<s>[INST] context: Management of open fracture 

Open fracture need immediate surgery to clean the area of the injury.
Because of the break in the skin, debris and infection can travel to the fracture location, and lead to a high rate of infection in the bone.
Once an infection is established, it can be a difficult problem to solve.
Treatment of established bone infections often requires multiple surgeries, prolonged antibiotic treatment and long-term problems.
Therefore, every effort is made to prevent this potential problem with early surgery.
All open fractures, no matter how trivial they are must be assumed to be contaminated.
The four essential principles of treatment for management of open fractures are : -


Antibiotic prophylaxis
Urgent wound and fracture debridement.
Stabilization of fracture (fracture fixation)
Early definitive wound cover 

​Debridement

Patient is taken immediately to surgery and debridement is done by removal of contaminated and devitalized tissue, copious irrigation by sterile solution (usually saline).
As a general rule it is best to leave cut nerves and tendons alone, though if the wound is absolutely clean and no dissection is require, and provided the necessary expertise is available, they can be sutured.

Wound closure

A small, uncontaminated wound in a Grade I or II fracture may (after debridement) be sutured, provided this can be done without tension.
In the more severe grades of injury, immediate fracture stabilization and wound cover using split-skin grafts, local or distant flaps is ideal, provided both orthopaedic and plastic surgeons are satisfied that a clean, viable wound has been achieved after debridement.
In the absence of this combined approach at the time of debridement, the fracture is stabilized and the wound is left open and dressed with impervious dressing.
Return to surgery for a 'second look' should have definitive fracture cover as an objective. It should be done by 48-72 hours, and not later than 5 days.

Stabilizing the fracture

Stabilizing the fracture is important in reducing the likelihood of infection and assisting recovery of the soft tissues.
The method of fixation depends on the degree of contamination, length of time from injury to operation and amount of soft tissue damage.
If there is no obvious contamination and definitive wound cover can be achieved at the time of debridement, open fractures of all grades can be treated as for a closed injury. Internal fixation or external fixation depends on the individual characteristic of fracture.
If wound is contaminated and clean wound cannot be obtained by debridement or if wound cover is delayed, then external fixation by a fixator is safer.

Coming back to question

Debridement, Internal fixation and external fixation all are used in the treatment of open fracture.
For one answer go ahead with debridement because debridement is the most important step and is done in all open fractures.
On the other hand, whether to stabilize the fracture either by internal fixation or external fixation, depends upon specific situations. [/INST] question: Open fracture is treated by -a) Tourniquetb) Internal fixationc) Debridementd) External fixation | options: A: bcd B: acd C: ac D: bd | answer: A </s>