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PubMed1989

The use of quantitative bacterial counts in open fractures.

Late infections remain a significant complication in the treatment of open fractures, occurring in 2% to 25% of all open fractures. Recently there has been a trend toward early soft-tissue coverage of open fracture wounds. Quantitative bacterial counts have been used primarily by plastic surgeons to assess the viability of primary versus delayed wound closures. Quantitative bacterial counts were obtained in 52 consecutive open fractures in 50 patients to assess the correlation between quantitative bacterial counts and subsequent sepsis, to determine the effect of time to debridement on the quantitative bacterial count, and finally to review the bacteriology of open fractures. Forty-one of the 52 fractures had positive quantitative bacterial counts. Four of eight (50%) fractures with quantitative bacterial counts greater than 10(5) developed late sepsis, while only two of 44 (5%) with quantitative bacterial counts less than 10(5) or negative quantitative counts became infected. There was no correlation between time to debridement and quantitative bacterial count levels. A significant percentage of the positive quantitative bacterial counts were gram-negative organisms.

Adult↗

PubMed1989

Intramedullary nailing of open fractures of the femoral shaft.

The cases of eighty-six patients in whom eighty-nine open fractures of the femoral shaft had been treated by intramedullary nailing with reaming were retrospectively reviewed. Twenty-seven fractures were classified as grade-I open fractures; sixteen, as grade-II open fractures; and forty-six, as grade-III open fractures. Immediate intramedullary nailing was done for fifty-six fractures, and delayed stabilization (five to seven days after delayed closure of the wound) was done for thirty-three fractures. A prerequisite for immediate intramedullary nailing was that irrigation and debridement of the open wound be done within eight hours after injury. All fractures healed in an average of 5.2 months. No infections occurred in the sixty-two grade-I, grade-II, or grade-IIIA open fractures, regardless of whether immediate or delayed intramedullary nailing was performed. Of the twenty-seven grade-IIIB fractures, infection developed in three: in one after immediate intramedullary nailing and in two after delayed intramedullary nailing. We concluded that, if a thorough and timely debridement can be accomplished, immediate intramedullary nailing of grade-I and grade-II open fractures of the femoral shaft does not increase the risk of postoperative infection. Selected patients who have a grade-III open fracture may be candidates for immediate intramedullary stabilization, depending on the degree of the patient's associated injuries and the extent of disruption and contamination of the soft tissues of the thigh.

Adolescent↗

PubMedDate not supplied

Effect of delay of surgical treatment on rate of infection in open fractures in children.

This study reviews all open fractures treated at a tertiary children's hospital from 1990 to 1995 to determine whether delaying surgical debridement influences the rate of infection in the pediatric population. One hundred four open fractures were followed until both clinical and radiographic union was evident. A 1.0% rate of infection requiring surgical drainage, and a 1.0% rate of soft-tissue infection managed with oral antibiotics alone was found. Infection rates for fractures treated within 6 h of injury was 2.5%, and for fractures treated with >6 h delay was 1.6%. No significant statistical difference in infection rate with delay in surgical debridement was found (p = 0.77). Delays of 5 and 16 h were found in the two fractures complicated by infection, compared with an average delay of 12 h for those that healed uneventfully. Our findings suggest that in children given early parenteral antibiotics, operative irrigation and debridement may be delayed >6 h without an increased risk of infection. As this series contains only 18 patients with grade III open fractures and nine patients whose surgery was delayed >24 h, conclusions should not be made in these groups.

Adolescent↗

PubMed1979

Use of antimicrobials in the management of open fractures.

The role of antibiotic therapy in open fractures is secondary to adequate debridement, irrigation, and definitive wound care. Experimental and clinical studies indicate that parenteral administration of appropriate antibiotics within three hours after injury helps to prevent wound sepsis. Intial wound cultures of 158 open fracture wounds revealed bacterial growth in 70.3%. Eighty-six were Gram-positive, 57 were Gram-negative, and 32 yielded mixed bacterial growth. Sensitivity studies of these organisms suggest that cephalothin sodium is the most effective antibiotic for prophylaxis. In a prospective study from 1969 to 1975, treatment of 520 patients was as follows: debridement, copious irrigation, and primary closure for types 1 and 2 fractures and secondary closure for type 3 fractures. No primary internal fixation was done except in vascular injuries. Cultures were taken of all wounds and antibiotics were given before surgery and for three days postoperatively. In type 3 open fractures, severe soft tissue injury, and segmental or traumatic amputation, the infection rate was 9%, compared to a 44% infection rate in the retrospective study from 1955 to 1968.

