Tag Archives: open fracture

Complications

Early Antibiotic Administration In Open Fractures

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Recommendations for open fracture management has evolved over the past 20 years. The old-timey rule used to be: all open fractures need to be treated within 8 hours. This treatment could be washout and ORIF, washout and external fixation, or just washout alone. The washout was the constant across all types of management.

Then the orthopedics literature began to suggest that “lesser” fractures (Gustilo I – II) could go a bit longer. Some centers extended their required time to washout up to 12 or even 16 hours. Subsequently, the value of early IV antibiotics was recognized, and the time to washout started to change again.

Now, we have recommendations for early IV antibiotics competing with the old recommendations for prompt washout. Who is winning?

There are two recent papers that seem to provide conflicting recommendations regarding antibiotics. The first is in process for publication by the ortho group at San Francisco General Hospital. They studied 230 open fracture patients at their Level I Trauma center over a five-year period. They monitored for surgical site infection that occurred during the first 90 days after injury.

Here are the factoids:

  • It took 450 consecutive patients to find the 230 study patients due to these exclusion criteria: missing documentation of antibiotic administration, delayed presentation, and loss to followup
  • There were 169 Gustilo Type I or II fractures and 61 Type III fractures
  • They noted a trend (p = 0.053) toward infection in patients who had antibiotic administration an average of 83 minutes after arrival vs those who received them within one hour
  • Patients who received their antibiotics 2 hours after arrival had a 2.4x increase in likelihood for infection within 90 days

But there was another paper published in the same journal this year that shows the opposite result. This one is from the University of Bristol in the UK. This one reviewed only Gustilo Type III fractures and observed changes in the deep infection rate, before and after the National Health Service guidance on antibiotic administration changed from within three hours to one hour post-injury.

Some more factoids for you:

  • A total of 176 patients were identified at a single center, and only 152 were left after the usual exclusions
  • Average time to antibiotic administration decreased from 180 minutes to 160 minutes after the new guidance was issued (60 minutes(!))
  • Only 12 patients developed deep infections with a median followup of 26 months
  • On regression analysis, no obvious factors  for increased risk were identified

Bottom line: So what gives? Two different answers: antibiotics given after 2 hours is associated with an increased risk of infection, vs no difference?

No, not really. Talk about apples to bananas. The first study looks at all open fractures, not just the most severe. It does not really define “surgical site infection,” so can we assume it was any infection? We don’t know. The second study looked only at deep infections.

The sample sizes are marginal in both studies, although the first was able to show a significant result despite this. And, of course, these are association studies, so other factors could be at play to manifest an infection or not. Both groups showed an 8-11% infection rate of some kind in their Gustilo Grade III fractures. 

But the biggest issue with the second study is that, despite guidance that antibiotics should be given within an hour, the average time decreased from 3 hours to only 2:40. This is still beyond the two hour threshold to higher infection rates suggested in the first paper.

So what do I make of all of this? The UK paper is lacking the power and enough of a treatment change to be taken seriously. The San Francisco paper shows borderline results with a 2.4x increase in all infections if antibiotics are given after 2 hours. 

So until we have better data and larger series, 1 hour antibiotic administration seems like a painless way to decrease the likelihood of an infection. But whether that can safely delay the time to washout remains to be seen.

References:

  • Delay of Antibiotic Administration Greater than 2 Hours Predicts Surgical Site Infection in Open Fractures. Injury, in press, May 29, 2020.
  • Time to intravenous antibiotic administration (TIbiA) in severe open tibial fractures: Impact of change to national guidance. Injury 51:1086-1090, 2020.
Extremity

Fractures From Gunshots: Open Fracture Or Not?

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Penetrating trauma has been increasing over recent years, especially here in sleepy St. Paul MN. On occasion, we all see patients who have sustained gunshots that have caused fractures. The persistent question has been: open fracture or not?

