Is time to flap coverage of open tibial fractures an independent predictor of flap-related complications?

OBJECTIVES: The importance of the timing of flap coverage of open tibial shaft fractures remains controversial. Many studies have shown increased complications and infection rates associated with delay in coverage but have not controlled for risk factors that might be associated with both delay in coverage and complications. We hypothesized that the timing of flap coverage of open tibial fractures is not predictive of complications after controlling for known risk factors. DESIGN: Retrospective review. SETTING: Level I trauma center. PATIENTS: Sixty-nine patients treated for acute tibial fractures (45 tibial shaft, 17 plateau, and 12 pilon fractures) at our center from 2004 through 2009 required 74 flaps. Patients requiring flaps later for wound breakdown or infection were excluded. INTERVENTION: Electronic records and prospective trauma database were reviewed. All fractures were AO classified by a trauma fellowship-trained orthopaedic surgeon. MAIN OUTCOME MEASUREMENTS: Primary outcome was flap complication, defined as infection or other flap-related adverse outcome requiring surgical treatment. Logistic regression analysis was conducted. RESULTS: A logistic regression model that separated the first 7 days after injury from subsequent days found no increased risk for days 1 through 7. The odds of complications, and of infection in particular, increased by 11% and 16%, respectively, for each day beyond day 7 (P < 0.04). CONCLUSIONS: Even after controlling for known risk factors for complications, including injury severity, time to flap coverage was a significant predictor of complications. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Are certain fractures at increased risk for compartment syndrome after civilian ballistic injury?

BACKGROUND: Compartment syndrome after ballistic fracture is uncommon but potentially devastating. Few data are available to help guide clinicians regarding risk factors for developing compartment syndrome after ballistic fractures. Our primary hypothesis was that ballistic fractures of certain bones would be at higher risk for development of compartment syndrome. METHODS: A retrospective review at a Level I trauma center from 2001 through 2007 yielded 650 patients with 938 fractures resulting from gunshots. We reviewed all operative notes, clinic notes, discharge summaries, and data from our prospective trauma database. Cases in which the attending orthopedic surgeon diagnosed compartment syndrome and performed fasciotomy were considered cases with compartment syndrome. We excluded all prophylactic fasciotomies. Univariate analyses were conducted to identify risk factors associated with development of compartment syndrome. RESULTS: Twenty-six (2.8%) of the 938 fractures were associated with compartment syndrome. Only fibular (11.6%) and tibial (11.4%) fractures had incidence significantly higher than baseline for all ballistic fractures (p < 0.001). Fractures of the proximal third of the fibula were more likely to result in compartment syndrome than fractures of the middle or distal third (p = 0.03), as were fractures of the proximal third of the tibia (p = 0.01). No other demographic or injury parameters were associated with compartment syndrome. CONCLUSION: Ballistic fractures of the fibula and tibia are at increased risk for development of compartment syndrome over other ballistic fractures. We recommend increased vigilance when treating these injuries, particularly if the fracture is in the proximal aspect of the bone or is associated with vascular injury.