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BOAST Guidelines
BOAST 4
Trauma

Open Fractures

Sets the UK standards for the collaborative orthoplastic management of open fractures of the long bones, hindfoot, and midfoot to prevent deep infection and optimise limb salvage. Outlines specific timeframes for intravenous antibiotic delivery, joint orthoplastic surgical debridement, and definitive soft-tissue reconstruction.

Key standards

  • ›Patients with open fractures of long bones, hindfoot, or midfoot must be treated in or transferred to an Orthoplastic Centre.
  • ›Intravenous broad-spectrum prophylactic antibiotics must be administered ideally within 1 hour of injury.
  • ›Perform digital photography of the wound prior to applying a sterile dressing; avoid wound probing or washout in the emergency room.
  • ›Perform and record neurovascular assessments before and after reduction, splinting, and manipulations.
  • ›Immediate surgical debridement is mandatory for gross contamination (agricultural, aquatic, faecal), acute compartment syndrome, or devascularising arterial injury.
  • ›Solitary high-energy open fractures require formal excision within 12 hours; low-energy open injuries require excision within 24 hours.
  • ›Debridement and reconstruction must be performed jointly by senior orthopaedic and plastic surgeons.
  • ›Definitive skeletal fixation and soft-tissue reconstruction should ideally occur simultaneously at initial debridement, or within 72 hours (maximum 7 days).
  • ›Cases must be submitted to TARN and reviewed at joint orthoplastic audit meetings.

Introduction

  • Open fractures of long bones, hindfoot, and midfoot carry high risks of severe infection, osteomyelitis, non-union, and limb loss.
  • Definitive treatment requires an integrated orthoplastic approach between orthopaedic and plastic surgery teams operating within dedicated Major Trauma Networks.

Standards

  • Service Delivery & Referral: Patients sustaining open fractures of long bones, hindfoot, or midfoot must be transferred directly or referred promptly to a specialist Orthoplastic Centre. Distal injuries (hand, wrist, forefoot, digits) can be treated locally following equivalent orthoplastic principles.
  • Definition of an Orthoplastic Centre: A combined service delivering consultant-led care from both Orthopaedic and Plastic surgery disciplines, equipped with scheduled joint emergency operating lists, dedicated combined clinics, and specialist nursing teams capable of managing complex flaps and external or internal skeletal fixation.

Initial Assessment & Resuscitation

  • Antimicrobial Therapy: Intravenous prophylactic broad-spectrum antibiotics must be administered as early as possible, ideally within 1 hour of the initial injury, adhering to published regional or network guidelines.
  • Neurovascular Assessment: Perform and clearly document systematic neurological and vascular assessments before and immediately after any manipulation, limb realignment, or splintage. Maintain high vigilance for acute compartment syndrome.
  • Wound Handling: Gross contamination should be gently removed, but deep exploration, washing, or wound probing in the emergency department is prohibited. Take a digital photograph of the wound prior to applying a sterile saline-soaked dressing and securing with an occlusive barrier.
  • Haemorrhage & Splintage: Haemorrhage must be controlled with direct pressure; limb alignment should be restored and stabilised using a rigid or traction splint.

Investigation

  • Radiology: Obtain orthogonal radiographs of the injured segment including the joints above and below.
  • Trauma CT Protocols: When polytrauma imaging is indicated, a head-to-toes CT scanogram should be performed to guide targeted regional computed tomography limb sequences during the same imaging episode.
  • Vascular Imaging: Where vascular compromise persists despite fracture reduction, proceed immediately to surgical exploration or immediate CT angiography in accordance with arterial injury standards.

Surgical Timing & Operative Debridement

  • Immediate Debridement (Emergency): Mandatory immediate surgical intervention is indicated for wounds with gross marine, agricultural, or faecal contamination, or when accompanied by acute limb ischemia or compartment syndrome.
  • Urgent Debridement: Other solitary high-energy open fractures (Gustilo-Anderson IIIA/B) should undergo formal wound excision within 12 hours of injury. Low-energy open injuries should be debrided within 24 hours of injury.
  • Joint Orthoplastic Excision: Surgical debridement must be performed jointly by senior orthopaedic and plastic surgery consultants on a scheduled trauma list, using extending surgical incisions rather than merely exploring through traumatic wounds.

Skeletal Fixation & Soft-Tissue Coverage

  • Skeletal Stabilisation: Attain stable fracture fixation at the time of primary debridement using internal fixation or temporary spanning external fixators.
  • Definitive Reconstruction: Definitive skeletal stabilisation and soft-tissue coverage should ideally occur at the primary debridement, or within 72 hours of injury, not exceeding a maximum window of 7 days.
  • Temporary Dressings: If primary closure or definitive coverage is deferred, apply negative pressure wound therapy (NPWT) or sterile non-adherent dressings; do not leave exposed cortical bone, joints, or neurovascular bundles to desiccate.

Documentation and Governance

  • Both specialties must contribute to simultaneous operative records and joint postoperative follow-up pathways.
  • All open fractures treated within the trauma network must be submitted to the Trauma Audit & Research Network (TARN), and combined local orthoplastic morbidity and mortality meetings must be held regularly.

Exam-tested points

  • ›The '6-hour rule' for all open fractures is obsolete; surgical timing is stratified into immediate (vascular compromise, compartment syndrome, heavy contamination like agricultural/marine), within 12 hours (high-energy), and within 24 hours (low-energy).
  • ›Antibiotics must be delivered within 60 minutes of injury; examiners routinely test this specific time target.
  • ›The emergency room management must NOT include wound irrigation or wound exploration; take a photo, dress with saline-soaked gauze, splint, and avoid disturbing the dressing until the patient is in the operating theatre.
  • ›Definitive soft-tissue coverage and fixation window: ideally within 72 hours of injury, with an absolute upper limit of 7 days.
  • ›Definition of an Orthoplastic Centre includes combined orthopaedic and plastic consultant presence, joint emergency trauma operating lists, specialized allied nursing, combined follow-up clinics, and TARN audit data submission.
  • ›Vascular assessment is dynamic: an absent pulse before reduction that does not return promptly with restoration of length requires immediate joint vascular/orthopaedic intervention according to the BOAST arterial injury guideline.
Official BOA source
Read the official guideline

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