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Orthopaedics & Traumatology, Surgery &... Sep 2022Studies on the association of open tibia fractures and acute compartment syndrome (ACS) show confusing results, with some papers highlighting a positive association, and...
BACKGROUND
Studies on the association of open tibia fractures and acute compartment syndrome (ACS) show confusing results, with some papers highlighting a positive association, and others failing to do so. The aim of this study was to determine if an open tibia fracture is at increased risk of ACS occurrence, when compared to a closed fracture.
HYPOTHESIS
Skin injury in the setting of an open tibia fracture does not prevent from ACS occurrence, because the energy transmitted to the limb during trauma may lead to soft tissue lesions, including skin lacerations and ACS.
PATIENTS AND METHODS
In total, 711 consecutive adult patients (mean age 44.6 years; 65.8% males) sustaining 725 tibia fractures between 01.01.2005 and 31.12.2009 were included in this retrospective study. The outcome measure was ACS. The following variables were assessed: soft tissue condition, age, sex, low- vs. high-energy injury, type of fracture, associated contiguous skeletal injury. A logistic regression model was used and adjustment was performed for age and sex.
RESULTS
ACS occurred in 10.4% of proximal intra-articular fractures, 10.4% of extra-articular fractures and 3.3% of distal intra-articular fractures, and in 8.7% of closed fractures, 7.8% of open Gustilo 1 fractures and 13.3% of open Gustilo 2 and 3 fractures. Open lesions were not associated with ACS when tibia fractures were considered as a whole. When stratifying by types of fractures, open Gustilo 2 and 3 lesions were associated with ACS in proximal intra-articular fractures (p=0.048). There was no association with closed or any type of open lesions for extra-articular fractures. There were not enough ACS cases among distal intra-articular fractures to draw conclusions.
DISCUSSION
As ACS may occur with any type of open tibia fractures, clinicians should not be wrongly reassured by an open fracture, assuming that the wound would relieve the pressure inside the muscle compartments. There is a weak association between open Gustilo 2 and 3 lesions and ACS in proximal intra-articular fractures only. These findings are important for surgeons treating these injuries, especially by intubated, sedated or obtunded patients.
LEVEL OF EVIDENCE
III; retrospective diagnostic study.
Topics: Adult; Compartment Syndromes; Female; Fractures, Closed; Fractures, Open; Humans; Intra-Articular Fractures; Male; Retrospective Studies; Tibia; Tibial Fractures; Treatment Outcome
PubMed: 34929394
DOI: 10.1016/j.otsr.2021.103188 -
Medicine Jul 2022We aimed to investigate the incidence, characteristics, and treatments of open fractures in children and adolescents (≤18 years old). We retrospectively reviewed the... (Observational Study)
Observational Study
We aimed to investigate the incidence, characteristics, and treatments of open fractures in children and adolescents (≤18 years old). We retrospectively reviewed the records of 2418 children and adolescents who presented with traumatic fractures and were admitted to our university-affiliated hospitals, among which 206 patients (8.5%) presented with open fractures. The patients' clinical and radiographic records were reviewed, and the age, gender, cause of injury, injury season, injury week, associated injuries and complications were collected. This study enrolled 1789 males (74.0%) and 629 females (26.0%) with an average age of 11.2 ± 5.0 years. The patients were divided into an open fracture group (OF group, n = 206) and a group with no open fracture (No-OF group, n = 2212). There were 206 patients (8.5%) who presented with open fractures and the most common fracture sites were the tibia (31.1%, 64/206) and fibula (20.9%, 43/206). The patients in the OF group presented with higher frequency of emergency admission (P < 0.001), self-supporting medical insurance (P < 0.001), MVCs (P < 0.001), wounded by machine (P < 0.001), struck by object (P < 0.001), hurt/cut by others (P < 0.001), lower limb fractures (P < 0.001), multiple fractures (P = 0.010), associated injuries (P < 0.001) and wound infection (P = 0.003) then the patients in the No-OF group. The most common complication were wound infection (5.8%) and pneumonia (1.0%) in the OF group, wound infection (2.1%) and pressure sores (2.0%) in the No- OF group. Multivariate logistic regression analysis indicated that mechanical trauma (OR = 64.229, P < 0.001), being hurt/cut by others (OR = 26.757, P < 0.001), and being struck by an object (OR = 15.345, P < 0.001) were stronger risk factors for open fracture than were low falls; additionally, lower limb fractures (OR = 5.970, P < 0.001), upper limb fractures (OR = 5.865, P < 0.001) and multiple fractures (OR = 5.414, P < 0.001) were stronger risk factors than craniofacial fractures for open fractures. The frequency of surgical treatment for the patients with traumatic open fractures (87.9%, 181/206) was significantly higher than those without open fractures (72.2%, 1596/2212) (P < 0.001). The hospital stays and fees for surgical treatment for the patients with traumatic open fractures were significantly higher than those without open fractures (P < 0.001). Etiology (especially being injured by a machine or being hurt/cut by others) and the fracture site (including lower limb fractures and upper limb fractures) were independent risk factors for open fractures. Traumatic open fractures presented with higher surgical treatment rate, hospital stays and fees.
