Date: Mon, 23 Sep 2002 13:03:49 -0400

Subject: Grade 1 Open Fx

Are there any of you NOT taking Grade 1 open injuries to the OR for debridement?

Jason Nascone
Washington DC


Reply at: Orthopaedic Trauma Association forum

Date: Mon, 23 Sep 2002 13:58:23 -0500

From: Obremskey, William T

Most Type I fractures are unstable as the surrounding soft tissue was disrupted enough to cause an inside out wound in the extremity. Due to the instability they need to go to the OR for stabilization. I do not think that a type I metacarpal fx needs to go to the OR.

The question is timing? Can a type I fx wait 8-24 hrs to be washed out and stabilized? The recent JOT article from Alberta Canada and the Vanderbilt experience (to be presented at the OTA) do not indicate that time to debridement was a predictor of deep infx or non-union.

Bill Obremskey


Date: Mon, 23 Sep 2002 16:46:12 -0400

From: Jason Nascone

I agree completely that the appropriate place for open fractures is the OR. The other issue is the varibility of debridement from surgeon to surgeon. I see continuing problems with open fractures not going to the OR for formal washouts at major Metro Level 1 trauma Center. Its frightening.

J Nascone MD
Washington DC


Date: Mon, 23 Sep 2002 18:35:43 -0400

From: OTS1

Do you really know its a grade I without anesthesia?

Roy Sanders, M.D.
Tampa, Florida


Date: Wed, 25 Sep 2002 08:38:54 -0400

From: Jason Nascone

These injuries need to go to the OR for evaluation, debridement and stabilization. Present situation here is multiple community orthopaedists not always taking open injuries to the OR at level 1 center. Any sugestions?

J Nascone
Washington DC


Date: Wed, 25 Sep 2002 10:00 AM EST

From: Bill Burman

Before institutional amnesia sets in, it might be of interest to consider this paper from the Annual OTA Meeting in Dallas in 1988.

While the paper was never published, I am having difficulty finding one that was which would contradict it.

Bill Burman, MD
HWB Foundation

Date: Wed, 25 Sep 2002 10:58:49 -0400

From: James Carr

I think we overtreat a number of these, but the problem is selection of Gr I open fractures for nonop treatment. We have all seen small wound openings with some form of contamination discovered when things are opened up. The infrequent cases of reported gas gangrene are many times from small puncture wound open fractures. We used to treat all gunshot fx with debridement- look at how that has changed. Conversely, maybe we don't help out these fractures as the LA county paper suggested. I think you need to monitor this as a QA issue, and somehow filter cases with open fx + no trip to the OR for debridement to be reviewed for infection.

Jim Carr


Date: Thu, 26 Sep 2002 04:06:41 EDT

From: Aobonedoc

I take all open fractures to the OR for I+D.

Sincerely and respectively,

M. Bryan Neal, MD
Arlington Orthopedics and Hand Surgery Specialists, Ltd.
1100 W. Central Road, Suite 304
Arlington Heights, Illinois 60005


Date: Thu, 26 Sep 2002 06:40:49 -0700

From: Paul Kosmatka

Bill,

The OTA paper provides interesting data. I wonder what happens to the data when you throw out the 17 patients in the debridement group that were treated with ORIF? The groups are not comparable as a result of this treatment variable. Was it the debridement or the ORIF that resulted in higher complications?


Date: Thu, 26 Sep 2002 12:51 EST

From: Bill Burman

Paul,

Standard of care these days is fixation of open fractures. Presumably fixation protects the soft tissues and thereby the delivery of the immune response and antibiotics to the area of injury - lowering the infection rate. With proportionally more ORIF, one could argue that the formal debridement group was provided a favorable bias in terms of infection protection and yet it had more infection.

My purpose here is not to argue the merits of this paper which is available only in abstract form. Bob Keller, past chair of the AAOS Committee on Outcomes, said that much of the data upon which we base our clinical practice and teaching is severely flawed. I would go further to say that in many cases, for many simple questions (e.g. "what should I do with a grade 1 open fx?") it appears to be nonexistent - even though we should be able to begin to address these questions by simple, local QA surveillance, as Jim Carr suggests.

Bill Burman, MD
HWB Foundation