Open fractures of the upper limb - do the BOAST guidelines need an update?

Abstract

Aims: This scoping review aims to explore the published literature on the current management strategies and outcomes of open upper limb injuries using the BOAST 4 guidelines as a structure.

Materials and methods: A comprehensive search of the MEDLINE, EMBASE, Cochrane and OrthoSearch computerised literature databases (from January 2012 through April 2022) was performed. The medical subject headings used were "open fracture"/ "Gustilo Anderson" and "forearm" or "radius" or "ulna" or "elbow" or "humerus" or "clavicle" or "shoulder" or "scapula". Abstract titles were reviewed for relevance. If the article was deemed eligible, the article was retrieved and reviewed in full.

Results: The literature reveals lower rates of infection for upper limb injuries compared to their lower limb counterparts. Early antibiotic administration remains a key component of their management. Those without significant soft tissue injury (Gustilo Anderson 1) can often be treated as per their closed counterparts and timing to definitive fixation can be safely delayed in selected cases.

Discussion: There is limited high quality evidence available on the management of open upper limb injuries with guidelines built on borrowed principles from the more studied open tibia fractures. What the available evidence does show is that with lower infection rates and a more forgiving soft tissue envelope it may be safe to diverge from the current BOAST guidelines in certain cases. This has relevance in complex fracture patterns requiring specialist input where it is not possible to achieve definitive fixation in 72 h and when there are other life threatening injuries to manage. Despite this early antibiotic administration and debridement within 24 h remains a key component of the early management.

Keywords: BOAST; Open fracture; Upper limb.