Do these patients need antibiotics? A wound washout? Are they at risk for lead poisoning? Unfortunately, there are no consistent answers in the textbooks. The orthopedic trauma group and MetroHealth in Cleveland sent surveys to 385 members of the Orthopedic Trauma Association (OTA) to see if there was some consensus.

A total of 173 of the surveys were completed, which is actually a very good success rate.  About 72% were in practice at a Level I center, 18% at a Level II, and 10% at Level III/IV or non-trauma centers.

There was considerable heterogeneity among the responses. Here are the summaries for the specific questions asked:

How would you treat a gunshot injury near bone without fracture?

The majority of respondents recommended non-operative treatment and some form of antibiotics. However, there was no consensus regarding route of administration or duration. About 75% were in favor of a single dose of IV antibiotics, and half of those also recommended addition oral antibiotics. The presence of a retained bullet did not change management.

How would you treat a gunshot with a stable fracture to the fibula?

Three quarters of the respondents recommended the same management as above (IV antibiotics + oral), although about 10% would admit for IV antibiotics and 10% would do a washout or debridement. Only 7% recommended no antibiotics or debridement.

How would you treat a gunshot traversing the  knee joint with a retained bullet?

About half stated they would explore the joint and the other half would not. Nearly all recommended antibiotics, with the majority in favor of a single dose IV followed by some duration of oral.

Is the union rate of a tibial shaft fracture from a gunshot treated surgically different than a non-gunshot fracture?

Half of the participants thought it would be the same, a quarter thought it would be higher, and a quarter lower.

What about a gunshot with a displaced tibia fracture without other skin wounds?

About half recommended fixation with irrigation and debridement with perioperative antibiotics. A quarter would do the same, but without the irrigation and debridement. About 10% would extend the antibiotic duration.

How would you handle a gunshot traversing bowel that results in a stable pelvic fracture?

There was no agreement here at all. The majority (61%) would not debride the fracture, but would recommend IV antibiotics. Most of those recommended at least 24 hours of coverage. The remaining surgeons recommended surgical debridement, and were evenly split over brief vs longer antibiotic duration.

Bottom line: This is a “How we do it study” that is based on science as interpreted by these orthopedic surgeons. In general, OTA members behave as if they consider gunshots to bone as open fractures. More than 90% recommend antibiotics any time a bullet touches the bone. But once the fracture requires operative management, it is treated like a non-gunshot fracture from the standpoint of debridement and antibiotics.

The most interesting part of this survey was the total lack of consistency in the answers. It is clear that there is wide variation in the practice patterns of these surgeons, which usually signifies a lack of good data pertaining to the problem.

In my next post, I’ll discuss the lead poisoning question I mentioned above.

Reference: Variation in treatment of low energy gunshot injuries – a survey of OTA members. Injury 49:570-574, 2018.

 

 

General

Amaze Your Friends! The “Greasy Blood” Sign

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Today, I’m writing about a clinical observation that I’ve not seen documented in the doctor books. Maybe it has and I’ve missed it. You be the judge.

I call this particular observation the “greasy blood” sign. You have probably seen it before in your practice as a trauma professional. It is present when you see blood (usually venous) coming from an extremity puncture wound or laceration. What makes it unique is the presence of what looks like drops of oil floating on the surface of the blood.

Here are some learning points about this “greasy blood” sign:

  • What you are actually seeing is fat from bone marrow issuing from an underlying fracture
  • It is most commonly seen in blunt trauma with an open fracture
  • It generally comes from femur or tib/fib fractures, although I’ve seen it a few times from upper extremity fractures
  • If it is associated with a penetrating injury, it is always a gunshot and typically the underlying fracture is very comminuted

Have you seen this sign in your practice? If so, tweet or comment and share any nuances you’ve experienced.

General

More On Time To Surgery After Open Fractures

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Open fracture dogma has mandated management of these injuries within an 8 hour window. Over the past several years, there has been a growing number of good papers that dispute this fact. As is the norm, many are retrospective in nature, or meta-analyses of retrospective papers. 