Anti-Bacterial Agents↗

PubMed1985

Open fractures of the extremities. The case for open treatment.

Meticulous care of open wounds in open fractures is essential to prevent development of infection. Wounds should be treated by early excision and early delayed or secondary closure. Primary closure is not necessarily beneficial and can actually increase the risk of infection. Culture for aerobic and anerobic organisms should be obtained at initial examination, and antibiotic treatment should be started before wound excision. The experience at Duke University Medical Center, Durham, North Carolina, during the past 40 years has demonstrated that open treatment of open wounds is safe and highly successful in preventing gas gangrene and osteomyelitis.

Academic Medical Centers↗

PubMed1986

Acute management of severe soft-tissue damage accompanying open fractures of the lower extremity.

Open fractures of the lower extremity accompanied by extensive soft-tissue damage can be effectively managed by a collaborative approach between orthopedic and plastic surgeons. The fundamental concepts of this aggressive, systematic approach are adequate debridement and soft-tissue healing by delayed primary intention. The protocol that has evolved at the MIEMSS Shock Trauma Unit involves emergency radical debridement of all devitalized soft tissue and bone fragments together with external stabilization of the fractured extremity. The zone of injury, which is often not apparent at presentation, is determined by serial debridements performed in the operating room over several days. When the wound is defined, soft-tissue closure is obtained with local or free muscle transfer. In very high energy-induced trauma, local muscle flaps are often involved in the zone of injury or are inadequate to cover the resultant defects. Free muscle transfers that provide large amounts of undamaged, well-vascularized tissue are therefore the reconstructive alternative of choice for such injuries. Bone defects are bridged 4 to 6 weeks after soft-tissue closure with cancellous or vascularized fibula grafts depending on defect size. This regimen, which has virtually eliminated the problem of infection, has been successful in salvaging and rehabilitating these severely injured lower extremities.

Accidents, Traffic↗

PubMed1994

Immediate internal fixation for open fractures of the long bones of the upper and lower extremities.

Immediate open reduction with internal fixation was performed on 66 open fractures (54 patients) of the long bones in the upper or lower extremity, including one clavicle. Using the classification system of Gustilo, there were 13 (20%) type I, 30 (45%) type II, 11 (16%) type IIIA, six (9%) type IIIB, and six (9%) type IIIC soft tissue injuries. Thirty-two patients had associated major multiple trauma. Eighty-eight percent of the patients had good functional results using a modification of Katenjian's criteria. There were three late deep infections (4.5%), all at the sites of type III fractures. The nonunions occurred in four open fractures (6.1%). We conclude that, if a complete and timely debridement can be accomplished, immediate internal fixation of open fractures allows for improvement in ultimate function and a decrease in mortality in patients with multiple trauma. This procedure should be performed in selected patients who have type III open fractures, with careful attention to the general status of the patient and the severity of the soft tissue wound at the fracture site.

Adolescent↗

PubMed1980

Primary open reduction and internal fixation of open fractures.

Our experience with primary open reduction with rigid internal fixation of 50 open fractures is presented. Twenty-seven patients had associated major multiple trauma. Twenty fractures were articular and 26 involved 3rd-degree wounds. The infection rate of 4%. A system of staged sequential debridement and wound management is presented. The authors believe this system has contributed to the low infection rate. No secondary amputations occurred. Eighty-two per cent of the patients had good functional results using Charnley's criteria. Fatal post-traumatic cardiopulmonary failure did not occur. The authors feel that early definitive fracture care employing rigid fixation which avoids casts, and allows improved wound management and early mobilization of the multiple-trauma patient, has decreased the cardiopulmonary and metabolic consequences commonly associated with polytrauma patient care.

Adolescent↗

PubMed2005

Management of open fractures.

The large spectrum of open fractures is an amalgamation of injuries with the single variable in common of communication of the fractured bone with the outside environment, and thus an increased risk for infection. Contributing to the presence of bacteria within the fracture site is devascularized soft tissue, the degree of which can be directly attributed to the amount of energy imparted to the tissues. The currently used classification system aids in defining the degree of severity of these injuries and their subsequent risk for infection. The basic management principal for all of these injury patterns remains essentially the same, however: prevention of infection through debridement, wound management, antibiotic usage, and fracture stabilization. Frequently multiple surgical procedures will be required in order to obtain an infection free, united fracture with adequate soft tissue coverage (1).

Anti-Bacterial Agents↗

PubMed1975

[Bacterial flora and preventive antibiotic treatment in open fractures].

