The definitive guide to securing your ST1 Orthopaedic Training Number.
BOAST Guidelines
This is a general page covering all the BOAST Guidelines that I feel you should read prior to your interview. These guidelines should be used in conjunction with the other topics covered in the core knowledge section.
Use these guidelines alongside the core knowledge information and then test yourself using the question bank for optimal performance.
1. BOAST: Diagnosis and Management of Compartment Syndrome of the Limbs.
Acute compartment syndrome occurs when elevated intracompartmental pressure compromises tissue perfusion, leading to ischaemia and irreversible damage if untreated. It most frequently follows fractures of the tibia and forearm but can also occur with high-energy soft tissue injuries, crush injuries, reperfusion after ischaemia, or tight casts and dressings. The key early clinical features are severe pain out of proportion to the injury and pain on passive stretch; altered sensation may also occur. Pulses are usually preserved, and absent pulses typically suggest arterial injury or systemic hypotension rather than compartment syndrome itself. Where diagnosis is uncertain or in unconscious patients, compartment pressure monitoring may be indicated. Urgent fasciotomy is the definitive treatment and should not be delayed once the diagnosis is made.
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2. BOAST: Diagnosis and Management of Open Fracture.
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Open fractures are orthopaedic emergencies with a high risk of infection, non-union and limb loss. They most often result from high-energy trauma and require immediate recognition and management. Key principles include early intravenous antibiotics within 1 hour, urgent assessment and documentation of vascular and neurological status, and realignment and splintage of the limb. Wounds should only be handled to remove gross contamination, photographed, covered with saline-soaked gauze and an occlusive film; “mini-washouts” outside theatre are not appropriate. Definitive care requires an orthoplastic approach, with timely debridement (immediate for heavily contaminated or ischaemic injuries, within 12–24 hours for others), and soft tissue coverage ideally within 72 hours. Internal fixation should only be undertaken when definitive soft tissue cover is available. Early specialist involvement and adherence to these principles are essential to optimise limb salvage and functional outcomes.
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3. BOAST: The Management of Distal Radius Fractures.
Distal radial fractures are common injuries after both high- and low-energy trauma, with management aimed at restoring function rather than radiological perfection. Assessment should document mechanism, skin integrity, vascular and neurological status, with standard PA and lateral wrist radiographs. Manipulation, if needed, should be under regional anaesthesia by a trained practitioner. Stable fractures may be treated non-operatively with early mobilisation; plaster casts should hold the wrist in neutral with 3-point moulding. In patients ≥65 years, non-operative management is often appropriate unless there is significant deformity or neurovascular compromise. Volar displaced fractures are unstable and usually require plate fixation. Surgery, when indicated, should be performed within 72 hours for intra-articular fractures and within one week for extra-articular fractures. All patients should be reviewed in fracture clinic within 72 hours, and assessed for falls risk, bone health, and functional recovery.
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4. BOAST: The Management of Patients with Pelvic Fractures.
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Pelvic fractures are often high-energy injuries associated with major haemorrhage, urological injury and other trauma, and should be managed in a Major Trauma Centre within a defined network pathway. Initial management follows ATLS principles, with a pelvic binder applied pre-hospital if bleeding is suspected. Tranexamic acid (TXA) should be given within 1 hour, and haemodynamically unstable patients managed with massive transfusion protocols. If instability persists, options include pelvic packing or interventional radiology embolisation as part of a damage control orthopaedics strategy. Imaging should include CT with contrast, but post-binder pelvic X-ray is mandatory once the patient is stable, as binders may mask ring disruption. Definitive fixation should occur within 72 hours once physiology is optimised, and open pelvic fractures require urgent multidisciplinary care. Early referral, orthoplastic and urological input, and clear transfer pathways are essential to reduce morbidity and mortality.
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5. BOAST: The Management of Supracondylar Fractures of the Humerus in Children.
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Supracondylar fractures of the humerus are the most common elbow fractures in children and carry risks of neurovascular injury, malunion, and compartment syndrome. Initial management requires careful documentation of radial pulse, capillary refill, and radial, median (including anterior interosseous) and ulnar nerve function. Surgery should be performed on the day of injury, but urgent intervention is needed for absent pulse, impaired perfusion, open fractures, or threatened skin. Most vascular compromise resolves with reduction; a limb with good perfusion does not require arterial exploration even if the pulse is absent. Stabilisation should be achieved with at least two K-wires, using crossed wires for stability or divergent lateral wires to reduce ulnar nerve risk. If medial wires are used, precautions to protect the ulnar nerve must be taken. Persistent ischaemia after reduction requires brachial artery exploration by a surgeon competent in small vessel repair. Ongoing post-operative monitoring of neurovascular status is essential until the risk of vascular compromise or compartment syndrome has passed. Routine long-term follow up is not usually required, though indications for review must be documented. Remember to rule out NAI.
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6. BOAST: The Management of Ankle Fractures.
