Open Fracture

Open fractures are classified by Gustilo-Anderson: Grade I (<1cm clean wound), Grade II (1–10cm moderate contamination), Grade IIIA (adequate soft tissue cover), Grade IIIB (requires soft tissue flap), Grade IIIC (vascular injury). BOAST 4 mandates…

BOA/BAPRAS BOAST 4 Standards

The pathway

1 · Immediate ATLS assessment

Primary survey — exclude life-threatening injuries before focusing on fracture
Assess neurovascular status distal to fracture: pulses, capillary refill, sensation, motor
Grade the wound using Gustilo-Anderson classification: I / II / IIIA / IIIB / IIIC

2 · Photograph then dress wound

Photograph wound ONCE in emergency department before dressing
Apply saline-soaked gauze covered by dry outer dressing
Do NOT disturb wound further until definitive theatre — each exposure increases infection risk
Splint limb in anatomical position

3 · IV antibiotics within 1 hour of injury

IV co-amoxiclav 1.2g within 1 hour of injury (BOAST 4 standard)
Farm, soil-contaminated, or heavily soiled wounds: add IV metronidazole 500mg
Penicillin allergy: IV clindamycin 600mg + IV gentamicin 5mg/kg
Continue antibiotics until definitive soft tissue closure (maximum 72h)

4 · Tetanus prophylaxis

Check immunisation history
Unvaccinated or uncertain status: tetanus immunoglobulin (TIG) 250 IU IM + tetanus toxoid at separate site
Vaccinated >10 years ago: booster toxoid only

5 · Imaging and specialist referral

X-ray fracture in 2 planes after primary survey
CT angiogram if IIIC (vascular injury) suspected
Early contact with plastic surgery for all Grade III — do not wait until out of hours
Vascular surgery if IIIC

6 · Definitive management within 72 hours

Debridement timing (BOAST): immediately if vascular compromise or heavily contaminated (agricultural, aquatic, sewage); within 12h for other high-energy; within 24h for low-energy
Vascular compromise is an immediate call, not a timed target — follow the BOAST for arterial injuries
Definitive soft tissue cover within 72 hours of injury, if not achieved at debridement — a separate clock from debridement
Internal fixation only when soft tissue cover can immediately follow

7 · Post-operative monitoring

Hourly neurovascular checks for compartment syndrome (6 Ps) for 48 hours post-fixation
Wound review at 48–72h
Microbiology review of intra-operative wound swabs
Physiotherapy and rehabilitation plan from day 1

Drugs

Drug	Dose	Route	Notes
Co-amoxiclav	1.2g Q8h	IV	Within 1 hour of injury. Continue until definitive soft tissue closure (max 72h).
Metronidazole	500mg Q8h	IV	Add for farm, contaminated, or heavily soiled wounds.
Clindamycin	600mg Q8h	IV	Penicillin allergy alternative. Combine with gentamicin 5mg/kg OD.
Gentamicin	5mg/kg OD	IV	Penicillin allergy regimen. Once daily dosing. Check trough levels. Avoid in AKI.
Tetanus immunoglobulin (TIG)	250 IU	IM	For unimmunised or uncertain vaccination status. Give at separate site from toxoid.

When to escalate

Vascular injury (Gustilo IIIC) — vascular surgery NOW, and immediate debridement; do not wait on a clock,Compartment syndrome developing post-fixation — emergency 4-compartment fasciotomy,Systemic sepsis from wound contamination — ITU/HDU, broaden antibiotics per microbiology,Grade IIIB/IIIC without plastic surgery cover achievable within 72 hours — transfer to plastic surgery network centre,Gas gangrene signs (crepitus, rapid spreading erythema, systemic toxicity) — emergency surgical debridement

Reference: BOA/BAPRAS BOAST 4 Open Fracture Guidelines 2017 (updated 2020)

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