Date: Sun, 23 Mar 2003 10:46:44 -0500
Subject: infection after fasciotomy
From: Fred Barrick
Does anyone know of a source of the incidence of infection after fasciotomy for a closed tibia fracture? I have searched to no avail.
E. Frederick Barrick, MD
Director of Orthopaedic Trauma
Inova Fairfax Hospital
Falls Church, VA
Date: Mon, 24 Mar 2003 14:49
From: Bill Burman
Fred
not specifically closed tibia fx but for extremity compartment syndrome -
7.3% infection for early (<12 hrs) versus 28% for late decompression - Surgery 1997 Oct;122(4):861-6
and 100% after 35 hours - J Trauma 1996 Mar;40(3):342-4
Date: Mon, 24 Mar 2003 14:51:19 -0600
From: Frederic B. Wilson, M.D.
Bill,
Do you recall how that squares with the couple papers presented at OTA in Toronto that did not show a significant increase in infection rates for Open fractures that went longer than 8 hours to I&D. I'll look tonight after I get home but it seems that the quality of debridement and irrigation has a much larger impact than the time to surgery.
Frederic B. Wilson, M.D.
Assistant Professor
Trauma and Adult Reconstruction
Department of Orthopaedic Surgery
Tulane University School of Medicine
New Orleans, LA, 70112
Date: Tues, 25 Mar 2003 08:13
From: Bill Burman
Fred
I think the Toronto OTA 2002 papers:
found that some delay (as required to stabilize the polytrauma patient) was tolerable before debridement and treatment of open fractures. I don't think these papers specifically discussed timing related to complications of treatment of closed compartment syndromes.
Date: Tue, 25 Mar 2003 08:38:53 -0500
From: James Carr
This is an interesting topic. The rule to never close open fx came largely as a result of WWII experience. There was an order issued that no open fx would be closed primarily. They were seeing too many disasters from wound closure (the same observations also happened with ex-fix, and internal fixation which also were banned in forward hospitals). This practice, coupled with the knowledge that bacteria double in number rather quickly, has contributed to practice today. However, civilian fx are different than WWII fx, and as these papers show, maybe there is room to delay definitive Rx. Keep in mind that you need to factor in treatment rendered in the ER- antibiotics, wound lavage, fx reduction, and I personally think that constitutes early treatment < 6 hours. That treatment is almost always rendered the first hours after injury.
Also keep in mind that the rare cases of gas gangrene occur in situations like a puncture wound open fx of the wrist which is casted and sent home.
Jim Carr
Date: Tue, 25 Mar 2003 09:40:11 -0600
From: Frederic B. Wilson, M.D.
Bill,
I had also looked up those references from the Toronto OTA. What I was referring to was the thought that we are probably looking at an analogous situation with the issue of open fasciotomy wounds, in that the risk of infection is probably in the same realm. The article by Rohmiller et al shows an infection rate of 5.4% and the article by Taitsman et al shows an infection rate of 7.2%.
While dangerous to try to extrapolate from these studies directly to the question of infection rates after fasciotomies, I believe we can infer that the fasciotomies and resulting open wounds are not the culprit, but rather the extent of injury to the extremity. My take is that rate will fall somewhere between 5-10%, higher with more severe injury, lower with less severe injury, as suggested by the Taitsman (Harborview) study.
Frederic B. Wilson, M.D.
Assistant Professor
Trauma and Adult Reconstruction
Department of Orthopaedic Surgery
Tulane University School of Medicine
New Orleans, LA, 70112
Date: Tue, 25 Mar 2003 22:04:11 +0530
From: DR T I GEORGE
Something from our experience. Purely anecdoctal and not based on statistics.
Earlier days we used to do fasciotomies and leave the wound open for a delayed closure(mostly split thickness skin grafts or secondary sutures). However of late we had been primarily skingrafting these wounds on day one. Though there are some degree of graft losses we feel that the infection rate is considerably less or even negligible.
A lesson from Bailey and Love's text book of surgery " skin is the best dressing you can apply on a wound".
DR T I GEORGE
Consultant Orthopaedic Surgeon,
Polytrauma, Micrvascular and Hand Surgery Unit,
Metropolitan Hospital,
Trichur. South India