Experience of managing open fractures of the lower limb at a major trauma centre.
BACKGROUND
In April 2012 the John Radcliffe Hospital in Oxford became a major trauma centre (MTC). The British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons joint standards for the management of open fractures of the lower limb (BOAST 4) require system-wide changes in referral practice that may be facilitated by the MTC and its associated major trauma network.


METHODS
From 2008 to 2013 a multistep audit of compliance with BOAST 4 was conducted to assess referral patterns, timing of surgery and outcomes (surgical site infection rates), to determine changes following local intervention and the establishment of the MTC.


RESULTS
Over the study period, 50 patients had soft tissue cover for an open lower limb fracture and there was a significant increase in the proportion of patients receiving definitive fixation in our centre (p=0.036). The median time from injury to soft tissue cover fell from 6.0 days to 3.5 days (p=0.051) and the median time from definitive fixation to soft tissue cover fell from 5.0 days to 2.0 days (p=0.003). The deep infection rate fell from 27% to 8% (p=0.247). However, in 2013 many patients still experienced a delay of >72 hours between injury and soft tissue cover, primarily owing to a lack of capacity for providing soft tissue cover.


CONCLUSIONS
Our experience may be relevant to other MTCs seeking to identify barriers to optimising the management of patients with these injuries.
Oxford University Hospitals NHS Trust , UK.
A M
AM
Ali
Oxford University Hospitals NHS Trust , UK.
J M
JM
McMaster
Oxford University Hospitals NHS Trust , UK.
D
D
Noyes
Oxford University Hospitals NHS Trust , UK.
A J
AJ
Brent
Oxford University Hospitals NHS Trust , UK.
L K
LK
Cogswell
D004739:England / Q000453:epidemiology; D005597:Fractures, Open / Q000453:epidemiology* / Q000601:surgery*; D006801:Humans; D008485:Medical Audit; D012189:Retrospective Studies; D013978:Tibial Fractures / Q000453:epidemiology* / Q000601:surgery*; D014193:Trauma Centers; D016896:Treatment Outcome
Lower limb; Major trauma centre; Open fracture