Session IV Scientific Basis for Fracture Care
Does a Delay from Time of Injury to Surgical Intervention Affect the Incidence of Infection after Open Fractures in Multiple Trauma?
Emil H. Schemitsch MD, FRCS(C), R. Benko, J.P. Waddell MD, FRCS(C)
St. Michael's Hospital, University of Toronto, Toronto, Ontario, CANADA
Purpose: To determine the effect of delay from time of injury to surgical intervention on the incidence of infection after open fractures in patients with multiple trauma.
Method: One hundred and sixty-one patients with 200 open fractures were prospectively entered into a trauma database over an 8 year period (Jan. 1987-Dec.1994). All patients had sustained multiple trauma, so that isolated extremity injuries were excluded. The age, sex, mechanism of injury, method of fracture treatment, ISS, Glasgow Coma Scale, days in ICU, days ventilated, days in hospital, type of soft tissue coverage, time to soft tissue coverage, number of anesthetics, and amount of blood products transfused were recorded. The presence of femoral, tibial, humeral, forearm, pelvic and other fractures was also recorded. Soft tissue wounds were classified according to the system of Gustilo et al. A standard protocol for management of the open wound was employed including antibiotic prophylaxis, wound debridement and irrigation. The time from injury to surgical intervention was broken into 6 groups (2-4, 4-6, 6-8, 8-10, 10-12, >12 hours).
Results: There were 112 males and 49 females with a mean age of 32 years. Mean ISS was 23. There were 38 type I wounds, 90 type II, 32 type III A, 13 type III B, and 22 type III C. In 5 fractures, consensus could not be reached regarding the grade. The overall infection rate was 12%, increasing in severity from Grade I (0%) to Grade III B/C (25.7%) (p=0.001). The average time elapsed from injury to surgical intervention was 6.1 hours. There was no effect of time elapsed from injury to surgical intervention on infection rates (p=0.63).
There was also no relationship between age, sex, mechanism of injury, method of fracture treatment, ISS, Glasgow Coma Scale, fracture site and the incidence of infection. The rate of infection was associated with days ventilated (p=0.002), days in hospital (p=0.08), number of anesthetics (p=0.001), and amount of blood products transfused (p=0.03).
Discussion: There was no effect of time from injury to surgical intervention on infection rates after open fractures in patients with multiple trauma. Although prompt intervention is important with open fractures, other critical injuries can be safely dealt with as a priority, if necessary. Overall patient morbidity may be a more important prognostic indicator for the occurrence of infection in patients with multiple trauma.