Timing of closure of open fractures

Traditionally, closure of open fractures after initial debridement has been delayed to minimize the risk of complications, particularly infection. This practice developed before the widespread use of systemic antibiotics, local antibiotic bead pouches, advanced debridement methods, and improved fracture stabilization techniques. Current evidence indicates that infections after treatment of open fractures frequently are not caused by initial contaminating organisms but often are acquired in the hospital. Recent studies comparing primary with delayed closure have not demonstrated an increased rate of complications. Considering the improvements in open fracture wound care, the increasing incidence of resistant nosocomial infections, and the cost implications of a dogmatic delayed-closure strategy, wound care protocols for open fractures should be reevaluated. Because of lack of data specifically addressing the timing of closure of such wounds, studies comparing primary versus delayed closure are needed.     

Comparison of delayed and primary wound closure in the treatment of open tibial fractures

INTRODUCTION: Primary wound closure in the management of open tibial fractures has generally been discouraged. Several prior studies suggest that infections are not caused by the initial contamination, but are instead the result of organisms acquired in the hospital. Primary wound closure after adequate wound care and fracture stabilisation could therefore be considered a reasonable option. MATERIALS AND METHODS: We analysed 95 patients with open tibial fractures (Gustilo-Anderson type 1 to 3A) treated with primary fracture stabilisation and either delayed wound closure (group I) or primary wound closure (group II), with a minimum follow-up of 12 months. RESULTS: Group I included 46 patients with a mean age of 30.2 years (16-56), and a mean follow-up of 13.5 months (12-18). Group II included 49 patients with a mean age of 33.4 (18-69), and a mean follow up of 13.7 months (12-16). One infection developed in group I (2%), and two infections developed in group II (4%). This difference was not found to have any statistical significance. CONCLUSION: Our results support other recent reports that the infection rate is not increased following primary wound closure after thorough debridement of less severe open fractures. The length of stay following primary closure (group II) was significantly shorter, and that should result in substantially more cost effective care of these serious injuries. We conclude that primary wound closure is a safe option in properly selected cases. Prospective multi-centre studies are needed to further evaluate the safety and efficacy of this treatment alternative.     

Primary or delayed closure for open tibial fractures

Of 110 consecutive open tibial fractures 90 were reviewed and analysed retrospectively with particular reference to wound closure, method of stabilisation, infection rate and the incidence of non-union. There were 41% Gustilo type I, 39% type II and 20% type III injuries. The incidence of deep infection was 20% after primary wound closure compared with 3% after delayed closure, and eight of the nine non-unions followed primary closure. We conclude that primary wound closure should be avoided in the treatment of open tibial fractures.     

Severe open tibial fractures: a study protocol

A prospective randomized study of severe open tibial fractures (Type II and III) was performed. Individual fractures were randomized to treatment groups according to initial antibiotic therapy: One consisted of a first-generation cephalosporin, and the other consisted of a third-generation cephalosporin. Initial antibiotic therapy was given in all patients for 48 h and then specific antibiotic treatment was used as indicated by culture. The purpose of this study was to determine whether or not additional gram-negative coverage had an effect on the overall infection rate or the type of infection in severe open tibial fractures. Additional factors, such as the timing of bone grafts and soft tissue coverage, were evaluated in this study as well. Although there was no statistical difference in the rate of infection with the use of a first- versus a third-generation cephalosporin, there was a trend toward a decreased infection rate as well as toward less morbid infections with the use of a third-generation cephalosporin. The study also confirms that early bone graft should not be performed prior to 6 weeks post injury or after successful soft tissue coverage has been achieved. On the other hand, soft tissue coverage procedures should be performed at the earliest possible date to decrease the overall infection rate.     

A comprehensive treatment approach is necessary for the closure of open window thoracostomy: an institutional review of 35 cases

Purpose

Although life-threatening situations can be avoided using an open window thoracostomy (OWT), the closure is often difficult. We investigated the predictors of a successful closure of an OWT at the time of OWT creation.

Methods

Thirty-five consecutive patients who underwent an OWT at our institute between January 1991 and December 2010 were reviewed. We directly compared the patients with and without a successful OWT closure. A logistic regression analysis was employed to determine the predictive factors of a successful closure.

