In 2016 the National Institute for Clinical and Care Excellence (NICE) published a suite of five trauma-related guidelines including the Guideline on Complex Fractures NG37. A significant component of this guideline related specifically to open fractures. Following the publication of that complete trauma suite of five related guidelines there was further work by NICE resulting in the formulation of a Quality Standard Statement. A NICE quality standard is a concise set of statements designed to drive and measure priority quality improvements within a particular area of care. For the entire trauma suite this was distilled to five statements; one of these was specific to open fractures.
The relevant recommendations from the NICE guideline NG37 and statement from the Quality Standard are included and presented below both for easy reference. It also allows the concordance that exists between the text in the rest of this book, the Open Fracture BOAST and NICE to be better appreciated.
© NICE (2016) NG37 Fractures (Complex): Assessment and Management. Available from www.nice.org.uk/guidance/ng37 All rights reserved. Subject to Notice of rights.
NICE guidance is prepared for the National Health Service in England. All NICE guidance is subject to regular review and may be updated or withdrawn. NICE accepts no responsibility for the use of its content in this product/publication.
Statement 3 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.
1.1 Pre-hospital settings
Initial management of open fractures before debridement
1.1.8 Do not irrigate open fractures of the long bones, hindfoot or midfoot in pre-hospital settings.
1.1.9 Consider a saline-soaked dressing covered with an occlusive layer for open fractures in pre-hospital settings.
1.1.10 In the pre-hospital setting, consider administering prophylactic intravenous antibiotics as soon as possible and preferably within 1 hour of injury to people with open fractures without delaying transport to hospital.
Splinting long bone fractures of the leg in the pre-hospital setting
1.1.11 In the pre-hospital setting, consider the following for people with suspected long bone fractures of the legs:
◆ a traction splint or adjacent leg as a splint if the suspected fracture is above the knee
◆ a vacuum splint for all other suspected long bone fractures.
Destination for people with suspected fractures
1.1.12 Transport people with suspected open fractures:
◆ directly to a major trauma centre or specialist centre that can provide orthoplastic care if a long bone, hindfoot or midfoot are involved, or
◆ to the nearest trauma unit or emergency department if the suspected fracture is in the hand, wrist or toes, unless there are pre-hospital triage indications for direct transport to a major trauma centre.
1.2 Hospital settings
1.2.1 Use hard signs (lack of palpable pulse, continued blood loss, or expanding haematoma) to diagnose vascular injury.
1.2.2 Do not rely on capillary return or Doppler signal to exclude vascular injury.
1.2.3 Perform immediate surgical exploration if hard signs of vascular injury persist after any necessary restoration of limb alignment and joint reduction.
1.2.5 Do not delay revascularisation for angiography in people with complex fractures.
Whole-body CT of multiple injuries
1.2.8 Use whole-body CT (consisting of a vertex-to-toes scanogram followed by CT from vertex to mid-thigh) in adults (16 or over) with blunt major trauma and suspected multiple injuries. Patients should not be repositioned during whole-body CT.
1.2.9 Use clinical findings and the scanogram to direct CT of the limbs in adults (16 or over) with limb trauma.
Management of open fractures before debridement
1.2.20 Do not irrigate open fractures of the long bones, hindfoot or midfoot in the emergency department before debridement.
1.2.21 Consider a saline-soaked dressing covered with an occlusive layer (if not already applied) for open fractures in the emergency department before debridement.
1.2.22 In the emergency department, administer prophylactic intravenous antibiotics immediately to people with open fractures if not already given.
Limb salvage in people with open fractures
1.2.23 Do not base the decision whether to perform limb salvage or amputation on an injury severity tool score.
1.2.24 Perform emergency amputation when:
◆ a limb is the source of uncontrollable life-threatening bleeding, or
◆ a limb is salvageable but attempted preservation would pose an unacceptable risk to the person’s life, or
◆ a limb is deemed unsalvageable after orthoplastic assessment.
Include the person and their family members or carers (as appropriate) in a full discussion of the options if this is possible.
1.2.25 Base the decision whether to perform limb salvage or delayed primary amputation on multidisciplinary assessment involving an orthopaedic surgeon, a plastic surgeon, a rehabilitation specialist and the person and their family members or carers (as appropriate).
Debridement, staging of fixation and cover
1.2.27 Surgery to achieve debridement, fixation and cover of open fractures of the long bone, hindfoot or midfoot should be performed concurrently by consultants in orthopaedic and plastic surgery (a combined orthoplastic approach).
1.2.28 Perform debridement:
◆ 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.
1.2.29 Perform fixation and definitive soft tissue cover:
◆ at the same time as debridement if the next orthoplastic list allows this within the time to debridement recommended in 1.2.28, or
◆ within 72 hours of injury if definitive soft tissue cover cannot be performed at the time of debridement.
1.2.30 When internal fixation is used, perform definitive soft tissue cover at the same time.
Photographic documentation of open fracture wounds
1.3.4 All trusts receiving patients with open fractures must have information governance policies in place that enable staff to take and use photographs of open fracture wounds for clinical decision-making 24 hours a day. Protocols must also cover the handling and storage of photographic images of open fracture wounds.
1.3.5 Consider photographing open fracture wounds when they are first exposed for clinical care, before debridement and at other key stages of management.
1.3.6 Keep any photographs of open fracture wounds in the patient’s records.
Documentation of neurovascular status
1.3.7 When assessing neurovascular status in a person with a limb injury, document for both limbs:
◆ which nerves and nerve function have been assessed and when
● motor function using the Medical Research Council (MRC) grading system
◆ which pulses have been assessed and when
◆ how circulation has been assessed when pulses are not accessible.
Document and time each repeated assessment.
1.5 Training and skills
These recommendations are for ambulance and hospital trust boards, medical directors and senior managers within trauma networks
1.5.1 Ensure that each healthcare professional within the trauma service has the training and skills to deliver, safely and effectively, the interventions they are required to give, in line with the NICE guidelines on non-complex fractures, complex fractures, major trauma, major trauma services and spinal injury assessment.