Recently, a paper was published that detailed a (small) prospective and multi-center study (3 hospitals in Canada) looking at deep infection, Gustillo grade, antibiotics, and time to treatment. My hopes were raised! 

Here are the factoids:

  • 939 patients were screened, but only 736 were actually enrolled
  • Only 482 completed the entire study (>90 days clinical followup and an interview after 1 year). Others with less clinical followup were still included and analyzed.
  • Information on fracture grade, time to antibiotic administration, time to OR, and development of deep infections were recorded. Cellulitis and pin site infections were not considered.
  • Time to antibiotic administration ranged from 1 hour to 10 hours (!!?)
  • Time to OR ranged from 6 to 13 hours
  • 46 patients developed deep infections, and 56 had cellulitis or pin site infections
  • Of those who developed infections, there was no clear association with time to OR
  • Also in those with infections, antibiotics were given after about 3 hours, vs 2.5 hours in those without.

The authors concluded that neither time to antibiotic administration nor time to surgery made any difference on deep tissue infections. But should I believe them?

Bottom line: SLOPPY! If you just read the abstract you might believe the wrong thing. This paper cobbled together surgeons at 3 different centers and let them do their own thing. The researchers just observed the management that these fellowship trained surgeons chose. No guidelines. No protocols. The variability of practice in this study leaves me flabberghasted. The median time to antibiotic administration was 3 hours, with some waiting up to 10 hours! The median time to OR was 9 hours, not so far off the 8 hour mark the everyone seems to look at. No wonder they couldn’t find any differences.

Give antibiotics early. Get to the OR in a reasonable amount of time, preferably using the Gustillo grade to take high grades there sooner. And keep your eye on the literature for papers that are much, much better than this one!

Related posts:

Reference: Time to Initial Operative Treatment Following Open Fracture Does Not Impact Development of Deep Infection: A Prospective Cohort Study of 736 Subjects. J Orthop Trauma 28(11):613-619, 2014.

General

The 8 Hour Rule For Open Fractures: We’re So Over That

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For decades, the standard of care for irrigation and debridement (I&D) of open fractures has been within 8 hours of injury. There is a growing body of orthopedic literature that says this isn’t necessarily so.

A paper presented at AAST, but not yet published, retrospectively looked at their experience with early (<8hrs) vs late I&D in a series of 248 patients. They looked at infection rates stratified by time and upper vs lower extremity.

They found that the infection rates overall were not significantly different. However, when subgrouped by extremity and higher Gustilo type >= III, they noted that both delayed I&D and Gustilo type correlated with infection risk. For the upper extremity, only Gustilo type >= III correlated with a higher infection rate.

The authors concluded that all lower extremity open fractures should be dealt with in the 8 hour time frame, whereas upper extremity fractures can be delayed for lower Gustilo classes.

Bottom line: I don’t necessarily buy into all the results from this small study. The orthopedic literature has already refined this concept. At Regions Hospital, we allow up to 16 hours to I&D for open fractures up to and including Gustilo class IIIA. Above that, the 8 hour rule is followed. We periodically review our registry data on all open fracture patients to make sure that the extended time frame patients are not experiencing an increase in wound complications. And they haven’t in our 8 year experience in handling them this way.

Refresher on the Gustilo classification system:

  • Class I – open fracture, clean wound, <1cm laceration
  • Class II – clean wound, laceration >1cm with minimal soft tissue damage
  • Class IIIA – clean wound, more extensive soft tissue damage or laceration, periosteum intact, minimal contamination
  • Class IIIB – extensive soft tissue damage with periosteal stripping or bone damage, significant contamination
  • Class IIIC – arterial injury without regard for degree soft tissue injury

Reference: Open extremity fractures: does delay in operative debridement and irrigation impact infection rates? AAST 2011 Annual Meeting, Paper 22.