Background: Traditional recommendations hold that open fractures in both children and adults require urgent surgical débridement for a number of reasons, including the preservation of soft-tissue viability and vascular status as well as the prevention of infection. Following the widespread use of early administration of antibiotics, a number of single-institution studies challenged the belief that urgent surgical débridement decreases the risk of acute infection.
Methods: We performed a retrospective, multicenter study of open fractures that had been treated at six tertiary pediatric medical centers between 1989 and 2000. The standard protocol at each medical center was for all children to be given intravenous antibiotics upon arrival in the emergency department. The medical records of all children with open fractures were reviewed to identify the location of the fracture, the interval between the injury and the time of surgery, the Gustilo and Anderson classification, and the occurrence of acute infection.
Results: The analysis included 554 open fractures in 536 consecutive patients who were eighteen years of age or younger. The overall infection rate was 3% (sixteen of 554). The infection rate was 3% (twelve of 344) for fractures that had been treated within six hours after the injury, compared with 2% (four of 210) for those that had been treated at least seven hours after the injury; this difference was not significant (p = 0.43). When the fractures were separated according to the Gustilo and Anderson classification system, there were no significant differences in the infection rate between those that had been treated within six hours after the injury and those that had been treated at least seven hours after the injury. Specifically, these infection rates were 2% (three of 173) and 2% (two of 129), respectively, for type-I fractures, 3% (three of 110) and 0% (zero of forty-four), respectively, for type-II fractures, and 10% (six of sixty-one) and 2% (two of thirty-seven), respectively, for type-III fractures (p > 0.05 for all three comparisons).
Conclusions: In the present retrospective, multicenter study of children with Gustilo and Anderson type-I, II, and III open fractures, the rates of acute infection were similar regardless of whether surgery was performed within six hours after the injury or at least seven hours after the injury. The findings of the present study suggest that, in children who receive early antibiotic therapy following an open fracture, surgical débridement within six hours after the injury offers little benefit over débridement within twenty-four hours after the injury with regard to the prevention of acute infection.
Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.
1 Division of Orthopedic Surgery, Childrens Hospital Los Angeles, MS# 69, 4650 Sunset Boulevard, Los Angeles, CA 90027
2 Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
3 Pediatric Orthopedic and Scoliosis Center, 3030 Children's Way, Suite 410, San Diego, CA 92123-4208
4 Children's Orthopaedics of Atlanta, 5545 Meridian Mark Road, Suite 250, Atlanta, GA 30342
5 The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Wood Building, 2nd Floor, Philadelphia, PA 19104