Quality statement 3: Open fractures

Quality statement

People with open fractures of long bones, the hindfoot or midfoot have fixation and definitive soft tissue cover within 72 hours of injury if this cannot be performed at the same time as debridement.

Rationale

Delays in the fixation and cover of open fractures of the long bones of the lower and upper limbs, hindfoot or midfoot can lead to infections and further complications, such as amputations. Ideally fixation and soft tissue cover should be performed at the same time as first debridement, but this might not be possible if it would prevent completion of debridement within the recommended time scales. In these circumstances, ensuring that fixation and soft tissue cover are completed within 72 hours of injury should result in fewer complications, reductions in unplanned surgery and length of hospital stays, and faster return to normal activities.

Quality measures

Structure

Evidence that orthopaedic and plastic surgery specialities have a joint orthoplastic surgery service that allows for fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot within 72 hours of injury if this cannot be performed at the same time as debridement.

Data source: Local data collection, for example local protocols.

Process

a) Proportion of open fractures of long bones, the hindfoot or midfoot with fixation and definitive soft tissue cover performed within 72 hours of injury if this cannot be performed at the same time as debridement.

Numerator – the number in the denominator with fixation and definitive soft tissue cover performed within 72 hours of injury.

Denominator – the number of open fractures of long bones, the hindfoot or midfoot where fixation and soft tissue cover cannot be performed at the same time as debridement.

Data source: Local data collection.

b) Proportion of open fractures of long bones, the hindfoot or midfoot with fixation and definitive soft tissue cover performed within 72 hours of injury.

Numerator – the number in the denominator with fixation and definitive soft tissue cover performed within 72 hours of injury.

Denominator – the number of open fractures of long bones, the hindfoot or midfoot.

Data source: The Trauma Audit and Research Network collects data on BOAST4 patients who received soft tissue coverage within the target of 72 hours.

Outcomes

a) Rates of unplanned surgery after surgery on open fractures.

Data source: Local data collection, for example local audit of patient records.

b) Non-emergency amputation rates for people with open fractures.

Data source: Local data collection, for example local audit of patient records.

c) Length of hospital stay for people with open fractures.

Data source: Local data collection, for example using Hospital Episode Statistics data from NHS Digital. The Trauma Audit and Research Network also collects data on length of stay in hospital for trauma patients.

d) Time taken to return to normal activities for people with open fractures.

Data source: Local data collection, for example patient surveys.

What the quality statement means for different audiences

Service providers (major trauma centres, specialist orthoplastic centres, trauma units and district general hospitals) ensure that orthoplastic surgery lists and joint working arrangements are in place for consultants in orthopaedic and plastic surgery to perform fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot concurrently and within 72 hours of injury if this cannot be performed at the same time as debridement.

Healthcare professionals (orthopaedic and plastic surgery consultants) perform fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot concurrently and within 72 hours of injury if this cannot be performed at the same time as debridement.

Commissioners (clinical commissioning groups and NHS England) ensure that they commission services that have an orthoplastic surgery list and a combined orthoplastic approach to performing fixation and definitive soft tissue cover of open fractures of long bones, the hindfoot or midfoot within 72 hours of injury if this cannot be performed at the same time as debridement.

People with breaks in a bone complicated by a wound have their broken bones fixed using wires, plates, screws or rods (known as internal fixation) or an external frame (known as external fixation). The wound then needs to be repaired to reduce the chance of infection. When possible all of these steps should be done during a single operation. When more than 1 operation is needed, the steps should be completed within 72 hours.

Source guidance

Fractures (complex): assessment and management (2016, updated 2017) NICE guideline NG37, recommendations 1.2.27 and 1.2.29

Definitions of terms used in this quality statement

Open fractures of long bones, the hindfoot or midfoot

A fracture of long bones, the hindfoot or midfoot associated with an open wound. The skin may be pierced by the bone or by a blow that breaks the skin at the time of the fracture. The bone may or may not be visible in the wound. This term is synonymous with 'compound fracture'.

[NICE's full guideline on fractures (complex): assessment and management, glossary]

Fixation

The final surgical implantation of internal or external metalwork for the purposes of repairing a bone and fixing it into place.

[NICE's full guideline on fractures (complex): assessment and management, glossary]

Definitive soft tissue cover

Final closure of the open fracture wound, using a local flap of skin, or skin grafted from another part of the body.

[NICE's full guideline on fractures (complex): assessment and management, glossary]

Debridement

The whole process of opening up of a wound, or pathological area (for example, bone infection), together with the surgical excision of all avascular, contaminated, infected, or other undesirable tissue. Debridement should be performed:

  • immediately for highly contaminated open fractures

  • within 12 hours of injury for high‑energy open fractures (likely Gustilo–Anderson classification type IIIA or type IIIB) that are not highly contaminated

  • within 24 hours of injury for all other open fractures.

[NICE's full guideline on fractures (complex): assessment and management, glossary and recommendation 1.2.28]