Open fracture identified
Wound that communicates with the fracture. Adult pathway. Gustilo grade is confirmed in theatre after debridement.
All Pathways
Orthopedic SurgeryEmergency
Open Fracture Management (BOAST Open Fractures)
Open Fracture Management (BOAST Open Fractures): Open fracture identified → ATLS primary survey first → IV antibiotics as soon as possible, within 1 h o...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action ATLS primary survey first
Treat life-threatening injuries before the limb.
- Control bleeding: direct pressure, packing, or tourniquet as distal as possible
- Re-align and splint the limb; recheck pulses and nerves after each manoeuvre and document
- Photograph the wound when first exposed; remove gross contamination only
- Cover with saline-soaked gauze and occlusive film; no washout in the ED
- Give analgesia before wound and fracture care
03Action IV antibiotics as soon as possible, within 1 h of injury
Adult doses. Severe beta-lactam allergy, pregnancy, renal impairment or child: read the details before you give.
- All open fractures: cefazolin 2 g IV (3 g if >120 kg), then repeat 8-hourly
- Suspected type III (wound >10 cm, high energy, gross contamination, farm injury): cefazolin plus gentamicin, or piperacillin-tazobactam alone, or ceftriaxone alone
- Immediate severe beta-lactam allergy: clindamycin or vancomycin instead of cefazolin
- Gentamicin: avoid in pregnancy, renal impairment and myasthenia gravis; caution in older adults. Dose: see local aminoglycoside guideline
- Farm or soil (Clostridium risk): add high-dose benzylpenicillin; severe penicillin allergy: ID advice. Fresh or salt water: add cover for Aeromonas, Vibrio and Pseudomonas per local or ID advice (no doxycycline in pregnancy)
- Most open fractures: stop 24 h after wound closure or cover; no benefit beyond 72 h. Water or soil contamination: short course, 3 to 5 days. Other doses: see eTG Antibiotic or local guideline
04Action Tetanus prophylaxis: open fracture is a tetanus-prone wound
Base the dose on vaccination history.
- 3 or more doses, last dose more than 5 years ago: booster dT or dTpa (dTpa if pregnant)
- Fewer than 3 doses or history uncertain: vaccine plus tetanus immunoglobulin (TIG) IM
- TIG dose: 250 IU if 24 h or less since injury; 500 IU if more than 24 h
- Humoral immune deficiency or HIV: give TIG whatever the vaccination history
- Child under 10 years: DTPa as per schedule
05Action Refer now to an orthoplastic centre
Long bone, hindfoot or midfoot: transfer directly to a centre with combined orthopaedic and plastic surgery. Hand, wrist, forefoot or digit: may be managed locally.
- Orthopaedic and plastic consultants plan debridement, fixation and cover together
- Rural or remote site: give antibiotics, splint and dress, then arrange urgent retrieval; do not wait for local surgery
- Trauma CT if indicated: include the limb; CT angiogram if arterial injury is suspected
06Warning If ischaemia or compartment syndrome: surgery now
Ischaemia (pulse differs from the other side after re-alignment): start revascularisation within 1 h of arrival. Compartment syndrome (pain out of proportion or on passive stretch; an open wound does not exclude it): immediate fasciotomy.
- Regional block, sedation or low GCS can mask the signs: hourly checks; consider compartment pressure measurement
- Arterial injury: CT angiogram; temporary shunt, then stabilise the bone, then definitive repair
- Consider fasciotomy after revascularisation; consultant orthopaedic plus vascular or plastic surgeon
07Action Debridement timing: immediately, 12 h or 24 h
Time counts from injury.
- Immediately: highly contaminated (farm, water, sewage) or vascular compromise
- Within 12 h: other high-energy open fractures
- Within 24 h: all other low-energy open fractures
08Action Surgical debridement in theatre
Consultant-led, orthopaedic and plastic surgeons together. Extend the wound along fasciotomy lines.
- Excise all non-viable tissue to healthy bleeding tissue
- Remove bone fragments that have no soft-tissue attachment
- Plan a second look if tissue viability is uncertain
- After debridement: fresh instruments, re-prep and re-drape before fixation
09Action Irrigate with normal saline
Do not add soap. Pressure does not change outcome.
