By: 25 October 2011

Randall W. Culp, MD, and Jeff W. Johnson, MD.
The Journal of Hand Surgery. January 2010. Vol. 35A. No. 1. Pp. 137-140.

When a person has a high-energy traumatic leg injury resulting in a bone fracture and an open wound, getting to a trauma center and getting treatment is a real emergency. Emergency doctors and staff need to know what the results are of delayed treatment for injuries of this type. With open fractures, the risk of deep infection is a big problem. Irrigation and debridement should be done within the first six hours after the injury. Sometimes, soft tissue coverage is needed.

Getting treatment in the first six hours seems simple, but these patients often have multiple other life-threatening injuries that demand more immediate attention. And they may live in a rural setting or need to be transported from one hospital to a trauma center. All of that takes time and attention away from the leg injury. It’s clear that urgent treatment is needed. But how soon? What’s the optimum time for best results? These are the questions a study group tried to answer with this study.

They reviewed the charts of 315 patients who had high-energy leg injuries and who were treated at one of eight trauma centers. They collected a variety of data and information from the patients’ medical records. Type of injury, time periods (in hours), and treatment administered were recorded. Patient characteristics such as age, gender, and other injuries were also noted. The patients were divided into two groups depending on whether they were admitted directly to the trauma center (direct group) or had to be transferred from another hospital (transfer group).

Patients ranged in ages from 16 to 69. Certain patients were not included in the study. Patients excluded were those who were in a coma or had a spinal cord injury, burn patients, or military personnel. Anyone who was admitted or transferred to the trauma center more than 24 hours after the injury was also left out of this study. The direct group was all admitted within the first eight hours after injury. Half of the transfer group made it to the trauma center within the first three hours. The remaining transfer patients arrived in equal numbers between four and 10 hours and 11 and 24 hours.

The number of patients in each group who developed infections was compared. Two types of infection were targeted: wound infection and osteomyelitis. Only infections involving the injury site that started during the first three months after the injury were counted. This information was analysed based on the time periods and other patient factors listed. They were trying to see if any particular factor or group of factors combined together might predict who was most likely to develop infection. Of course, the eventual goal is to reduce and/or eliminate infections altogether. This might be possible if any of the predictive risk factors can be changed up front.

Their findings can be divided into two lists: those factors that made a significant difference on infection rates and those that didn’t. First, the factors associated with an increased risk of major infection:

  • Severe tibial fractures (classified as Gustilo Type IIIC): more than two centimeters of bone loss present
  • Treatment with a metal plate instead of a nail inside the bone to hold it together while the fracture heals
  • Treatment with external fixation
  • Time from injury to trauma center (longer delays, greater risk of infection)
  • Patients who were delayed in getting to a trauma center by more than two hours had five times the risk of infection compared to those who arrived within two hours of their injuries. Once the patient made it to the trauma center, the timing of other events didn’t seem to reach significant levels according to statistical analysis.

Factors that did not seem to contribute to the risk of infection included:

  • Age, sex, or level of education and economic status
  • Smoking status
  • General health or number of other health problems (e.g., heart disease, diabetes, cancer)
  • Extent of all injuries: amount of muscle damage, skin defects, nerve damage
  • Type of treatment other than the use of fixation type described above

Mostly useful for friends, family, and emergency medical personnel transporting patients, surgeons will find the conclusions useful, too. First, severe traumatic leg injuries should be treated at a trauma center whenever possible to avoid the risk of infection and other complications. Instead of going to a local hospital, it may be better to go directly to the trauma center even if it’s further away. Of course, it depends on the condition of the patient. If life saving measures are needed, hospital admission with delayed transfer to trauma center may be unavoidable. All things considered, admission to a trauma center within two hours of the injury significantly reduces the risk of infection later.

The treatment standard of operative debridement for these injuries within six hours of the traumatic event is still advised. But it appears that preventing infection is more dependent on getting the patient to the trauma center than on how soon the debridement is done.

The authors suggest a follow-up study looking at the timing of prophylactic antibiotics after severe leg injuries and the risk of infection. The information from such a study could help surgeons prioritise which aspects of treatment are most important: antibiotics, debridement, fracture stabilization, soft-tissue coverage, or limb-salvage procedures.