Topics: Adolescent; Child; Female; Fractures, Multiple; Fractures, Open; Humans; Incidence; Male; Retrospective Studies; Wound Infection
PubMed: 35777018
DOI: 10.1097/MD.0000000000029828 -
Surgical Infections Apr 2021Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and... (Review)
Review
Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.
Topics: Anti-Bacterial Agents; Anti-Infective Agents, Local; Fractures, Open; Humans; Surgical Wound Infection; Therapeutic Irrigation
PubMed: 32589513
DOI: 10.1089/sur.2020.075 -
Injury Jun 2021Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their... (Review)
Review
BACKGROUND
Open tibia fractures are a common injury following road traffic collisions and place a large economic burden on patients and healthcare systems. Summarising their economic burden is key to inform policy and help prioritise treatment.
METHODS
All studies were identified from a systematic search of Medline, Embase and the Cochrane Central Register of Controlled Trials. We included any human with a diagnosed open tibia fracture, following any intervention. The primary outcome was any costs reported or patient return to work status. Secondary outcomes included average length of stay, wage loss, absenteeism and complications such as infection, amputation and nonunion. Data was extracted and we performed a descriptive narrative summary.
RESULTS
We reviewed 1,204 studies from our searches. A total of 34 studies were included from 14 different countries. The average age was 37.7 years old and 76% of the patients were male. 6.5% were Gustilo I, 12% Gustilo II and 82% Gustilo III. Initial direct hospitalisation costs were reported to be between £356 to £126,479 with an average length of stay of 56 days (3.1-244). 89% of participants were working pre-injury, 60% fully returned to work, 17% returned to work part time or changed profession and 22% did not return to work at one-year. The most common complications reported were 22% infection, 11% nonunion and 16% amputation. Mean follow-up duration for the studies was 25 months.
CONCLUSION
The economic burden of open tibia fractures varies greatly, but it is costly for both hospitals and patients. The current evidence is predominantly from high-income countries (HICs), especially the USA. Further research is required to investigate the costs of open tibia fractures using validated costing tools, especially in low-income countries (LICs), to help inform and direct policy.
Topics: Accidents, Traffic; Adult; Amputation, Surgical; Cost of Illness; Female; Fractures, Open; Humans; Male; Tibia; Tibial Fractures
PubMed: 33691946
DOI: 10.1016/j.injury.2021.02.022 -
Ulusal Travma Ve Acil Cerrahi Dergisi =... Mar 2019Although early free flap coverage for lower extremity traumatic defects has been recommended by several authors, it is often not practical due to associated patient...
BACKGROUND
Although early free flap coverage for lower extremity traumatic defects has been recommended by several authors, it is often not practical due to associated patient injuries or logistics. The aim of this study was to evaluate the impact of subacute and delayed surgical timing on flap success.
METHODS
A retrospective analysis of adult patients who underwent a microsurgical free flap operation between 2007 and 2012 following lower extremity trauma was performed. The patients were divided into 2 groups according to the time period between the injury and the free flap operation: a subacute group (flap performed 10 to 29 days after injury) and a delayed repair group (>30 days after injury). The details of patient demographics, the mechanism of injury, timing from operation to discharge, minor and major complications, and flap failure rates were evaluated and compared.
