New standards for the treatment of open fractures of the lower limb published

Press release- 14 September 2009

Two major British surgical associations, the British Association of Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) and the British Orthopaedic Association (BOA) have worked together to create updated multi-disciplinary standards for the treatment of open fractures of the lower limb.  

The Standards are evidence-based and detail the optimal treatment for people with these challenging injuries to improve patient outcomes and will be shared on a national and international level. The Standards replace previous UK guidelines and contain new and important recommendations for medical professionals working with patients with lower limb trauma. 

Keith Willett, National Clinical Director for Trauma Care, said of the published work: 
“Standards for the management of open fractures of the lower limb is an essential reference text for orthopaedic, plastic surgery, emergency medicine and rehabilitation specialists who treat these injuries, as well for those who plan and commission trauma care.  The transfer for definitive care of these patients into specialist orthoplastics surgical facilities will be integral to the planned development of regional trauma networks. I will certainly be asking the National Institute for Health and Clinical Excellence (NICE) to consider, as part of their formal process for setting Quality Standards, the standards proposed by the surgical associations, and to ensure they are shared widely with both clinicians and commissioners through NHS Evidence”.

The facts
•  Orthopaedic and plastic surgeons regularly treat open lower limb fractures – often seen as a result of motor vehicle accidents and sporting accidents as well as in some severe falls in the elderly.
•  The average district general hospital serving a population of 250,000 will treat 60 cases of tibial shaft fractures a year. About 25% of these will be open fractures.
•  Infection rate for these injuries is up to 30% developing significant infection, this falls to 10% with the best management.
•  In 2007/08, there were just over 12,000 cases that involved open wounds or fractures of the lower limb in the UK.
•  Nearly one third of open fractures to the lower limb (31%) involved a patient who is 75 years old or older.
•  The treatment of lower limb injuries resulted in almost 45,000 (44,863) bed days last year, which cost the NHS £9.8m. 

Professor Simon Kay, President of BAPRAS, said: 
“These Standards give practical guidance to those surgeons dealing with complex injuries, and should be put in use at all hospitals across the country.  However, the most complex of open fractures should be treated at specialist centres.  Concentration of treatment at specialist centres has become the norm in the treatment for cancer, stroke and myocardial infarction. Applying the same concept to treatment of lower limb fractures will improve outcomes for patients.”   

Clare Marx, President of the British Orthopaedic Association, said:
This publication is a timely and excellent example of inter-disciplinary collaboration towards better patient care. I congratulate members of the BAPRAS and BOA working party for the outstanding documents they have produced. The various formats of publication – ‘blue book’, BOA Standard (BOAST) and textbook – will prove invaluable reference works for our colleagues in a number of disciplines who deal with these complex injuries.”

The standards are compatible with the proposals for trauma systems and trauma centres in England. They are also relevant to pre-hospital, emergency room and hospital clinicians worldwide. 

BAPRAS and BOA have been working to promote the joint care of patients with severe open fractures of the lower limb to minimise complications and optimise outcomes. They established a working group with experienced clinicians to define the standards. The authors are all practicing specialists in the UK with a particular interest in the evidence-based management of open fractures of the lower limb, from an orthopaedic, plastic surgery and infection control viewpoint.


Notes to Editors
For more information on NICE guidelines and NHS evidence please go to

About the Standards for the management of open fractures of the lower limb

•  The full publication (with all supporting evidence and citations) is available to purchase in hard copy for a small charge. It is expected that those working in this field will wish to obtain their own copy. Details are on 
•  The two Associations will also be making the standards available electronically without charge to support colleagues in the developing nations who are not in a position to purchase their own copy.  
•  A short guide to the standards, containing all the key recommendations, is being distributed widely and is also available to download from and


BAPRAS, the British Association of Plastic, Reconstructive and Aesthetic Surgeons, is the voice of plastic surgery in the UK. It aims to increase the understanding of the professional specialty and scope of plastic surgery, promoting innovation in teaching, learning and research.

Founded in 1946 (originally as the British Association of Plastic Surgeons), today BAPRAS has nearly 800 members and is the official professional representative body for reconstructive and  aesthetic plastic surgeons providing services to patients on the NHS and privately in the UK.

Members of the public can find a member plastic surgeon in their area by logging on to The GMC specialist register can be checked to find out if a surgeon is on the plastic surgery specialist register

About BOA 

The BOA is the professional association for trauma and orthopaedic surgeons in the UK and those abroad who have had orthopaedic training in the UK or who show a continuing interest in the affairs of the Association. Founded in 1918, our mission is to bring relief to people suffering from injury or musculoskeletal disorder by advancing the science, art and practice of orthopaedic surgery. The BOA currently has about 4000 members in the UK and overseas, the majority of these are UK consultant and trainee orthopaedic surgeons.