In 172 patients with open fractures of long tubular bones the wound bacterial flora was studied on their admission to the clinic and in occurrence of suppurative complications. There were no cases of "outdoor" microorganisms being the cause of suppuration. Pathogenic agents of suppurative infection differed from "outdoor" strains in their species content, signs of pathogenicity, sensitivity to antibiotics. As a rule, suppuration was preceded by soft tissues necrosis. Since wound suppuration was produced not by the initial or changed "outdoor" microorganisms but hospital strains, which penetrate in the wound due to inadequate observation of the rules of asepsis and antisepsis in surgical treatment or subsequent dressing, then prophylactic antibioticotherapy should cover mostly sensitivity of hospital bacterial strains. To this end, the study of bacteriological background for each surgical department seems to be absolutely necessary. In a small zone of the soft tissues injury under conditions of secure fixation of bone fragments with Ilizarov apparatus a limited use of antibiotics is believed to be permissible.

Anti-Bacterial Agents↗

PubMed1999

Aggressive treatment of 119 open fracture wounds.

BACKGROUND: The purpose of this study was to determine whether immediate primary closure of open fracture wounds can be performed without increasing the incidence of infections and delayed unions/nonunions. Although the traditional management of these injuries has been open treatment, a trend toward immediate primary closure has evolved on our service. METHODS: All open fractures presenting to an urban Level I trauma center during a 42-month period were reviewed. Of the 127 patients with open fractures, 90 patients (119 open fractures) were initially treated at the above institution within 24 hours of injury, had fractures proximal to the carpus or tarsals, and were followed-up until fracture union. All patients underwent emergent wound irrigation and debridement. The method of fracture immobilization and timing of wound closure was left to the discretion of the attending orthopedic surgeon. Immediate primary closure was used in 22 of 25 Grade I open fractures (88%), 37 of 43 Grade II fractures (86%), 24 of 32 Grade IIIa fractures (75%), 4 of 12 Grade IIIb fractures (33%), and 0 of 7 Grade IIIc fractures (0%). RESULTS: Eight fractures (7%) were complicated by a deep wound infection/osteomyelitis, and 19 fractures (16%) developed a delayed union/nonunion. Statistical analysis revealed no significant difference in delayed/nonunion and infection rates between immediate and delayed closures. CONCLUSION: Immediate primary closure of open fracture wounds after a thorough debridement by an experienced fracture surgeon appears to cause no significant increase in infections or delayed union/nonunions. In addition, early closure may decrease the requirement for subsequent debridements and soft-tissue procedures, thereby minimizing surgical morbidity, shortening hospital stays, and reducing costs. We feel that a randomized, prospective study of this aggressive approach to open fracture care is warranted.

Female↗

PubMed1975

[Therapeutic principles and results in the management of open fractures of the tibial].

In open fractures of the leg, in which because of any reason no primary stable osteosynthesis can be performed, threading with Kirschner wire is preferred by the authors. This method assures adaptation stability, with minimal osteosynthesis. Primary closure of the wound in the soft parts is striven by the authors, - if necessary, even by plastic surgery. If primary healing of the wound is obtained and also the other conditions are favourable, the treatment after 7-10 days is the same as after covered fractures: stable osteosynthesis is performed. On the other hand, if suppuration of the wound occurs, the opposing fixed fracutre bone ends assure favourable conditions for the successful surgical treatment of the fracture. A further advantage of the method is that it may be performed without special instruments and without greater surgical experience. The results obtained with this surgical treatment of open leg fractures in the 4 years' material of the Traumatological Department of the First Surgical Clinique of the University Medical School, Pécs, are discussed by the authors.

Fracture Fixation↗

PubMed1997

Efficacy of cultures in the management of open fractures.

Two hundred forty-five open fractures were reviewed retrospectively to determine the prognostic value of wound bacterial cultures concerning deep infections requiring surgical management. Only 8% of organisms grown on predebridement cultures eventually caused infection; 7% of cases with negative predebridement cultures became infected. Of cases that did become infected, predebridement cultures grew the infecting organism only 22% of the time. Postdebridement cultures were more accurate in predicting infection; however, of cases that became infected, the infecting organism was present on postdebridement cultures only 42% of the time. It is concluded that predebridement and postdebridement bacterial cultures from open fracture wounds are of essentially no value, and it is recommended that they not be done.

Debridement↗

PubMed2003

Open fractures of the tibial shaft: an update.