- Normal saline; do not use castile soap (more reoperations in the FLOW trial)
- Low or very low (gravity) pressure is acceptable
- Volume by grade: 3 L type I, 6 L type II, 9 L type III
10Decision Grade IIIB or IIIC? Needs flap or arterial repair
Confirm the Gustilo grade after debridement. I: wound 1 cm or less, clean. II: 1 to 10 cm, no extensive soft-tissue damage. IIIA: high energy, soft tissue still covers bone. IIIB: bone exposed, needs flap. IIIC: arterial injury that needs repair.
- If Yes
- Grade IIIB or IIIC
11Action Grade IIIB or IIIC: staged fix and flap
Orthoplastic centre. IIIC: vascular repair as in the limb-threat step.
- Temporary spanning external fixation at first debridement if cover cannot follow
- Definitive soft-tissue cover (flap) within 72 h of injury
- Definitive internal fixation only when flap cover follows at the same operation
- Salvage or amputation: orthopaedic and plastic consultants, rehabilitation specialist, patient and family decide; two consultants document early amputation; if amputation, within 72 h of injury
12Warning After surgery: watch for compartment syndrome and infection
Check the limb hourly while at risk. Stop antibiotics 24 h after wound cover.
- Compartment syndrome: release dressings, elevate, re-examine within 30 min; decompress at once if diagnosed
- Infection: wound drainage, fever or rising CRP needs early surgical review
- Give information on expected recovery, rehabilitation, work and driving
13Outcome Fracture united without infection
Follow-up by the treating orthoplastic team.
If No- Grade I, II or IIIA
14Action Grade I, II or IIIA: fix and close
Soft tissue can cover the bone.
- Definitive internal fixation only if wound closure or cover follows at the same operation
- Otherwise: temporary external fixation
- Close at debridement if clean; otherwise close within 72 h of injury
- Path rejoins step 12Shared downstream outcome
Guideline Source
BOAST Open Fractures (BOA/BAPRAS, Dec 2017); antibiotics: AAST Critical Care Committee consensus (2024); limb threat: BOASt arterial injuries (Jun 2026) and BOASt compartment syndrome (Jul 2025)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Adults only: antibiotic doses are adult doses; use a paediatric guideline for children
- Gentamicin, piperacillin-tazobactam, ceftriaxone, clindamycin and vancomycin doses are not given: follow eTG Antibiotic or the local network guideline
- Gustilo grade is confirmed only in theatre; grade-based steps may change after debridement
- Hand, wrist, forefoot and digit fractures may follow local pathways
Contraindicated Populations
Children (adult doses only)
Applicable Regions
AUUKUSEU
AU: Tetanus per Australian Immunisation Handbook (TIG 250 IU, or 500 IU if more than 24 h). Trauma Victoria advises piperacillin-tazobactam for grossly contaminated wounds or presentation more than 8 h after injury; confirm the regimen with eTG Antibiotic or the local trauma network.
UK: BOAST Open Fractures: each trauma network must publish its own open-fracture antibiotic guideline.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Open Fracture Management (BOAST Open Fractures)?
The Open Fracture Management (BOAST Open Fractures) is a emergency clinical algorithm for Orthopedic Surgery. It provides a structured decision tree to guide clinical decision-making, based on BOAST Open Fractures (BOA/BAPRAS, Dec 2017); antibiotics: AAST Critical Care Committee consensus (2024); limb threat: BOASt arterial injuries (Jun 2026) and BOASt compartment syndrome (Jul 2025).
What guideline is the Open Fracture Management (BOAST Open Fractures) based on?
This algorithm is based on BOAST Open Fractures (BOA/BAPRAS, Dec 2017); antibiotics: AAST Critical Care Committee consensus (2024); limb threat: BOASt arterial injuries (Jun 2026) and BOASt compartment syndrome (Jul 2025).
What are the limitations of the Open Fracture Management (BOAST Open Fractures)?
Known limitations include: Adults only: antibiotic doses are adult doses; use a paediatric guideline for children; Gentamicin, piperacillin-tazobactam, ceftriaxone, clindamycin and vancomycin doses are not given: follow eTG Antibiotic or the local network guideline; Gustilo grade is confirmed only in theatre; grade-based steps may change after debridement; Hand, wrist, forefoot and digit fractures may follow local pathways. Individual patient factors may require deviation from these recommendations.
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