Delay in Management of Open Fractures Poses Infection Risk

A new study finds that a delay greater than eight hours in the debridement and irrigation (D&I) for open fracture increases the likelihood of infection in the lower extremity, but not the upper.

Researchers at Virginia Commonwealth University Medical Center (VCUMC; Richmond, USA) conducted a study that examined 404 patients with blunt open fractures (upper, 129; lower, 287) during a 6-year period from the VCUMC trauma registry. The patients were evaluated for age, injury severity score (ISS), physiologic derangement (systolic blood pressure, lactate, Revised Trauma Score [RTS]), and fracture type (Gustilo). Time to first D&I was calculated, and infection rates were correlated to that time. Regression analysis was performed to identify independent predictors of infection.

The results showed that rates of infection were 11% in the group that underwent D&I during the first 8 hours, and 19% in those that were delayed beyond 8 hours. For the lower extremity, both a delay of greater than 8 hours and higher Gustilo type correlated with the development of infection; but in the upper extremity, only higher Gustilo type correlated, and a delay to the first D&I did not increase the incidence of infection. When separated by extremity, Higher ISS, Gustilo grade, and delay were independent predictors for the lower extremity, but not for the upper extremity. The study was published in the May 2014 issue of the Journal of Trauma and Acute Care Surgery.

“Delay of greater than eight hours to the first debridement and irrigation for open fractures of the lower extremity increases the likelihood of infection; higher Gustilo type open fractures have a higher incidence of infection for both upper and lower extremities,” concluded lead author Ajai Kumar Malhotra, MD, and colleagues. “The results have important implications in an era of decreasing surgeon availability, especially in off hours.”

For decades, the standard of care for D&I of open fractures has been treatment within eight hours of injury, and was considered essential to reduce the risk of deep infection. But with the advent of powerful antimicrobials, this axiom has been challenged, claiming that early debridement may pose unjustified risks to patient safety.

Related Links:
Virginia Commonwealth University Medical Center