Results

OWT closure was only achieved in 12 patients. The closure of the OWT and absence of diabetes mellitus significantly influenced the survival of the OWT patients. The OWT in patients with preceding lung resection was difficult to close, especially if the underlying disease was lung cancer. The existence of a bronchopleural fistula (BPF) was not related to successful closure. Among the post-lung resection patients, the nutritional status tended to affect the success of the closure.

Conclusion

Successful closure is difficult to predict at the time of the creation of an OWT. A comprehensive approach, including nutritional support and the precise timing of intervention is critical to promote a successful closure.     

Early versus delayed closure of open fractures

The desired outcome in the management of Type III open injuries is not merely salvage but a limb which is functional, painless and aesthetically pleasing. The aim is to also achieve this outcome with the least number of reconstructive surgical procedures and minimal hospital stay. This is now possible by the emergence of many new concepts, by which primary closure is one. While the traditional expected standard of care was to leave the wound open and delay closure, the current evidence favours primary closure in open injuries if the following indications are met: (a) debridement performed within 12h, (b) no skin loss primarily or secondarily during debridement (Ganga Hospital Score [Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg Br 1990;72:125-8]: score of '1' or '2'), (c) skin approximation possible without tension, (d) no farmyard of gutter contamination, (e) debridement performed to the satisfaction of the surgeon and (f) no vascular insufficiency.     

A protocol for the management of pediatric type I open fractures

Background

The management of pediatric type I open fractures remains controversial. There has been no consistent protocol established in the literature for the non-operative management of these injuries.

Methods

A protocol was developed at our institution for the non-operative management of pediatric type I open forearm fractures. Each patient was given a dose of intravenous antibiotics at the time of the initial evaluation in the emergency department. The wound was then irrigated and a closed reduction performed in the emergency department. The patient was admitted for three doses of intravenous antibiotics (over approximately a 24-h period) and then discharged home without oral antibiotics.

Results

In total, 45 consecutive patients were managed with this protocol at our hospital between 2004 and 2008. The average age was 10 (range 4–17) years. The average number of doses of intravenous antibiotics was 4.06 per patient. Thirty patients (67 %) received cefazolin (Ancef®) as the treating medication and 15 patients received clindamycin (33 %). There were no infections in any of the 45 patients.

Conclusion

In this study we outline a consistent management protocol for type I open pediatric forearm fractures that has not previously been documented in the literature. Our results corroborate the those reported in the literature that pediatric type I open fractures may be managed safely in a non-operative manner. There were no infections in our prospective series of 45 consecutive type I open pediatric forearm fractures using our protocol. Using a protocol of only four doses of intravenous antibiotics (one in the emergency department and three additional doses during a 24-h hospital admission) is a safe and efficient method for managing routine pediatric type I open fractures non-operatively.     

Ankle injuries in distal tibial spiral shaft fractures: results from an institutional change in imaging protocol

Introduction

Posterior malleolus and other articular ankle injuries are known to concomitantly occur with tibial shaft fractures, especially spiral fractures of the distal one-third diaphysis. Due to our heightened awareness of this combined injury, our department instituted a new preoperative ankle imaging protocol for all distal one-third spiral tibia shaft fractures. The purpose of this study was to evaluate the effectiveness of an imaging protocol involving radiographs, CT and magnetic resonance imaging (MRI) in a distal one-third spiral tibia fracture cohort.

Materials and methods

All operatively treated patients with a spiral distal one-third tibial shaft fracture from February 2012 to March 2013 underwent a standardized ankle imaging protocol. Patients had preoperative orthogonal ankle radiographs as well as a CT scan of the tibia that included the ankle. All ankle imaging was scrutinized for evidence of an ankle injury. If no ankle fracture was identified, patients would then undergo an ankle MRI.

Results

Twenty-five patients met the inclusion and exclusion criteria for this study. Concomitant osseous ankle injuries were identified by radiograph and CT in 56 % (14/25) of cases. The remaining 44 % (11/25) of patients had no evidence of a combined injury by radiograph or CT and therefore underwent an MRI. Of the MRI cohort, 64 % (7/11) were found to have an occult ankle fracture. The overall incidence of a combined injury using our protocol was 84 % (21/25). Identification of an occult injury led to a change in management for all of these patients.

Conclusions

Concomitant ipsilateral ankle and distal one-third spiral tibial shaft fractures are more common than previously reported. Utilizing a new imaging protocol, we found that the incidence of this combined injury was 84 %. Recognition of the ankle fracture component in this tibial shaft cohort can be important as it may alter the surgical plan and postoperative management.     

