Open fractures: the BOAST standard, timings and the Gustilo–Anderson classification

What the standard is

UK practice for open fractures is set by two documents that say the same thing: the British Orthopaedic Association Standard for Trauma on open fractures, written jointly with the British Association of Plastic, Reconstructive and Aesthetic Surgeons and last revised in December 2017, and the NICE guideline on complex fractures, NG37. Both are built on one idea — that an open fracture is a combined bone and soft-tissue injury, and that outcomes are best when orthopaedic and plastic surgeons plan and operate together. The written paper is set to this practice, so the timings below are worth knowing exactly.

In the emergency department

The patient is assessed and resuscitated as a trauma patient first; the open fracture is rarely the injury that threatens life. Once that is done, the standard asks for a short and specific sequence.

1. Antibiotics. Intravenous prophylactic antibiotics as soon as possible, ideally within one hour of injury. The agent follows local policy; in practice the first dose is often given before the patient reaches hospital.
2. Neurovascular examination. The vascular and neurological status of the limb is examined and documented, and the examination is repeated systematically, particularly after reduction or the application of a splint.
3. Realign and splint. The limb is brought back into alignment and splinted.
4. The wound. It is handled only to remove gross contamination and to allow photography, then dressed with saline-soaked gauze under an occlusive film. Irrigation or ‘mini-washouts’ outside the operating theatre are not indicated, and the wound is not repeatedly uncovered.
5. Imaging and the plan. Trauma imaging follows the trauma network’s protocol. A management plan is agreed between the orthopaedic and plastic surgeons and written in the notes.

Where the patient goes matters as much as what is done on arrival. Patients with open fractures of long bones, the hindfoot or the midfoot are taken directly, or transferred, to a specialist centre that can provide orthoplastic care. Open fractures of the hand, wrist, forefoot and digits can be managed locally.

When to debride

The old rule that every open fracture must be debrided within six hours has gone. Published series did not show that operating inside six hours reduced infection, whereas operating at night with an inexperienced team and no plastic surgeon clearly had costs. The standard replaces a single deadline with three, according to contamination and energy.

Debridement means excision, not washing. The wound is extended along fasciotomy lines where possible, so that the incisions do not compromise later flap options; the bone ends are delivered; and all devitalised skin, fat, muscle and unattached bone is removed in a systematic sequence from superficial to deep and from the periphery of the wound to its centre. Low-pressure irrigation follows. Once debridement is complete, anything done afterwards in the same operation is treated as a clean procedure, with the limb re-prepared and fresh instruments.

Stabilisation and soft-tissue cover

• Definitive soft-tissue closure or cover should be achieved within 72 hours of injury if it cannot be performed at the time of debridement.
• Definitive internal stabilisation should be carried out only when it can be followed immediately by definitive soft-tissue cover — the principle often summarised as ‘fix and flap’. An implant left exposed in an open wound is the situation to avoid.
• If cover is not immediate, the fracture is held with a spanning external fixator and the wound is temporarily dressed; negative pressure wound therapy may be used as a temporary dressing, but it is not a substitute for cover and does not extend the 72-hour window.
• Antibiotics continue until definitive soft-tissue closure or for a maximum of 72 hours, whichever is sooner.

The Gustilo–Anderson classification

Gustilo and Anderson described three types of open fracture in 1976, and Gustilo, Mendoza and Williams subdivided type III in 1984. The classification grades the severity of the soft-tissue injury and the energy of the fracture, and the risk of infection and of non-union rises with the grade.

Two points about the classification are tested more than the definitions themselves. First, the grade is assigned at surgical debridement, once the wound has been extended and the true zone of injury can be seen: the size of the skin wound in the emergency department routinely underestimates what lies beneath it. Second, the distinction between IIIA and IIIB is made by whether the bone can be covered after debridement, not by the length of the wound — and IIIC is defined by the arterial repair alone.

The classification has limits. Agreement between observers is only moderate, and it says little about function. That is one reason the UK standard does not use the grade to decide where a patient should be treated: the decision to transfer to an orthoplastic centre is based on the bone involved, not on a grade assigned in the emergency department.

Salvage or amputation

The decision between limb salvage and primary amputation in a severe injury is a multidisciplinary one, made by senior orthopaedic and plastic surgeons with the patient and family wherever possible, and with rehabilitation specialists involved early. Emergency amputation is reserved for a limb that is the source of uncontrollable life-threatening bleeding, or one that is unsalvageable. Scoring systems do not make the decision, and an insensate sole at presentation is not on its own an indication to amputate.