RESULTS
The study included 35 patients who underwent 37 free flap operations. A total of 20 patients were operated on 10 to 29 days after the injury (subacute repair group), and 15 patients were operated on more than 30 days after the injury (32-92 days) (delayed repair group). No significant correlation was found between the timing of the reconstruction, flap failure, and complication rates.
CONCLUSION
Both subacute and delayed reconstruction for lower extremity traumatic defects can be performed with favorable results with appropriate wound preparation and precise preoperative planning.
Topics: Fractures, Open; Free Tissue Flaps; Humans; Leg Injuries; Plastic Surgery Procedures; Retrospective Studies
PubMed: 30892665
DOI: 10.5505/tjtes.2018.28302 -
Orthopaedics & Traumatology, Surgery &... Feb 2014Distal humeral fractures represent 2% of all adult elbow fractures. Injury mechanisms include high-energy trauma with skin involvement, and low energy trauma in... (Review)
Review
Distal humeral fractures represent 2% of all adult elbow fractures. Injury mechanisms include high-energy trauma with skin involvement, and low energy trauma in osteoporotic bone. Treatment goals are anatomical restoration in young, high-demand patients and quick recovery of activities of daily living in the elderly. Complete fractures are relatively easy to diagnose, but partial intra-articular fractures are not. The clinical diagnosis must take into account potential complications such as open injuries and ulnar nerve trauma. Standard X-rays with additional distraction series in the operating room are sufficient in complete articular fracture cases. Partial intra-articular fractures will need CT scan and 3D reconstruction to fully evaluate the involved fragments. SOFCOT, AO/OTA and Dubberley classifications are the most useful for describing fractures and selecting treatment. Surgery is the optimal treatment and planning is based on fracture type. Complete fractures are treated using a posterior approach. Triceps management is a function of fracture lines and type of fixation planned. Constructs using two plates at 90° or 180° are the most stable, with additional frontal screw for intercondylar fractures. Elbow arthroplasty may be indicated in selected patients, having severely communited distal humerus fractures and osteoporotic bone. Open fractures make fixation and wound management more challenging and unfortunately have poorer outcomes. Other complications are elbow stiffness, non-union, malunion and heterotopic ossification.
Topics: Adult; Aged; Arthroplasty; Bone Plates; Bone Screws; Elbow Joint; Fracture Fixation, Internal; Fracture Healing; Fractures, Comminuted; Fractures, Open; Humans; Humeral Fractures; Image Interpretation, Computer-Assisted; Imaging, Three-Dimensional; Intra-Articular Fractures; Middle Aged; Osteoporotic Fractures; Postoperative Complications; Prognosis; Reoperation; Tomography, X-Ray Computed; Elbow Injuries
PubMed: 24461911
DOI: 10.1016/j.otsr.2013.11.002 -
Archives of Orthopaedic and Trauma... Nov 2011Fractures of the ankle are fairly common injuries. Open ankle fractures are much less common and associated with severe injuries to surrounding tissues. We have... (Review)
Review
Fractures of the ankle are fairly common injuries. Open ankle fractures are much less common and associated with severe injuries to surrounding tissues. We have performed a systematic review of the literature concerning the clinical results and complication rates in the treatment of open ankle fractures. We conducted a search limited to the following databases: Pubmed/Medline, Cochrane Database of Systematic Reviews, Cochrane Clinical Trial Register and Embase. These were searched from 1968 to April 2010 to identify studies relating to the treatment of open ankle fractures. Fifteen articles concerning 498 patients with treatment of an open ankle fracture were identified. The number of included patients varied from 11 to 64. There were 2 prospective and 13 retrospective studies. All articles were case series and classified as Level IV evidence. In 373 cases, open ankle fractures were treated by immediate internal fixation. In 125 cases, a conservative treatment or delayed/other fixation treatment was followed. Of those patients treated by immediate internal fixation, 81% had satisfactory result. Poor results (15%) were most commonly due to non-anatomic reductions, articular surface damage or deep infection. When conservative treatment was followed, 76% had satisfactory results. The most reported complications after immediate internal fixation were deep infection (8%) and skin necrosis (14%). There is a lack of high quality literature concerning the (operative) treatment of patients with open ankle fractures. Remarkable is that most authors reported satisfactory results after performance of their treatment protocol. Based on the available literature, we formulated guidelines regarding: timing of operative treatment, wound irrigation, the role of internal fixation, wound coverage and closure, the use of antibiotics and additional therapies.
