BOAST 4 Algorithm 6th September 2013
Background The British Orthopaedic Association and the British Association of Plastic, Reconstructive and Aesthetic Surgeons reviewed their 1997 guidance and published a review of all aspects of the acute management of these injuries using an evidence-based approach, leading to the Standards for the Management of Open Lower Limb Fractures, which are free to download from www.boa.ac.uk and www.bapras.org.uk. The BOAST 4 guideline is derived from these standards. The BOAST 4 guideline requires: 1. Early identification of severe open fractures of the tibia 2. Joint care from orthopaedic and plastic surgeons 3. Surgical wound debridement and operative fracture stabilisation within 24 hours 4. Definitive soft-tissue cover within 72 hours of injury. http://www.boa.ac.uk/lib/libpub/documents/boast%204%20- %20The%20Management%20of%20Severe%20Open%20Lower%20Limb%20Fractures.pdf The TARN Specialist Screen for BOAST 4 enables submission of data on these injuries including a more detailed choice of operative procedures which relate to OPCS codes for both the surgical stabilisation of the fracture and the soft tissue cover procedures. Data Coordinators have been advised to complete details for both procedures in order to accurately evaluate the care of these injuries. Following extensive discussions with the MTC Orthopaedic Group and the Clinical Reference Group an algorithm has been agreed that will serve the BOAST 4 measure and reflect true practice. Gustilo open fracture classification Patients with an open tibial fractures, submitted to TARN, will require a fracture classification the Gustilo fracture classification with definitions will be used (attached). Once this data is entered then patients with Gustilo Grade IIIB and IIIC will be included as the denominator in any future BOAST4 analysis. BOAST4 did avoid specifying Grade IIIB/C because of inter-observer variability. Nevertheless, we believe that this will give a satisfactory solution and, importantly, the denominator must be defined by the injury and not the treatment. The classification should be made by the senior surgeon at the end of the debridement(s) and recorded clearly in the operating note. If a patient requires repeat debridement, so that the classification changes (e.g., from IIIa to IIIb), it is the final classification before definitive wound cover that will be used for BOAST4 and CQUIN. If this is not evident in the clinical notes then the TARN patient submission will be returned to the coordinator requesting the Gustilo grade to be entered. Numerator Number of patients who have definitive cover of severe open lower limb fractures within BOAST 4 guidelines within 72 hours of injury to first receiving hospitals. This includes TU (secondary transfers) or MTC (primary transfers). Clarification of BOAST4 Guideline: Stabilisation within 24 hours of injury and soft tissue cover within 72 hours of injury. Denominator Total number of patients who have an ISS >8 and have severe and open lower limb fractures requiring stabilisation and soft tissue coverage Clarification of BOAST4 Fracture Classification: Patients with an open tibial fracture will require a Gustilo fracture classification and this can be recorded with the injury descriptions in the Trauma Audit & Research Network data collection process. Gustilo Grades IIIB and IIIC will be used to identify included patients. Page 2 of 6
Gustilo Classification I II III IIIA IIIB IIIC Open Fracture. Clean wound, wound less than 1 cm, minimal soft tissue injury Open fracture. Wound greater than 1 cm, moderate soft tissue injury without extensive soft-tissue damage, flaps, avulsions Open fracture with extensive damage to soft tissues, including muscle, skin, and neurovascular structures or loss or an open segmental fracture. This type also includes: Fractures over 8 hours old Fractures requiring vascular repair Farm injuries with soil contamination Type III fracture with adequate soft tissue (periosteal) coverage of fractured bone despite extensive soft tissue laceration or damage. Includes severely comminuted fractures Type III fracture with extensive soft tissue loss and periosteal stripping and bony exposure. Usually associated with massive contamination. Will often need further soft-tissue coverage procedure (i.e. free or rotational flap) Type III fracture associated with arterial injury requiring repair irrespective of degree of soft-tissue injury. Page 3 of 6
