
  5. Pin-site carecompressive dressing left 10 to 14 days; daily care only if discharge
  6. Second-look debridementdate planned (usually 48 to 72 hours for type III)
  7. Plastic surgery opinionif bone or implant cannot be covered
  8. Weight bearingnon-weight bearing, with walker, until reviewed
  9. Check X-rayAP and lateral of the whole bone

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.K., 32 years, motorcyclist hit by a truck 4 hours earlier, with an open comminuted fracture of the right tibial shaft and a 6 cm anteromedial wound.

Case details

Date: 04/08/2026. Emergency. OT 3.

Time of injury 19:30 (per attendant). In OT 23:10. Spinal given 23:20. Incision 23:35. End 01:05.

Surgeon: Dr A. (3rd-year resident, Orthopaedics). Assistant: Dr B. (1st-year resident). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Diagnosis: open comminuted fracture, middle third shaft of right tibia and fibula, Gustilo-Anderson type IIIA on initial assessment.

Road injury. Wound contaminated with road dust.

Inj ceftriaxone 2 g IV given in casualty at 20:45. Tetanus toxoid given in casualty at 20:50.

Pre-op distal status: dorsalis pedis and posterior tibial pulses felt, capillary refill under 2 seconds, sensation intact in all toes, toe movements present. Leg compartments soft.

Consent: general, procedure-specific (including repeat debridement, flap, amputation) and anaesthesia consent taken in Marathi from patient; brother as witness.

WHO checklist sign in and time out done. Side marked.

Anaesthesia and position

Spinal anaesthesia. Supine, right leg elevated on bumps. Thigh tourniquet applied but not inflated. C-arm from the left side.

Wound washed with normal saline. Limb painted with povidone-iodine from mid-thigh to toes and draped with the foot free.

Findings

6 x 3 cm transverse wound over anteromedial right leg at the junction of middle and distal thirds. No skin loss. Skin edges contused for about 3 mm.

Road grit and grass in the subcutaneous plane and on the bone ends; not embedded in bone.

Tibia comminuted with a 3 cm butterfly fragment. Periosteum stripped for about 4 cm. Tibialis anterior partly torn; small area of non-contractile muscle.

Anterior tibial vessels and deep peroneal nerve not exposed. No tendon cut.

Final grade: Gustilo-Anderson type IIIA (high-energy comminuted fracture, soft tissue can cover the bone).

Procedure

Wound extended 3 cm proximally and 3 cm distally along the medial border of tibia.

Skin edges excised about 3 mm all round to bleeding edge. Contaminated subcutaneous fat excised.

Fascia opened. About 10 g of dark, non-contractile tibialis anterior removed until muscle was red and contracted on pinching.

Bone ends delivered and cleaned. One 1 x 1 cm free cortical fragment without soft tissue attachment removed. Butterfly fragment attached to soft tissue, kept.

Medullary canal ends cleaned with a rongeur. No curettage.

Irrigation with 9 litres normal saline by gravity flow. No additives.

Gloves, gowns and instruments changed. Limb re-draped.

Monolateral external fixator: two Schanz pins in proximal tibia and two in distal tibia, anteromedial face, placed through separate stab incisions away from the wound, predrilled through a sleeve, bicortical. Reduction by traction, checked on C-arm in AP and lateral views; alignment acceptable. Clamps tightened.

Closure

Surgical extensions closed with interrupted polyamide (Ethilon) 2-0. Traumatic wound closed loosely without tension with interrupted Ethilon 2-0. No drain.

Sterile moist gauze dressing. Pin sites wrapped with compressive gauze.

Below-knee posterior slab to keep ankle at neutral.

At end: dorsalis pedis felt, capillary refill under 2 seconds, toe movements present.

Specimens and implants

Debrided tissue discarded in yellow bag. No culture sent.

External fixator: make ______, monolateral, 4 Schanz pins (diameter ___ mm, length ___ mm), 1 rod, 4 pin-rod clamps. Lot/batch numbers ______. Stickers pasted in the file and entered in the OT implant register.

End of procedure

Estimated blood loss 250 ml. No transfusion. Tourniquet not inflated.

Mop, needle and instrument count correct, confirmed by scrub nurse.

No intra-operative complications.

