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BOAST Guidelines
BOAST (Frailty / Fragility)
Trauma

The Care of the Older or Frail Orthopaedic Trauma Patient

Sets out the multidisciplinary standards of care for older or frail orthopaedic trauma patients presenting with fragility fractures, emphasising early comprehensive assessment, rapid surgical stabilization within 36 hours allowing immediate full weight-bearing, proactive perioperative medical optimisation, and secondary fracture prevention.

Key standards

  • ›Multidisciplinary orthogeriatric shared care established from the time of admission.
  • ›Prompt multimodal analgesia including the early administration of regional anaesthetic blocks where applicable.
  • ›Orthogeriatrician review within 72 hours of presentation (ideally within 24 hours).
  • ›Surgical intervention undertaken within 36 hours of admission for patients requiring operative treatment.
  • ›Surgical fixation or arthroplasty designed and performed to allow immediate, unrestricted full weight-bearing.
  • ›Consultant-led or senior-supervised surgical and anaesthetic delivery for all high-risk cases.
  • ›Early mobilization out of bed by postoperative day one supported by dedicated allied health teams.
  • ›Formal bone health and falls risk assessment prior to discharge for secondary fracture prevention.

Introduction

Older patients sustaining low-energy fragility fractures represent a vulnerable cohort characterised by multimorbidity, cognitive impairment, and physical frailty. This standard outlines auditable benchmarks developed collaboratively to optimise outcomes, reduce mortality, and facilitate functional recovery through multidisciplinary ortho-geriatric co-management.

Initial Assessment and Resuscitation

  • Immediate multidisciplinary assessment on arrival, addressing pain, cognitive state (using validated screening tools), hydration, and nutritional status.
  • Rapid analgesia administered promptly via multimodal pathways, incorporating early regional nerve blocks (e.g., fascia iliaca compartment block) where appropriate to reduce systemic opioid requirements.
  • Identification and documented staging of pressure injury risk with prompt implementation of skin preservation measures.

Multidisciplinary Care

  • Care must be delivered through a formalised orthogeriatric co-management model.
  • Routine ortho-geriatric medical review performed within 72 hours of admission (ideally within 24 hours) to optimise medical conditions, manage polypharmacy, and steer perioperative management.
  • Identification of underlying causes of falls and baseline functional capacity.

Timing and Surgical Standards

  • Operative treatment, when indicated, should occur within 36 hours of hospital admission to minimise complications of recumbency and reduce perioperative mortality.
  • Surgery must be planned and executed to achieve absolute or relative stability that permits immediate, unrestricted full weight-bearing for activities of daily living.
  • Senior surgical and anaesthetic involvement (consultant-led or directly supervised) is required for high-risk frail individuals.

Postoperative Rehabilitation

  • Mobilisation out of bed must be initiated on postoperative day one unless explicit, documented clinical contraindications exist.
  • Coordinated allied health input (physiotherapy and occupational therapy) tailored to baseline cognition and functional potential.

Secondary Prevention and Governance

  • Systematic fracture liaison service (FLS) assessment for secondary prevention of fragility fractures, including bone health optimization, bone protection pharmacotherapy, and falls assessment.
  • Routine submission of patient care and outcome data to national clinical registries (e.g., National Hip Fracture Database / relevant national audit frameworks).

Exam-tested points

  • ›Surgical timing cutoff: operative fixation or replacement should take place within 36 hours of admission, which is a frequent FRCS viva benchmark aligning with Best Practice Tariff and NHFD criteria.
  • ›Weight-bearing philosophy: modern implants and reconstructive choices in the frail population must allow immediate full weight-bearing (constructs necessitating non-weight bearing are generally contraindicated unless unavoidable).
  • ›Regional analgesia: early fascia iliaca or femoral nerve blocks decrease acute delirium rates, reduce opiate-related complications, and improve preoperative physiology.
  • ›Acceptable reasons to delay surgery beyond 36 hours: acute reversible medical emergencies (e.g., correctable coagulopathy, acute coronary syndrome, decompensated heart failure, severe electrolyte derangements, sepsis), but delay for non-essential administrative investigations is inappropriate.
  • ›Fracture Liaison Service (FLS) integration: every fragility fracture patient requires dual workup for fall mitigation and osteoporosis therapy (DXA scan or direct initiation of parenteral/oral antiresorptives/anabolics depending on age and clinical criteria).
Official BOA source
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