Comparison of delayed and primary wound closure in the treatment of open tibial fractures.

INTRODUCTION: Primary wound closure in the management of open tibial fractures has generally been discouraged. Several prior studies suggest that infections are not caused by the initial contamination, but are instead the result of organisms acquired in the hospital. Primary wound closure after adequate wound care and fracture stabilisation could therefore be considered a reasonable option. MATERIALS AND METHODS: We analysed 95 patients with open tibial fractures (Gustilo-Anderson type 1 to 3A) treated with primary fracture stabilisation and either delayed wound closure (group I) or primary wound closure (group II), with a minimum follow-up of 12 months. RESULTS: Group I included 46 patients with a mean age of 30.2 years (16-56), and a mean follow-up of 13.5 months (12-18). Group II included 49 patients with a mean age of 33.4 (18-69), and a mean follow up of 13.7 months (12-16). One infection developed in group I (2%), and two infections developed in group II (4%). This difference was not found to have any statistical significance. CONCLUSION: Our results support other recent reports that the infection rate is not increased following primary wound closure after thorough debridement of less severe open fractures. The length of stay following primary closure (group II) was significantly shorter, and that should result in substantially more cost effective care of these serious injuries. We conclude that primary wound closure is a safe option in properly selected cases. Prospective multi-centre studies are needed to further evaluate the safety and efficacy of this treatment alternative.

Gunshot fractures of the humeral shaft treated with external fixation.

In a prospective study, we assessed 38 consecutive gunshot fractures of the humeral shaft treated between 1 April 1990 and 30 June 1994. The average age was 34 (range, 16-60) years. Average follow-up was 31 (range, 8-50) months. Low-velocity fractures occurred in 35 patients. All fractures were comminuted and displaced. Nerve injuries (radial and/or median) occurred in eight and vascular injuries in three patients. All three vascular injuries had combined nerve injuries. The arteries and nerves were explored; only one artery was found severed and required repair; two arteries and all explored nerves were in continuity. All patients had minimal debridement, antibiotic therapy and stabilization of the fracture with an external fixator. The wounds healed by granulation in 27 patients; seven had secondary closure, and four had split skin grafts. The external fixator was left in place for 6-24 (average, 16) weeks. In 34 patients union occurred between 12 and 24 (average, 16) weeks. Two patients with delayed union required bone grafting. Nonunion occurred in two patients (5%). Full recovery of the nerve palsy without further intervention was observed in seven of the eight cases. Superficial pin track infection was present in five patients; two had deep wound sepsis, and one had bone sepsis. We recommend this treatment for low-velocity humeral shaft fractures.