Open Fracture Management (EAST/BOAST Guidelines)

Algorithm Steps

1. ▶

   Start

   Open Fracture Identified

   Fracture with overlying wound communicating with bone

   1. ●

      Action

      ATLS Primary Survey

      Assess and stabilize life-threatening injuries first

      • Airway, Breathing, Circulation
      • Control hemorrhage with direct pressure
      • Assess neurovascular status of limb
      • Cover wound with saline-soaked sterile dressing
      • Photograph wound before covering
      1. ●

         Action

         Prophylactic Antibiotics <1 Hour

         Administer within 1 hour of injury (BOAST)

         • Grade I/II: Cefazolin 2g IV (or Cefuroxime 1.5g IV)
         • Grade III: Add Gentamicin 5mg/kg IV
         • PCN allergy: Clindamycin 600-900mg IV
         • Heavily contaminated: Add Metronidazole 500mg IV
         • Continue antibiotics 24-72h based on wound
         1. ◆

            Decision

            Gustilo-Anderson Classification

            Grade the open fracture

            • Grade I: Wound <1cm, minimal contamination, simple fracture
            • Grade II: Wound 1-10cm, moderate soft tissue damage, no flap
            • Grade IIIA: >10cm wound, adequate soft tissue coverage
            • Grade IIIB: Extensive soft tissue loss, periosteal stripping, requires flap
            • Grade IIIC: Arterial injury requiring repair
            1. ●

               Action

               Grade I/II Management

               Lower severity - simpler treatment

               • Surgical debridement within 24 hours
               • Irrigate with low-pressure saline (3-6L)
               • Internal fixation often appropriate
               • Primary closure may be possible
               • Antibiotics 24-48 hours
               1. ●

                  Action

                  Surgical Debridement

                  Thorough wound management

                  • Extend wound for adequate visualization
                  • Remove ALL nonviable tissue
                  • Debride to healthy bleeding tissue
                  • Preserve periosteum where possible
                  • Remove loose bone fragments without soft tissue
                  • May require serial debridements q48-72h
                  1. ●

                     Action

                     Wound Irrigation

                     Evidence-based irrigation technique

                     • Normal saline (soap may reduce infection)
                     • Low-pressure irrigation preferred
                     • Volume: 3L (Grade I), 6L (Grade II), 9L+ (Grade III)
                     • Avoid high-pressure pulsatile lavage on bone
                     • FLOW trial: Soap + low pressure = lower reoperation
                     1. ◆

                        Decision

                        Fixation Strategy

                        Choose appropriate stabilization

                        1. ●

                           Action

                           Internal Fixation

                           Appropriate for Grade I/II, clean Grade IIIA

                           • IMN or plate fixation
                           • Good soft tissue envelope required
                           • Adequate debridement completed
                           • Lower infection risk than delayed
                           1. ●

                              Action

                              Wound Closure/Coverage

                              Soft tissue management

                              • Primary closure if clean Grade I within 24h
                              • Delayed primary closure at 3-5 days
                              • NPWT as bridge to closure/grafting
                              • Flap coverage for Grade IIIB within 72h
                              • Split-thickness skin graft for granulating wounds
                              1. ✓

                                 Outcome

                                 Fracture Healed

                                 Successful union without infection

                              2. ⚠

                                 Warning

                                 Monitor for Infection/Nonunion

                                 Complications requiring intervention

                                 • Infection rate: 2% (Grade I) to 50%+ (Grade IIIB)
                                 • Signs: persistent drainage, fever, elevated CRP
                                 • May require hardware removal, repeat debridement
                        2. ●

                           Action

                           External Fixation

                           Damage control for severe injuries

                           • Grade IIIB/IIIC injuries
                           • Severely contaminated wounds
                           • Vascular repair required
                           • Polytrauma patient
                           • Convert to internal when safe (7-14 days)
            2. ●

               Action

               Grade IIIA Management

               High energy with adequate coverage

               • Urgent debridement (<6 hours ideal)
               • High-volume irrigation (9L+)
               • External fixation or definitive fixation
               • Delayed primary closure
               • Antibiotics 72 hours
            3. ●

               Action

               Grade IIIB/IIIC Management

               Severe injury requiring multidisciplinary care

               • Emergency debridement ASAP
               • IIIC: Vascular surgery for arterial repair
               • Temporary external fixation
               • Plastic surgery consult for soft tissue coverage
               • Flap coverage within 72 hours (BOAST)
               • Staged definitive fixation
               1. ⚠

                  Warning

                  ⚠️ Grade IIIC - Vascular Emergency

                  Limb-threatening vascular injury

                  • Ischemia time critical - revascularize rapidly
                  • Shunt placement if delay to definitive repair
                  • Consider prophylactic fasciotomy
                  • Monitor for reperfusion compartment syndrome
      2. ●

         Action

         Tetanus Prophylaxis

         Update tetanus immunization

         • Td/Tdap if last booster >5 years ago
         • TIG 250 units IM if unknown/incomplete series
         • Check immunization history