This document provides guidelines for the treatment of open fractures. It defines open fractures and classifies them based on wound contamination and soft tissue injury. It emphasizes the importance of early intravenous antibiotics within 3 hours, serial examinations, vascular repair within 6 hours, and treatment by a multidisciplinary team for complex fractures. The guidelines recommend early wound debridement and stabilization, along with wound coverage within 7 days to prevent infection.

1. Open Fractures and BOAST
Guidelines
Sheweidin AZIZ – ST3 Trauma and Orthopaedics
Supervised by Mr Prabhakar Motkur – Consultant and Clinical Lead T&O
Boston Pilgrim Hospital
May 2016

2. Objective
1. Definition
2. Classification
3. Epidemiology
4. Microbiology
5. Initial management
6. Definitive management
7. BOAST guidelines
8. Evidence
9. Take home message

3. Take home message
• IV Antibiotics within 3 hours of injury and continue for 72 hours or
until closure
• Serial neurovascular examinations
• Vascular repair ≤6 hours
• Multidisciplinary team (Plastics and Orthopaedics) to treat complex
open fractures (Grade 3 A/B/C)
• Wound is handled to remove gross contamination and allow
photography  cover with saline soaked gauze and impermeable film
• Early transfer of patients to specialised centres
• Definitive stabilisation and wound cover within 72 hours and not
exceed 7 days

5. Definition
A fracture with direct
communication to the external
environment

6. TYPE WOUND CONTAMIN
-ATION
SOFT TISSUE INJURY BONE INJURY
<1cm Clean Minimal Simple minimal comminution
1-10cm Moderate Moderate
Some muscle damage
Moderate comminution
>10cm High Severe with crushing Usually comminuted
Soft tissue coverage may be
possible
>10cm High Very severe
Loss of coverage
Requires reconstructive surgery
Poor bone cover
Moderate to severe
comminution
>10cm High Very severe
Loss of coverage
Vascular injury
Soft tissue reconstructive surgery
Poor bone cover
Moderate to severe
comminution

7. Gustillo Classification I

8. Gustillo Classification II

9. Gustillo Classification IIIA

10. Gustillo Classification IIIB

11. Gustillo Classification IIIC

12. Epidemiology
• Diaphyseal fractures are more common than metaphyseal fractures
• Highest rates of diaphyseal fractures were seen in:
• Tibia 21.6%
• Femur 12.1%
• Radius and Ulna 9.3%
• Humerus 5.7%

13. Microbiology
• Poor tissue oxygenation & devitalisation of the surrounding tissues
including the bone provide a perfect medium for infection and
bacterial multiplication
• When left open >2 weeks – Wound is prone to nosocomial infection
such as pseudomonas species and gram negative species
• This phenomenon of hospital acquired infection emphasizes the
importance of a strict protocol for in-hospital management and early
wound coverage

14. Case - Patient Mr Smith 28 year old RTC Motorbike vs. HGV
Initial management
1. Assess and treat following ATLS
2. IV antibiotics and tetanus prophylaxis
3. Control bleeding – Direct pressure. DO NOT blindly clamp/apply
tourniquet
4. Soft tissue – Assess damage and NV status
5. Dressing - Remove gross contamination. Photograph. Impermeable
film cover
6. Stabilise – Splint. Repeat NV exam

15. Case - Patient Mr Smith 28 year old RTC Motorbike vs. HGV
Management in theatre
1. Aggressive debridement and irrigation
• Low pressure lavage using NaCl 0.9%. 3L, 6L or 9L
• Remove bone fragments without soft tissue attachments
2. Fracture stabilisation – Internal or external
3. Staged debridement – every 24 to 48 hours as needed
4. Early soft tissue coverage or wound closure
• Aim for less than 7 days to decrease risk of infection
5. Place antibiotic bead pouch in dirty wounds

16. Choice of antibiotics
• BOAST guidelines
• Start within 3 hours and continue until debridement
• Co-Amoxiclav 1.2g TDS IV
• OR Cefuroxime 1.5g TDS IV
• OR Clindamycin 600mg QDS IV if penicillin allergic
• Stat dose at wound excision and continue for 72 hours or until
wound closure whichever is sooner
• Co-amoxiclav 1.2g TDS IV and Gentamicin 1.5mg/Kg

17. Time of healing of open tibia fractures
Court-Brown et al. 1990
GUSTILLO TYPE TIME (weeks)
I 15
II 24
IIIA 27
IIIB 38
IIIC 74

18. Gustillo type and risk of infection
Patzakis MJ et al. 1989 77/1104 – early ABx
GUSTILLO TYPE Percentage
I 0-2
II 2-5
IIIA 5-10
IIIB 10-50
IIIC 25-50

19. Take home message
• IV Antibiotics within 3 hours of injury and continue for 72 hours or
until closure
• Serial neurovascular examinations
• Vascular repair ≤6 hours
• Multidisciplinary team (Plastics and Orthopaedics) to treat complex
open fractures
• Wound is handled to remove gross contamination and allow
photography  cover with saline soaked gauze and impermeable film
• Early transfer of patients to specialised centres
• Definitive stabilisation and wound clover within 72 hours and not
exceed 7 days

21. THANK YOU