Open Fracture Identified
Fracture with overlying wound communicating with bone
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Orthopedic SurgeryEmergency
Open Fracture Management (EAST/BOAST Guidelines)
Open Fracture Management (EAST/BOAST Guidelines): Open Fracture Identified → ATLS Primary Survey → Prophylactic Antibiotics <1 Hour → Gustilo-Anderson C...
Pathway Overview
17 steps
Algorithm Steps
17 total
01Start 02Action 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
03Action 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
04Decision 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
05Action 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
06Action 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
07Action 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
08Decision Fixation Strategy
Choose appropriate stabilization
09Action 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
10Action 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
11Outcome Fracture Healed
Successful union without infection
12Warning 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
13Action 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)
- Path rejoins step 10Shared downstream outcome
14Action 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
- Path rejoins step 06Shared downstream outcome
15Action 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
16Warning ⚠️ 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
- Path rejoins step 06Shared downstream outcome
17Action Tetanus Prophylaxis
Update tetanus immunization
- Td/Tdap if last booster >5 years ago
- TIG 250 units IM if unknown/incomplete series
- Check immunization history
- Path rejoins step 04Shared downstream outcome
Guideline Source
EAST PMG: Open Fractures Prophylactic Antibiotic Use + BOAST 4
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Antibiotic regimens may vary by institution
- Does not cover pediatric-specific considerations
- Contamination assessment subjective
- Surgical timing recommendations evolving
Applicable Regions
USEU
Version 1Next review: 2027-01-11
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Related Resources
Frequently Asked Questions
What is the Open Fracture Management (EAST/BOAST Guidelines)?
The Open Fracture Management (EAST/BOAST Guidelines) is a emergency clinical algorithm for Orthopedic Surgery. It provides a structured decision tree to guide clinical decision-making, based on EAST PMG: Open Fractures Prophylactic Antibiotic Use + BOAST 4.
What guideline is the Open Fracture Management (EAST/BOAST Guidelines) based on?
This algorithm is based on EAST PMG: Open Fractures Prophylactic Antibiotic Use + BOAST 4 (DOI: 10.1097/TA.0b013e31822e5bda).
What are the limitations of the Open Fracture Management (EAST/BOAST Guidelines)?
Known limitations include: Antibiotic regimens may vary by institution; Does not cover pediatric-specific considerations; Contamination assessment subjective; Surgical timing recommendations evolving. Individual patient factors may require deviation from these recommendations.
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