The treatment of open fractures of the tibial shaft continues to be a challenging problem for the orthopaedic surgeon. The basic principles of treatment for open fractures have changed little over the past decade; urgent wound débridement, early use of antibiotic therapy, skeletal stabilization, and early wound coverage remain the primary goals of treatment. However, the methods used to achieve these goals of treatment have evolved. Recent advances in the treatment of open fractures focus on the treatment of open fractures of the tibial shaft.

Anti-Bacterial Agents↗

PubMed2002

The choice of antibiotic in open fractures in a teaching hospital in a developing country.

Open fracture wounds may be contaminated, and the use of an appropriate antibiotic in the early stages of management reduces the risk of osteomyelitis developing. Environmental factors influence both the type of micro-organisms that are isolated from these wounds and the antibiotics that are chosen to manage the wounds. Before this study, the choice of antibiotic in the management of open fractures in our hospital was based on tradition and 'best guess' antibiotics. In a prospective study of 52 open fractures seen in the accident and emergency unit of University College Hospital, Ibadan, between January and June 2000, the positive bacterial culture yield was more than 70%. Staphylococcus aureus was the commonest microbial isolate, accounting for 37.5% of total isolates. The antibiotic sensitivity pattern revealed high efficacies for pefloxacin, ciprofloxacin and ceftriaxone against the isolated micro-organisms. In comparative costs, these antibiotics are cheaper than the combination of the 'best guess' antibiotics that were used previously. On the strength of this finding, we have suggested a change in the antibiotic policy of the hospital with regard to the antibiotic regimen to be used to complement the surgical management of open fractures.

Anti-Bacterial Agents↗

PubMed1994

The prevention of infection in open fractures: an experimental study of the effect of fracture stability.

An experimental model of a contaminated open fracture has been developed. This model has been used to test the hypothesis that stable fixation of a contaminated open fracture will reduce its susceptibility to infection. The tibiae of male New Zealand white rabbits were fractured and then fixed with either a dynamic compression plate (stable group) or a loose-fitting intramedullary rod (unstable group). The fracture site was then inoculated with a standard inoculum of Staphylococcus aureus. There were 20 rabbits in the stable group and osteomyelitis developed in seven (35 per cent); in the unstable group 15 (71 per cent) out of 21 animals developed osteomyelitis. This difference in infection rates was statistically significant (P < 0.02). This experimental study supports the concept of stabilization of open fractures in man.

Animals↗

PubMed1995

[Risk of infection in centro-medullary locking nailing of open fractures of the femur and tibia].

Intramedullary reamed locking nail of open fractures remains controversial because of the risk of infection. 1,474 closed reamed locked nailings were performed between 1974 and 1989 for femoral (744 cases) or tibial (730 cases) fractures. 349 fractures were open: 100 femoral fractures (51 Gustilo and Anderson Grade I and 49 Grade II) and 249 tibial fractures (140 Grade I, 99 Grade II et 10 Grade III). 24 femoral (3.2%) and 46 tibial (6.3%) nails were followed by infection. This difference is significant (p < 0.01). Reoperations for infection occur more frequently for femoral than tibial fractures (p < 0.05). There is no difference between the results of infection treatment between femoral or tibial fractures. Traumatic opening of the femoral fracture site does not affect the occurrence of an infection, its severity or the results of its treatment. Traumatic opening of the tibial fracture site significantly increases the infection rate (p < 0.001), and the incidence of infection increases with the severity of the soft tissue lesions; but the severity of the infection and the results of its treatment are not modified. Acute closed reamed intramedullary locking nail is the best treatment for open femoral or tibial fractures with respect to the bone healing and infection rate for Grade I and II fractures. For Grade III fractures, nailing must be followed by a coverage flap.

Femoral Fractures↗

PubMed1996

Open fractures of the tibia in children.

Ninety open fractures of the tibia treated at the authors' institution between 1985 and 1994 were retrospectively reviewed. There were 38 Grade I, 35 Grade II, and 17 Grade III fractures. All patients had debridement and lavage of the wound under general anesthesia. Seventeen wounds (19.8%) were closed primarily and 69 (80.2%) were left open. Forty fractures (45.0%) were stabilized in casts, 31 (34.8%) in an external fixator, and 18 (20.2%) with casts and internal fixation. Six patients (7.1%) had superficial infection occur, 2 had vascular injuries, 1 of whom required an amputation, and only 1 had a neurologic injury. The average time to union was 4.5 months (range, 1.2-28.3 months). there were 10 delayed and 7 nonunions. Multiple regression analysis showed that only age of the patient and grade of the fracture were significantly associated with union time. Open fractures of the tibia in children older than 12 years of age have a high risk of developing delayed or nonunion when compared with the same injuries in children younger than 6 years of age.

Adolescent↗