Shifted to post-operative ward in stable condition. Pulse 92/min, BP 124/78 mmHg.

Post-op orders

Right leg elevated on pillows. Toe circulation, sensation and movement every hour for 6 hours, then 4-hourly. Inform if pain increases or toes turn pale or numb.

Inj ceftriaxone 2 g IV once daily, to stop 24 hours after wound closure (wound closed at this operation).

Analgesia as per unit acute pain protocol (drug, dose and times written on the drug chart).

Non-weight bearing on right leg.

Check X-ray right leg with knee and ankle, AP and lateral, tomorrow.

Wound inspection and second-look debridement planned on 06/08/2026 if wound doubtful.

Signature

Dr A., JR-3, Orthopaedics. Reg. no. ________. 05/08/2026, 01:20.

Must document for this operation

  • Gustilo-Anderson grade, re-graded after debridement, with wound size and contamination. The final grade is given only after the wound has been explored, and it decides the antibiotic regimen and the plan for cover.
  • Time of injury, time of first antibiotic and time of debridement. Delay in antibiotics and in debridement of type III tibial fractures raises the infection risk, and audits look at these intervals.
  • Distal neurovascular status before and after surgery. A deficit found later cannot be judged as injury-related or surgery-related unless both are written.
  • What tissue was removed and what was kept, including bone fragments. The next surgeon at the second look needs to know what was left behind and why.
  • Irrigation fluid, method and volume. It shows that a proper lavage was done, which is the core of this operation.
  • Whether the wound was closed or left open, and the dressing used. This decides the date of the next procedure and the need for a plastic surgery opinion.
  • External fixator make, pin number and size, and lot or batch numbers with stickers. Needed for implant traceability, for billing, and for planning conversion to a nail or plate.

Common mistakes in these notes

  • Writing 'wound debridement done' with no wound size, grade or contamination.
  • Not recording the pre-operative pulses and sensation.
  • Leaving out whether the tourniquet was inflated and for how long.
  • Not writing the volume and type of irrigation fluid.
  • Not pasting the external fixator stickers or writing the pin sizes.
  • No clear plan for the second-look debridement or soft-tissue cover.

Indian practice and paperwork

  • NQAS expects tetanus prophylaxis to be given when indicated and antibiotic prophylaxis to be given as indicated before surgery. Write both, with time, in the note. (NQAS Assessor's Guidebook for District Hospitals 2020, ME E15.2)
  • NABH requires the batch and serial number of implants (external fixator pins and rods included) to be recorded in the patient's record, the master logbook and the discharge summary. (NABH 5th ed., MOM.10(d))
  • An audit of orthopaedic operation notes in a Mumbai tertiary centre found tourniquet time recorded in only 41.8% and closure details in 17% of notes. (Tuteja S et al., Indian J Orthop 2022;56(12):2223-2227, PMID 36507202)
  • Debrided human tissue that is not sent for testing is human anatomical waste and goes in the yellow bag. (Bio-Medical Waste Management Rules 2016, CPCB guidelines)

Sources

  • Azar FM, Sawyer JR, Throckmorton TW, eds. Campbell's Operative Orthopaedics. 15th ed. Elsevier; 2027, Ch 58, General principles of fracture treatment: Gustilo-Anderson classification, open fractures, antibiotic treatment, debridement and irrigation (Technique 58.2), fracture stabilisation, pp. 2513-2529.
  • Tornetta P III, ed; Wiesel SW, editor-in-chief. Operative Techniques in Orthopaedic Trauma Surgery. 2nd ed., Ch 50, External fixation of the tibia (Watson JT), pp. 530-547.
  • Campbell's Operative Orthopaedics 15e, Table 58.4 (Siebler et al.): type I/II cefazolin 2 g IV 8-hourly for 24 hours; type III without gross contamination ceftriaxone 2 g IV 24-hourly, 48 hours in total or 24 hours after wound closure, whichever is shorter; soil or faecal contamination add metronidazole 500 mg IV 8-hourly. Printed p. 2525.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Cefazolin 2 g IV (3 g if 120 kg or more) within 60 min before incision. Used here only as the project standard for adult cefazolin dosing; open-fracture antibiotic courses follow the Campbell table above. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

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