Michael D. Hunter MD1, Mark D. Hasenauer MD2, Atul F. Kamath MD3 and Kyle J. Jeray MD1 1Greenville Hospital System, Greenville, SC, USA 2Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA, USA 3Cleveland Clinic, Cleveland, OH, USA Proper early management of open fractures in the trauma bay is essential to afford patients the best orthopedic outcome. This includes application of splints and bedside irrigation, as well as administration of proper medications and appropriate resuscitation techniques. Early administration of antibiotics and resuscitation efforts can help reduce complications. Open fractures are initially managed in the trauma bay with local irrigation, splinting, and administration of antibiotics. Tetanus is administered as indicated as well. As experiments have suggested, antiseptics (such as povidone iodine) may be toxic to the host cells;1,2 therefore, gauze dressings moistened with normal saline may be the safest, least destructive choice for short‐term coverage. The administration of systemic antibiotics for open fractures has been the standard of care since 1974.3 A Cochrane review by Gosselin et al. showed that antibiotics given for open fractures reduce the infection risk by 59%.4 The current antibiotic recommendations stem from the original Gustilo and Anderson articles.5,6 Several studies agree that the single‐most‐important factor in reducing infection is early administration of the appropriate antibiotics.2–4,7–9 A 2015 journal article showed that antibiotics given >66 min after arrival in type III fractures were associated with increased infection rates (odds ratio [OR] = 3.78; 95% confidence interval [CI]: 1.16–12.31; p] = 0.03).10 Contrary to this, a prospective cohort study showed that timing of antibiotic of administration may be less important than Gustilo type for developing deep infection in open fractures.11 In current protocols, a first‐generation cephalosporin (usually cefazolin) is given for type I and II fractures, while an aminoglycoside (usually gentamicin) is often added for type III fractures or fractures with gross contamination based upon the work of Patzakis et al.7 Penicillin is also recommended for highly contaminated wounds or in areas with poor vascularity. Some exceptions to early systemic antibiotic therapy do exist, but these studies are primarily focused on hand fractures. For example, a systematic review and a randomized placebo‐controlled trial found that prophylactic antibiotics did not add to the prevention of infection in conjunction with routine treatment of open distal phalanx fractures with irrigation and debridement.8,12 Although these studies suggest that antibiotics may not be necessary, phalanx fractures are in highly vascular areas, lend to easier bedside irrigation/debridement, and are typically low‐energy injuries. Few articles give length of dosing recommendations for antibiotic therapy, although most surgeons agree that antibiotics should be continued for at least 24 hours after the final irrigation and debridement, similar to antibiotic prophylaxis recommendations for elective surgery.9 The importance of this question lies in determining the optimal time from when patients arrive at the hospital to when a formal irrigation and debridement should be conducted. Polytrauma patients are nonelective surgeries; however, operating within the six‐hour rule for irrigation and debridement should be balanced with the patient’s overall physiologic status, operating room availability, and reasonable demands on the surgeon. Based on the Gustilo/Anderson articles, open fractures have been considered emergent cases that need to undergo operative debridement within six hours of injury. However, only one study supports the idea of debridement of open fractures within six hours of injury; Kindsfater and Jonassen reviewed open tibial fractures and found a significant increase in infection rate in fractures that were delayed greater than five hours. One in fifteen open fractures (7%) became infected if debrided in <5 hours versus 12/32 open fractures (38%) debrided >5 hours after injury (p <0.03).13 On the contrary, many studies question the need for urgent irrigation and debridement (I and D) within six hours and some have even suggested no debridement is necessary for isolated type 1 open injuries in the pediatric population.14 Pollack concluded in a review article that within the modern era of antibiotics timing to I and D is not an independent predictor of postinjury infection.15 Later in the Lower Extremity Assessment Program (LEAP) study, he showed that there was no difference in outcomes when debridement occurred within the first 24 hours.16 In 2012, a systematic review showed no difference in time to operation and infection risk regardless of subtype. Overall infection rates ranged from 4 to 63%, with an OR of late compared to early debridement of 0.91 (95% CI: 0.70 to 1.18).17 Weber, in 2014, also released a cohort study of 736 patients which showed no difference in time to surgery on infection risk of open fractures.11 Dr. Srour and the University of Southern California examined 315 patients and again saw no difference in early or late infections when the index procedure was performed <6 hours after injury or between 6 and 24 hours.18
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Open Fractures
Clinical scenario
Top three questions
Question 1: In trauma patients with open fractures, does early antibiotic administration result in lower infection rates as compared to delayed antibiotic administration?
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Available literature and quality of the evidence
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Resolution of clinical scenario
Question 2: In polytrauma patients with open fractures, does timely irrigation and debridement result in decreased complications and infection rates as compared to delayed irrigation and debridement?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
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