Open fractures: it doesn't come out in the wash

Outcomes in patients with late debridement of open long bone fractures of the lower extremities in penetrating trauma: a retrospective review of the National Trauma Data Bank

BACKGROUND

The morbidity and mortality associated with open long bone fractures have been greatly reduced due to antibiotics and early surgical washout and debridement. Guidelines recommend early washout and debridement within 6-8 h; however, newer studies have shown that delaying surgical washout and debridement up to 24 h can be done safely without an increase in surgical site infection, wound nonunion or sepsis. All studies thus far have looked at combined blunt and penetrating open long bone fractures, without distinguishing between mechanism or type of injury. Our study looked specifically at open long bone fractures of the lower extremity caused by a penetrating mechanism of injury.

METHODS

We utilized the US National Trauma Data Bank and included patients who had diagnosis of lower extremity open long bone fracture from a penetrating mechanism and underwent irrigation and debridement (I&D) within 24 h of arriving to the hospital.

RESULTS

A total of 1014 patients qualified for the study. Of those, 736 (72.6%) patients underwent an I&D within 8 h and 278 (27.4%) underwent an I&D between 8 and 24 h after hospital arrival. When examining the patient outcomes, there were few cases and no significant differences in the occurrence of surgical site infections, sepsis or wound disruptions between the two groups.

CONCLUSION

The majority of the open long bone fractures were due to firearm injury. I&D of penetrating open long bone fracture can be performed within 24 h without any added infective morbidity.

Is nonoperative treatment of pediatric type I open fractures safe and effective?

PURPOSE

There is limited literature on nonoperative treatment of open type I pediatric fractures. Our purpose was to evaluate the rate of infection in pediatric patients with type I open fractures treated nonoperatively at our institution without admission from the emergency department (ED).

METHODS

We performed a retrospective chart review of all patients who sustained a type I open fracture of the forearm or tibia from 2000 through 2013. Forty patients fit the inclusion criteria: <18 years old with type I open fracture treated nonoperatively with irrigation and debridement, followed by closed reduction and casting of the fracture under conscious sedation in the ED. All patients were discharged home. The primary outcome was presence of infection. Secondary outcomes included occurrence of a delayed union, time to union, complications, and residual angulation.

RESULTS

There were no reported or documented infections. There was one case of a retained foreign body (<1 cm) in a mid-diaphyseal forearm fracture, which was removed in clinic at 4 weeks after the patient developed a granuloma with no infectious sequela. There was one case of a delayed union; all patients eventually had complete bony union. There was minimal residual angulation in both upper and lower extremities at last follow-up.

CONCLUSIONS

Nonoperative treatment of type I open fractures in pediatric patients can be performed safely with little risk of infection. This preliminary evidence may serve as a foundation for future prospective studies.

Acute management of open fractures: proposal of a new multidisciplinary algorithm

Despite the frequency of open fractures, their management remains one of the greatest and most debated orthopedic challenges. The current challenges that health care faces financially and clinically offer an opportunity to develop a universal reliable, reproducible, evidence-based protocol. The authors review the current evidence concerning the acute management of open fractures and suggest a modern treatment algorithm.