Topics: Ankle Injuries; Evidence-Based Medicine; Fractures, Open; Humans; Practice Guidelines as Topic
PubMed: 21713539
DOI: 10.1007/s00402-011-1349-7 -
Scientific Reports May 2023Postoperative surgical site infection (SSI) is common in open long bone fractures, so early administration of prophylactic antibiotics is critical to prevent SSI.... (Review)
Review
Postoperative surgical site infection (SSI) is common in open long bone fractures, so early administration of prophylactic antibiotics is critical to prevent SSI. However, the necessity of initial broad-spectrum coverage for Gram-positive and -negative pathogens remains unclear. The purpose of this study was to clarify the effectiveness of prophylactic broad-spectrum antibiotics in a large, national-wide sample. We reviewed an open fracture database of prospectively collected data from 111 institutions managed by our society. A retrospective cohort study was designed to compare the rates of deep SSI between narrow- and broad-spectrum antibiotics, which were initiated within three hours after injury. A total of 1041 type III fractures were evaluated at three months after injury. Overall deep SSI rates did not differ significantly between the narrow-spectrum group (43/538, 8.0%) and broad-spectrum group (49/503, 9.8%) (p = 0.320). During propensity score-matched analysis, 425 pairs were analyzed. After matching, no significant difference in the SSI rate was seen between the narrow- and broad-spectrum groups, with 42 SSIs (9.9%) and 40 SSIs (9.4%), respectively (p = 0.816). The probability of deep SSI was not reduced by broad-spectrum antibiotics compared with narrow-spectrum antibiotics in type III open long bone fractures.
Topics: Humans; Retrospective Studies; Fractures, Open; Antibiotic Prophylaxis; Anti-Bacterial Agents; Surgical Wound Infection; Propensity Score
PubMed: 37127796
DOI: 10.1038/s41598-023-34142-7 -
The Cochrane Database of Systematic... Apr 2022Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to... (Review)
Review
BACKGROUND
Open fractures of the major long bones are complex limb-threatening injuries that are predisposed to deep infection. Treatment includes antibiotics and surgery to debride the wound, stabilise the fracture and reconstruct any soft tissue defect to enable infection-free bone repair. There is a need to assess the effect of timing and duration of antibiotic administration and timing and staging of surgical interventions to optimise outcomes.
OBJECTIVES
To assess the effects (risks and benefits) of the timing of antibiotic administration, wound debridement and the stages of surgical interventions in managing people with open long bone fractures of the upper and lower limbs.
SEARCH METHODS
We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase and clinical trial registers in February 2021. We also searched conference proceedings and reference lists of included studies.
SELECTION CRITERIA
We included randomised controlled trials (RCTs) or quasi-RCTs that recruited adults with open fractures of the major long bones, comparing: 1) timings of prophylactic antibiotic treatment, 2) duration of prophylactic antibiotic treatment, 3) timing of wound debridement following injury or 4) timing of the stages of reconstructive surgery.
DATA COLLECTION AND ANALYSIS
We used standard methodological procedures expected by Cochrane. We aimed to collect data for the following outcomes: limb function, health-related quality of life (HRQoL), deep surgical site infection, delayed or non-union, adverse events (in the short- and long-term course of recovery), and resource-related outcomes.