Algorithm Submission of patient to TARN All care processes and outcome entered into the TARN electronic Data Collection & Reporting (edcr) system BOAST4 edcr - Specialist BOAST 4 Screen to be completed for all patients with open tibia fractures. Gustilo fracture classification to be included in injury descriptions. All details of processes of care including specific operations to be completed. Dispatch to TARN Dispatch the patient submission to TARN through the edcr Approval by TARN Injury severity coding and approval of submission by TARN staff. Create BOAST4 Report Analysis Selection of Patients: 1. Fracture ISS > 8 and open fracture to the tibia (& fibula in combination) including open Pilon fracture. Gustilo Grades IIIB and IIIC will be used to identify included patients. Abbreviated Injury Scale (AIS) descriptions Tibia Fracture - Open Proximal Tibia fracture - Open Proximal Tibia fracture- extraarticular - Open Proximal Tibia fracture- partial articular - Open Proximal Tibia fracture- complete articular - Open Page 4 of 6
Tibia Shaft fracture Open Tibia Shaft fracture simple - Open Tibia Shaft fracture Wedge - Open Tibia Shaft fracture complex - Open Distal Tibia fracture -Open Distal Tibia fracture extraarticular - Open Distal Tibia fracture partial articular - Open (inc. Pilon fracture) Distal Tibia fracture complete articular - Open Fibula fracture below ankle joint bimalleolar - Open Fibula fracture through ankle joint, bimalleolar - Open Fibula fracture through ankle joint, trimalleolar - Open 2. Gustilo open fracture classification Grade IIIB or IIIC injuries defined by operating surgeon and included within AIS codes 3. Fracture stabilisation and/or fixation within 24 hours Defined by Operation / OPCS codes (see below) 4. Soft tissue cover within 72 hours Defined by Operation / OPCS codes (see below) Procedures (OPCS codes defined) 1. Fracture stabilisation and/or fixation OPCS codes Acute Bone Shortening W17.4 Application of Ilizarov Frame W30.8 Primary Closed reducation and internal fixation W24.9 Primary closed reduction and External fixation W25.8 Primary closed Reduction Fracture W26.8 Primary open Reduction Fracture W22.9 Primary open Reduction & External Fixation W20.8 Primary ORIF - Nail W19.8 Primary ORIF - Pin W19.8 Primary ORIF - Plate W19.8 Primary ORIF - Screw W19.5 Primary ORIF - unspecified W19.9 Primary ORIF - Wire W19.6 Secondary open Reduction & External Fixation. W23.5 Secondary ORIF W23.1 2. Soft tissue cover General Direct wound suture S42.8 Free flap - unspecified S27.9 Page 5 of 6 OPCS codes Graft of skin - unspecified S39.9 Local fasciocutaneous flap S25.2 Local muscle flap Y64.9 Specific Axial pattern distant flap of skin S20.2
Axial pattern local flap of skin S27.2 Axial pattern local subcutaneous pedicle flap S26.2 Flap muscle - Microvacular free tissue transfer T76.1 Flap skin - Distant random pattern S20.4 Flap skin - Local random pattern S27.4 Flap skin - Local sensory S22.4 FLAP SKIN - Neurovascular island sensory S22.2 Harvest flap - Digitorum brevis (extensor) Y64.5 Harvest flap - Gastrocnemius Y64.3 Harvest flap - Gastrocnemius & skin Y62.3 Harvest flap - Gluteus maximus & skin Y61.4 Harvest flap - Gracilis muscle Y64.2 Harvest flap - Latissimus dorsi Y63.1 Harvest flap - Latissimus dorsi muscle & skin Y61.3 Harvest flap - Pectoralis & skin Y61.2 Harvest flap - Rectus abdominis & skin Y61.5 Harvest flap - Serratus anterior Y63.2 Harvest flap - Soleus muscle Y64.4 Harvest flap - Tensor fasciae latae & skin Y62.2 Harvest flap - Trapezius & skin Y61.1 Harvest lower leg flap of skin and fascia Y59.6 Harvest Skin Graft-Other Specified Y58.8 Harvet Flap Epigastric (Inferior) Y63.3 Meshed split autograft skin S35.2 Pedicle flap - Distant myocutaneous subcutaneous S17.2 Pedicle flap - Fasciocutaneous subcutaneous S18.2 Pedicle flap - Local fasciocutaneous subcutaneous S25.2 Page 6 of 6