Delayed primary closure of the septic open abdomen with a dynamic closure system

Background  

The major challenge in the management of patients with an infected open abdomen (OA) is to control septic peritonitis and intra-abdominal fluid secretion, and to facilitate repeated abdominal exploration, while preserving the fascia for delayed primary closure. We here present a novel method for closure of the infected OA, based on continuous dynamic tension, in order to achieve re-approximation of the fascial edges of the abdominal wall.     

Treatment of 78 type II and type IIIa open fractures by primary closure on suction drain: a prospective study

The purpose of this study was to assess if primary closure of wounds on a suction drain can be performed in open fractures after debridement and to determine the risk of infection and nonunion. A total of 78 type II and type IIIa open fractures were managed with primary closure on a suction drain. They were followed until union. Rates of infection, delayed union and nonunion were determined and compared with rates reported in the literature. Overall, 16 fractures (20.5%) were complicated with superficial infections and 8 fractures (10.2%) had deep infections. Delayed union was observed in 11 fractures (14.1%) and nonunion in 12 fractures (15.3%). Primary closure of a wound on a suction drain seems to cause no significant increase in rates of infection, nonunion or delayed union.     

负压封闭辅助引流技术联合锁定接骨板外用技术治疗胫骨中下段开放骨折的临床效果

背景:目前在国内锁定接骨板常作为内固定器材使用,国外仅有少数病例报道将其作为外固定器材使用,而负压封闭辅助引流技术联合锁定接骨板外用治疗开放骨折的病例,鲜有报道。目的:探讨负压封闭辅助引流技术(vacuum-assisted closure,VAC)联合锁定板外用治疗胫骨中下段开放骨折后的临床效果。方法:2010年6月至2011年6月,我院收治胫骨中下段开放骨折患者80例,随机分为A、B两组,每组40例。A组采用负压封闭辅助引流技术联合锁定接骨板外用技术,B组采用外固定架固定术后常规换药治疗。结果:80例患者随访3～12个月,平均7.5个月。A组软组织恢复时间(13.70±1.89)d,B组(18.00±2.82)d;A组肉芽生长时间(4.90±1.10)d,B组(13.40±1.89)d,外固定架持续时间A组(14.30±1.88)d,B组(40.40±5.64)d;A组骨折愈合时间(16.10±1.85)周,B组(29.40±2.91)周;A组总住院天数(4.90±1.10)周,B组(10.90±3.28)周;A组踝关节活动度为34.40°±0.69°,B组20.20°±6.07°。数据对比分析后,A组均优于B组(P<0.05)。结论:负压封闭辅助引流技术联合锁定接骨板外用技术简单,可靠,创伤小,功能恢复快,是治疗胫骨中下段开放骨折的合理方法。     

Emergency room thoracotomy for penetrating chest injury: effect of an institutional protocol.

BACKGROUND: Emergency room thoracotomy (ERT) can be life saving in patients with penetrating chest injury. A protocol was established at our institution stating that ERT be performed for cases of cardiac tamponade secondary to penetrating chest trauma on patients with vital signs/mentation in the field or on arrival to the emergency room. To validate our protocol, we reevaluated patients undergoing ERT at our institution. METHODS: In our retrospective review, there were 49 patients undergoing ERT over a 6-year period. RESULTS: Survival in patients with vital signs was approximately 50%. Survival in those without was 0%. Compared with the preprotocol data, the number of ERTs declined from 32.2 cases per year to 8.1 cases per year. Overall survival increased from 4% to 20%. Neurologic outcome remained unchanged. CONCLUSION: We believe that the data validate our protocol, and the establishment of a guideline has enabled us to maximize patient survival and minimize exposure risks to our staff.     

Debridement and wound closure of open fractures: the impact of the time factor on infection rates

Open fracture management represents an orthopaedic emergency. Early aggressive management of these debilitating injuries within the first 6h has been encouraged in order to minimise the risk of infection and long term sequelae. Debridement and wash-out of the wound, followed by stabilisation of the bony elements and closure of the soft-tissue envelope are all considered essential. However, the available scientific evidence supporting the timing of this multistage approach of open fracture management, and the "Six-hour rule" itself, are unclear. This review article analyses the available evidence regarding the impact of the timing of wound debridement and closure of open fractures of the lower extremity.