MAIN RESULTS
We included three RCTs of 613 randomised participants with 617 open fractures. Studies were conducted in medical and trauma centres in the USA and Kenya. Where reported, there was a higher proportion of men and a mean age of participants between 30 and 34 years old. Fractures were in the upper and lower limbs in one study, and were tibia fractures in two studies; where reported, these were the result of high-energy trauma such as road traffic accidents. No studies compared the timing of antibiotic treatment or wound debridement. Duration of prophylactic antibiotic treatment (1 study, 77 participants available for analysis) One study compared antibiotic treatment for 24 hours with antibiotic treatment for five days. We are very uncertain about the effects of different durations of antibiotic treatment on superficial infections (risk ratio (RR) 1.19, 95% CI 0.49 to 2.87, favours 5 day treatment; 1 study, 77 participants); this was very low-certainty evidence derived from one small study with unclear and high risks of bias, and with an imprecise effect estimate. This study reported no other review outcomes. Reconstructive surgery: timing of the stages of surgery (2 studies, 458 participants available for analysis) Two studies compared the timing of wound closure, which was completed immediately or delayed. In one study, the mean time of delay was 5.9 days; in the other study, the time of delay was not reported. We are very uncertain about the effects of different timings of wound closure on deep infections (RR 0.82, 95% CI 0.37 to 1.80, favours immediate closure; 2 studies, 458 participants), delayed union or non-union (RR 1.13, 95% CI 0.83 to 1.55, favours delayed closure; 1 study, 387 participants), or superficial infections (RR 6.45, 95% CI 0.35 to 120.43, favours delayed closure; 1 study, 71 participants); this was very low-certainty evidence. We downgraded the certainty of the evidence for very serious risks of bias because both studies had unclear and high risks of bias. We also downgraded for serious imprecision because effect estimates were imprecise, including the possibility of benefits as well as harms, and very serious imprecision when the data were derived from single small study. These studies reported no other review outcomes.
AUTHORS' CONCLUSIONS
We could not determine the risks and benefits of different treatment protocols for open long bone fractures because the evidence was very uncertain for the two comparisons and we did not find any studies addressing the other possible comparisons. Well-designed randomised trials with adequate power are needed to guide surgical and antibiotic treatment of open fractures, particularly with regard to timing and duration of antibiotic administration and timing and staging of surgery.
Topics: Adult; Anti-Bacterial Agents; Debridement; Fractures, Open; Humans; Lower Extremity; Male; Plastic Surgery Procedures
PubMed: 35363374
DOI: 10.1002/14651858.CD013555.pub2 -
Joint Diseases and Related Surgery 2020This study aims to investigate the effects of associated factors like age, fracture level, accompanying fibular fractures and wound condition on healing by determining...
OBJECTIVES
This study aims to investigate the effects of associated factors like age, fracture level, accompanying fibular fractures and wound condition on healing by determining and comparing union scores of pediatric tibial fractures (PTFs).
PATIENTS AND METHODS
Forty-five patients with 46 PTFs (32 males, 13 females; mean age 9.5 years; range 2 to 16 years) who were treated by closed reduction and casting or operated between January 2016 and January 2019 were retrospectively evaluated. The union scores were evaluated at the end of fourth, sixth and eighth weeks and compared to each other. Effects of the age, associated fibular fractures, wound condition, fracture level and treatment type to union score were analyzed.
RESULTS
Twenty-eight (60.9%) out of 46 PTFs had associated fibular fractures and 18 (39.1%) did not. Motor vehicle accident was the most frequent etiologic factor (47.8%). Thirty-four out of 46 fractures were closed tibial fractures (73.9%) and 12 had open wound (26.1%). There was a negative correlation between age and the union scores (p<0.001 for each week). No significant difference was observed between the union score of diaphyseal and metaphyseal fractures at the fourth, sixth, and eighth weeks. The union scores of each week were higher in the conservative group compared to operative group (p<0.001 for each week). Associated fibular fracture group had lower union scores compared to isolated tibial fracture group at fourth, sixth and eighth weeks. Likewise, the union scores of the open fracture group were lower than the closed fracture group (p<0.05 for each week).
CONCLUSION
Associated fibular fractures, open fractures and aging negatively affect union scores of PTFs. Attention should be paid, particularly in these conditions, during the selection of the operation type and the follow-up period of PTFs.
Topics: Age Factors; Child; Conservative Treatment; Female; Fractures, Closed; Fractures, Open; Humans; Male; Orthopedic Procedures; Patient Selection; Radiography; Retrospective Studies; Tibia; Tibial Fractures; Trauma Severity Indices; Turkey
PubMed: 32962586
DOI: 10.5606/ehc.2020.75764