Nathan Cleary went down in the NRL preliminary final. Reports call it a compound ankle fracture with a dislocation. Here is why the first hour matters. Compound means open. The bone injury connects to the outside through a skin wound, so it is an infection problem and a soft tissue problem, not only a bone problem. Differentials: open fracture dislocation (what is reported), closed fracture dislocation with threatened skin, isolated tibiotalar dislocation, tibial plafond fracture. Only imaging and the surgeon sort these out. The protocol and why: Reduce and splint fast. Waiting for an xray delayed a reduced joint on film by a mean of 71 minutes and did not improve the first reduction (1). Antibiotics early. Past 66 minutes independently predicted deep infection in open tibia fractures, about 3.8 times the odds (2). Debride. Infection risk rose when debridement of high grade open fractures was delayed, about double the odds past 24 hours (3). Stabilize. An external fixator held reduc...