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Reducing Infection After Open Fractures
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Posted on: 09/22/2010
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When trauma results in open fractures, infection is often the next major problem to crop up. An open fracture means there is an open wound in the skin and underlying soft tissues. Any time an area of the body is open and unprotected by intact skin and soft tissues, the risk of infection goes up immediately.
Trauma surgeons grapple with what is the best way to prevent deep infections. Should they clean the wound and close it right away? That approach would limit how many bugs (bacteria) have access to the area. But if there is already infection brewing, it's not a good idea to close up the wound and let it fester.
Right now there is no standard of care or base guidelines from which to make the decision about how to handle the timing of closure of open fracture wounds. As the old saying goes, "It's every man (or surgeon) for himself (or herself)". Each surgeon assesses each patient and uses his or her own experience and clinical judgment when deciding what to do and when to do it.
It would be good to have some evidence-based guidelines to follow. This study may be the first to develop and test some guidelines based on the timing of wound closure. Surgeons from the Division of Orthopaedic Traumatology at the Saint Louis University School of Medicine in St. Louis (Missouri) treated 346 patients with open fractures.
Their protocol was to surgically clean the wound first. This procedure is called irrigation and debridement. Then they took a culture (tissue sample) and sent it to the lab. The pathologist looks at the culture under a microscope and examines it for bacteria (type and count). If the sample came back negative (no bacteria or very low numbers), then the wound could be closed up safely.
If the bacterial load remained high, then the wound was irrigated and debrided again. Another lab sample was taken and tested. This procedure was repeated every 48 hours as long as it took to get a negative result. Once the bacterial load was low enough then the wound site could be closed. A negative lab result on the first try meant the surgeon could repeat the irrigation and debridement technique then close up the wound right away.
And in case you are wondering, everyone was given a tetanus shot if needed and antibiotics in the emergency department at the time of the injury. In order to see if this approach worked, they collected data on each patient from the medical records. Fracture type and severity were classified using the Gustilo and Anderson system. These categories (e.g., Type I, Type II, Type IIIA, Type IIIB, Type IIIC) are well-known to orthopedic surgeons specializing in trauma cases. Number and type of infection were counted using these categories.
Fifteen of the 346 patients did have a deep infection at some point in their treatment. That's an overall rate of 4.3 per cent and compares favorably to seven per cent reported in other studies. A small number of patients (two) actually had a negative culture, wound closure, and then later developed infection. Those cases were treated with antibiotics specific to the type of bacteria present (usually a staph infection).
The deep infection rate was highest for the most severe (Type IIIC) fractures. The number of days before the wound could be closed was also the highest for Type IIIB and Type IIIC (high energy, severe) fractures. Most of the wounds that could be closed right away had Type I or II fractures (less bone and soft tissue damage).
Patients who had the greatest risk of developing an infection were diabetic and/or obese. Previous studies have reported that tobacco use increases the risk of infection and poor wound healing but that was not the case in this study.
The authors conclude by saying that their protocol has a good track record for reducing deep infections after trauma severe enough to create an open fracture and open wound. The use of repeated debridement before closing the wound has some merit. The downside of this treatment protocol is the added cost of repeated surgeries and delayed discharge from the hospital.
This proposed protocol doesn't change the fact that the surgeon must still use experience and expertise to analyze the situation and decide what's best for each patient. Surgeon judgment takes into account the type and severity of fracture, condition of the patient, and presence of bacteria when directing the timing of treatment and wound closure.
For best results, cultures should definitely be taken after irrigation and debridement. Patients with positive cultures go back to the operating room for repeat debridement. Negative cultures signal that the surgeon can close up the wound and send the patient home on oral antibiotics. This protocol requires careful attention to cultures and adequate debridement to lower infection rate but it can be done!
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References:
Christopher J. Lenarz, MD, et al. Timing of Wound Closure in Open Fractures Based on Cultures Obtained After Debridement. In The Journal of Bone and Joint Surgery. August 18, 2010. Vol. 92-A. No. 10. Pp. 1921-1926.
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*Disclaimer:*The information contained herein is compiled from a variety of sources. It may not be complete or timely. It does not cover all diseases, physical conditions, ailments or treatments. The information should NOT be used in place of visit with your healthcare provider, nor should you disregard the advice of your health care provider because of any information you read in this topic. |
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