An open fracture is a fracture that communicates with the outside world through a wound, and at the CST management and clinical station the answer is the BOAST open fracture standard said in order: antibiotics ideally within 1 hour of injury, neurovascular assessment documented and repeated, a photograph, gross contamination removed and the wound covered with saline-soaked gauze under an occlusive film, the limb realigned and splinted, and a combined orthoplastic plan. According to the British Orthopaedic Association and BAPRAS, whose standard dates from December 2017, the consequences of infection can be great for the patient and the community.

Key takeaways

  • BOAST says intravenous prophylactic antibiotics should be given as soon as possible, ideally within 1 hour of injury, following a published network guideline
  • Vascular and neurological status is assessed and documented, and repeated after any reduction or splinting; NICE NG37 asks for both limbs to be documented
  • Before formal debridement the wound is handled only to remove gross contamination and allow photography, then dressed with saline-soaked gauze and an occlusive film
  • Debridement is immediate for highly contaminated wounds or vascular compromise, within 12 hours of injury for other solitary high-energy fractures, and within 24 hours for low-energy fractures
  • Definitive soft tissue closure or coverage is achieved within 72 hours of injury if not done at debridement, and NG37 says to do it at the same time as internal fixation
  • Fixation and cover are planned concurrently by consultants in orthopaedic and plastic surgery, the combined orthoplastic approach

How do I assess a patient with an open fracture?

Assess an open fracture as a trauma patient first: a primary survey with catastrophic haemorrhage control, then the limb, using the CCrISP structure of immediate management, full assessment and a plan.

In the immediate stage control bleeding with direct pressure, give analgesia, and give intravenous antibiotics. In the full assessment examine and document the vascular and neurological status of the limb, then repeat it after every reduction or splint, as BOAST requires.

NG37 asks that you document for both limbs which nerves were assessed, sensibility, motor function on the MRC scale, which pulses were checked and how circulation was assessed when pulses were absent.

What must happen in the first hour after an open fracture?

In the first hour, antibiotics: BOAST says intravenous prophylactic antibiotics should be administered as soon as possible, ideally within 1 hour of injury, according to a readily accessible network guideline.

Check tetanus status and give the vaccine or immunoglobulin as the local policy directs. The antibiotic choice is the network's, so say that you would follow the trauma network guideline rather than name a drug the panel may not use.

How do I manage the wound before theatre?

Manage the wound before theatre by photographing it when it is first exposed, removing only gross contamination, and dressing it with saline-soaked gauze covered by an occlusive film, then leaving it alone.

According to BOAST, photographs are taken when the wound is first exposed for clinical care, before debridement and at other key stages, and kept in the record. NG37 says hospitals must have information governance in place so staff can take those photographs 24 hours a day.

Repeated inspection by every team that arrives is what the photograph prevents. Realign and splint the limb, and re-check the pulses and sensation after you have done so.

When is an open fracture debrided?

An open fracture is debrided immediately when the wound is highly contaminated, such as agricultural, aquatic or sewage contamination, or when there is vascular compromise from compartment syndrome or arterial disruption.

For other solitary high-energy open fractures BOAST sets debridement within 12 hours of injury, and for all other low-energy open fractures within 24 hours. NG37 uses the same three categories and describes the high-energy group as likely Gustilo-Anderson type IIIA or IIIB.

Debridement uses fasciotomy lines for wound extension where possible, and once it is complete any further procedure at the same sitting is treated as clean surgery, with fresh instruments and a re-prep and drape.

When is soft tissue cover achieved, and who plans it?

Soft tissue cover is achieved at the time of debridement where possible, and otherwise within 72 hours of injury, and it is planned jointly by consultants in orthopaedic and plastic surgery.

BOAST states that the management plan for fixation and coverage, and the initial debridement, should be undertaken concurrently by both consultants: the combined orthoplastic approach. NG37 adds that when internal fixation is used, definitive cover is done at the same time.

If cover cannot be immediate, NG37's 2022 update asks for a temporary dressing that avoids wound desiccation and minimises dressing changes. NG37 also says a delayed primary amputation, when indicated, is performed within 72 hours of injury.

Which investigations and referrals does an open fracture need?

An open fracture needs radiographs of the whole bone including the joints above and below, bloods with a group and save, and a referral to the orthopaedic registrar and, for any significant open injury, the plastic surgical team at the same time.

If there is a vascular concern the vascular surgeon is called in parallel, because BOAST puts vascular compromise in the immediate debridement category. Transfer to a major trauma centre with an orthoplastic service follows the network's pathway.

Who do I escalate an open fracture to?

Escalate an open fracture to the orthopaedic registrar at once, to the plastic surgery team for any wound that will need cover, and to the trauma team leader and vascular surgeon where the limb is ischaemic or the patient is polytraumatised.

Say the timings in your call: injured at 21:00, antibiotics given at 21:40, high-energy tibial fracture, so debridement is due by 09:00 and cover by 21:00 on day three. Numbers with a clock attached are what the panel rewards.

What is the interviewer listening for in an open fracture scenario?

The interviewer is listening for antibiotics within the hour, neurovascular status documented twice, the photograph and saline dressing, realignment and splinting, the three debridement timings, and the orthoplastic plan.

  • Trauma primary survey before the limb, even when the wound is the obvious problem
  • Compartment syndrome named as a reason for immediate surgery, with the standard's own words
  • The 12-hour and 24-hour categories attributed to BOAST and NG37 rather than guessed
  • Definitive cover within 72 hours, at the same time as internal fixation
  • Awareness that the wound is not to be explored or re-dressed on the ward

How this comes up at the CST interview

The open fracture scenario is a motorcyclist with a tibial wound in the emergency department at midnight, and the panel wants antibiotics, a photograph and the registrar in your first thirty seconds.

Follow-ups ask when the wound should be debrided, what changes if the foot is cold, and why the plastic surgeons are involved from the start rather than after fixation.

The coresurgeryinterview bank has a scored open fracture scenario among its 299 questions: /Question-Bank/Sample-Questions.