The first edition of the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and British Orthopaedic Association (BOA) book Severe Open Fractures of the Lower Limb in 2009 set the standards for collaborative management of these injuries. There have subsequently been major advances in the logistics, the provision, and the monitoring of care for patients sustaining injuries with open fractures in the UK. In 2012 major trauma centres and networks were established across England, in 2016 the National Institute for Health and Care Excellence (NICE) published guidance for managing complex fractures, and in 2017 based on this the Open Fracture BOAST (BOA STandards ) from the British Orthopaedic Association was updated.
In the light of these changes a new edition of this book was needed. As an example of orthoplastic collaboration the opportunity was taken to expand on this work and involve a broader group in its production on behalf of BAPRAS and the BOA. We have been able to draw on the expertise of many colleagues with great experience and in-depth knowledge of managing these injuries. The contents have been updated to reflect the recent NICE Guidelines and latest literature. Paradigms in management have been generated through an evidence base and, when a clear choice between available alternatives for management is absent, the contributors provide a balanced view by highlighting the relative merits and drawbacks of each. In addition to the evidence-based recommendations, the authors have provided technical tips and descriptions of ‘how to do it’ where relevant.
The NICE Guidelines 2016 and the Open Fracture BOAST 2017 consolidated the orthoplastic approach to open fractures advocated in the first edition of this book. In each of those guidelines the range of injuries included was extended beyond the lower limb, hence this book now being titled Open Fracture Standards to accommodate this. It remains the case that much of the evidence and consequently the narrative of this book refers to the tibia. The book has been expanded to include new topics of relevance to the patient with open fractures. There are now chapters on how to set up a service to deal with open fractures, the psychological aspects of trauma, and management of fractures in the young and elderly populations. However, the core message and express intent is to enable the orthoplastic management of an open fracture whenever required. We envisage that this new edition with the included NICE Guidelines and Open Fracture BOAST will provide an easily accessible source of the guidance and standards for management of patients with open fractures.
We made the decision that in this publication we would replace the term debridement with the term wound excision, both in our own narrative and when referring to the publications of others. This should lead the reader to the principle that successful separation of tissues that are contaminated or non-viable from those that are healthy and viable relies on surgical excision of the former. Surgical access to the area requiring excision will include an extension of the traumatic wound by incision. The change in terminology from debridement to wound excision then encourages the concept that completion of the process relies on more than just lavage and dilution of contaminants.