Timing of surgical debridement in open fractures: Is the six‑hour rule still valid? A narrative review

Background: Open fractures are orthopedic emergencies associated with a high risk of infection and complications. For decades, the management of these injuries has been guided by the traditional “six‑hour rule,” recommending surgical debridement within six hours after injury to minimize infection risk. However, recent evidence has questioned the validity of this principle.

Objective: To review the historical origin of the six‑hour rule and evaluate contemporary evidence regarding the optimal timing of surgical debridement in open fractures.

Methods: A narrative review of clinical studies, systematic reviews, and international guidelines analyzing the relationship between time to debridement and infection rates in open fractures.

Results: Recent studies suggest that infection rates are not significantly increased when surgical debridement is performed within 12–24 hours, provided that early antibiotic therapy is administered. The severity of soft tissue injury, contamination, and adequacy of surgical debridement appear to play a more critical role than timing alone.

Conclusion: Current evidence does not strongly support the strict six‑hour rule. Early antibiotic administration and meticulous surgical debridement remain the key determinants of outcome in open fractures.