# @dr.tlesh on Instagram

- **Type:** Video
- **Original URL:** https://www.instagram.com/p/Dd9iuxgpgVX
- **Gondola URL:** https://gondola.cc/posts/71293331-drtlesh-instagram
- **Thumbnail:** https://img.gondola.cc/tr:w-,h-,fo-auto/postThumbnails/e850f3b6d7.jpg
- **Posted:** 2026-10-01T18:23:52.000+00:00
- **Account Owner:** Tyler Lesher (@dr.tlesh) — https://gondola.cc/dr.tlesh

## Caption

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 reduction better than a splint, 96.8 percent versus 73.1 percent (4).
Cover the soft tissue. Coverage after 5 days carried over 7 times the odds of infection (2).
Stop antibiotics on time. Type III open fractures: no more than 24 hours unless infection shows (5).

Open ankle fractures had more complications (33 vs 11 percent) and repeat surgeries (19 vs 7 percent) than closed (6). Open does not mean career over. It means more steps and a slower timeline.

Respect to everyone who got him off the field and into care. More when we know the surgical plan.

Refs (PubMed): 1) Wicks, Foot 2018, 30268006. 2) Lack, J Orthop Trauma 2015, 25526095. 3) GOLIATH, JBJS 2021, 33298796. 4) Foot 2025, 40730078. 5) SIS guidelines, Surg Infect 2022, 36350736. 6) Simske, OTA Int 2019, 33937670
#athletictrainer #sportsmedicine #athletictraining #rugby

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## Tags

rugby, athletictrainer, athletictraining, sportsmedicine

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