Timing of closure of open fractures

Amanda D Weitz-Marshall, Michael J Bosse
Journal of the American Academy of Orthopaedic Surgeons 2002, 10 (6): 379-84
Traditionally, closure of open fractures after initial debridement has been delayed to minimize the risk of complications, particularly infection. This practice developed before the widespread use of systemic antibiotics, local antibiotic bead pouches, advanced debridement methods, and improved fracture stabilization techniques. Current evidence indicates that infections after treatment of open fractures frequently are not caused by initial contaminating organisms but often are acquired in the hospital. Recent studies comparing primary with delayed closure have not demonstrated an increased rate of complications. Considering the improvements in open fracture wound care, the increasing incidence of resistant nosocomial infections, and the cost implications of a dogmatic delayed-closure strategy, wound care protocols for open fractures should be reevaluated. Because of lack of data specifically addressing the timing of closure of such wounds, studies comparing primary versus delayed closure are needed.

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Rune Jakobsen

Bogdans comments: This is another review article on a very convoluted topic that I still think has no proper answer: timing of wound closure in open fractures. While some recent data show that it’s safe to close grade 1 and 2 wounds, and sometimes even grade 3A wounds, provided the debridement is clean and you are sure of it, the reality is that most surgeons don’t really have a standard evidence-based protocol, because every patient is very different. I think it is more important to understand that you cannot be dogmatic about the soft tissues, and you must assess the risk of primary and secondary closure based on the individual patient. I have closed 3A wounds primarily, and left grade 2 wounds open because something about the debridement (or the patient) was not to my liking. The article echoes this as well in the discussion: “Surgical judgment, typically gained with experience, is required to successfully use an immediate wound-closure protocol.”

Some points from this article:

1. The greatest danger in terms of infection is not from the bone, but the muscle.
2. There is no specific protocol for irrigant volume, but most surgeons follow an easy rule -3-6-9, 3L for grade 1, 6L for grade 2, and 9L for grade 3. This is what I follow as well, although more is better; as my attendings used to say, “the solution to pollution is dilution.”
3. The literature on wound closure varies significantly in how the studies define infection, both in quality (osteomyelitis vs soft tissue) and depth (deep, superficial).
4. Most studies agree that early flap coverage (within 72 hours) has better results.


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