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Ankle fractures are common, usually following low-energy torsional injuries, and the goal of management is to restore and maintain a stable ankle mortise to optimise function and reduce the risk of post-traumatic arthritis. Initial care requires documentation of mechanism, skin integrity, circulation, sensation, and comorbidities that may affect outcomes. Deformed ankles should be urgently reduced and splinted, with repeat neurovascular assessment and confirmation of reduction on X-ray. Stable fractures can often be treated non-operatively with analgesia and early mobilisation, while unstable injuries usually require fixation within 24–48 hours in patients under 60. In older patients, close contact casting is an option if reduction can be maintained. Surgery should aim for accurate anatomical reduction and stabilisation of the mortise, with syndesmotic stabilisation if unstable. Most patients can weight-bear as toleratedunless contraindicated. Thromboprophylaxis should follow local protocols, and all patients should receive clear information on recovery, rehabilitation, and return to function.
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7. BOAST: The Management of Urological Trauma Associated with Pelvic Fractures.
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Urological trauma is rare but potentially life-threatening, most often following high-energy blunt trauma and commonly associated with pelvic fractures. Examination must include assessment of the perineum, genitalia, and a rectal exam, with findings documented; a high-riding or impalpable prostate/bladder neck on PR is a classic sign of urethral injury. A single, gentle attempt at urethral catheterisation is acceptable, but if unsuccessful, blood-stained, or draining only blood, a retrograde urethrogram should be performed. The presence of blood in urine requires a retrograde cystogram. If urethral catheterisation fails, a suprapubic catheter should be placed using an ultrasound-guided Seldinger technique. Bladder rupture management depends on type: intraperitoneal rupture requires laparotomy and repair, while extraperitoneal rupture may be managed with catheter drainage unless associated with an unstable pelvic fracture, when repair and fixation are recommended. Urethral rupture in adult males is usually managed with delayed repair at 3 months, whereas primary repair is reserved for specific scenarios (e.g. bladder neck injury, perineal degloving, penetrating trauma). All patients with displaced anterior pelvic fractures or urethral injury should be counselled about the high risk of urinary and sexual dysfunction, with access to an andrology service.
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8. BOAST: The Assessment of the Spine in a Trauma Patient.
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Spinal injury must be assumed in all trauma patients until excluded. Spinal immobilisation (collar, blocks, transfer precautions) should be applied immediately and continued until cleared by clinical assessment and imaging. A high index of suspicion is required in patients with high-energy mechanisms, pain, tenderness, neurological symptoms, or inability to rotate the neck 45°. Patients with ankylosing spondylitis should be immobilised in their natural kyphotic position. CT is first-line imaging, with thin-slice cervical CT and whole-body trauma scans including the cervical spine; CT angiography is indicated if blunt vascular injury is suspected. MRI is reserved for ambiguous CT, unconscious patients, neurological deficits, or suspected cord injury. Abnormal findings should prompt referral to the regional spinal service. For non-operative cases, the management plan must specify stability, duration of immobilisation, and follow-up, and be clearly documented and communicated to the patient.
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9. BOAST: The Management of a Peri-Prosthetic Joint Infection.
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Peri-prosthetic joint infection (PJI) can present with life-threatening sepsis and requires immediate recognition and urgent orthopaedic involvement. All patients with suspected acute PJI should follow a defined pathway from ED or primary care. In septic patients, the Sepsis Six protocol must be initiated, with urgent blood cultures, broad-spectrum IV antibiotics (after cultures), and emergent surgical drainage/debridement within 6 hours where possible. At least five microbiology samples should be taken with separate instruments, and histology considered if diagnosis is uncertain. In non-septic patients, antibiotics should be withheld until deep tissue samples are obtained. Initial investigations include FBC, CRP, renal function, and plain radiographs, noting that normal inflammatory markers do not exclude PJI, particularly in immunosuppressed patients. Documentation should cover timing of the index arthroplasty, wound healing, prior infections, antibiotic use, and assessment for other infection sources (including endocarditis). Stable patients should be reviewed by an orthopaedic consultant within 48 hours, with onward referral and definitive management guided by specialist society protocols.
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Fracture-associated arterial injuries require rapid recognition and immediate referral for joint management by surgeons skilled in both vascular repair and skeletal trauma. Haemorrhage must be controlled with direct pressure or a tourniquet; blind clamping should be avoided. A pulseless, deformed limb should be realigned, splinted, and re-examined before transfer, with neurological status documented as a timed entry. CT angiography should follow the trauma scanogram without patient repositioning. Revascularisation should occur within 4 hours, with temporary shunting used if definitive repair is delayed for skeletal stabilisation. Definitive repair or interposition graft is preferred over bypass. Patients should be counselled regarding amputation risk, and any decision for early amputation must be made by two consultants and documented. Fasciotomy should always be considered, with a low threshold in these cases. Postoperative care must occur in a high-acuity setting with staff competent in assessing the critically injured limb.
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There are more BOAST Guidelines on BOAST website but for your interview and clinical scenario it is more likely to be a trauma scenario rather than elective case.
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