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Open Fractures

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A Trial of Wound Irrigation in the Initial Management of Open Fracture Wounds.
FLOW Investigators, Bhandari M, Jeray KJ, Petrisor BA, Devereaux PJ, Heels-Ansdell D, Schemitsch EH, Anglen J, Della Rocca GJ, Jones C, Kreder H, Liew S, McKay P, Papp S, Sancheti P, Sprague S, Stone TB, Sun X, Tanner SL, Tornetta P 3rd, Tufescu T, Walter S, Guyatt GH.
N Engl J Med. 2015 Dec 31;373(27):2629-41

Rationale for inclusion: Published in NEJM, this prospective randomized multi-institutional trial of 2551 patients with open fractures found no difference in high or low pressure irrigation systems with respect to need for reoperation.  In addition, compared to castile soap, irrigation with normal saline had a lower rate of reoperation within 12 months of injury.

Citations - 37 (as of July 2017)

The relationship between time to surgical debridement and incidence of infection after open high-energy lower extremity trauma.
Pollak AN, Jones AL, Castillo RC, Bosse MJ, MacKenzie EJ; LEAP Study Group.
J Bone Joint Surg Am. 2010 Jan;92(1):7-15.

Rationale for inclusion: Contrary to previous recommendations, this study identified that time from injury to operative debridement did not independently predict the risk of infectious complications following severe high-energy open lower extremity trauma after evaluating 315 injuries at 8 level I trauma centers.  

Citations - 126 (as of July 2017)

Negative pressure wound therapy after severe open fractures: a prospective randomized study.
Stannard JP, Volgas DA, Stewart R, McGwin G Jr, Alonso JE.
J Orthop Trauma. 2009 Sep;23(8):552-7.

Rationale for inclusion: This prospective randomized trial of 62 high energy open fractures identified a decreased infection rate with use of negative pressure wound therapy as compared to standard gauze dressing placement.

Citations - 185 (as of July 2017)

Impact of smoking on fracture healing and risk of complications in limb-threatening open tibia fractures.
Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM; LEAP Study Group.
J Orthop Trauma. 2005 Mar;19(3):151-7.

Rationale for inclusion: Using prospective analysis of patients with open tibial fractures collected from 8 institutions, this trial identified that both current smokers and previous smokers had increased risks of infectious complications and nonunion as compared to nonsmokers.  

Citations - 250 (as of July 2017)

Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients.
Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM.
J Bone Joint Surg Am. 2000 Jun;82(6):781-8.

Rationale for inclusion: This 10 year evaluation of 1507 femur fractures concluded the use of immediate external fixation prior to later definitive intramedullary nailing is a safe and effective treatment algorithm for patients with multiple injuries or critical illnesses precluding immediate intramedullary nailing.

Citations - 316 (as of July 2017)

Compartment monitoring in tibial fractures. The pressure threshold for decompression.
McQueen MM, Court-Brown CM.
J Bone Joint Surg Br. 1996 Jan;78(1):99-104.

Rationale for inclusion: Utilizing a series of 116 patients with tibial fractures, this paper identified a 2.6% incidence in acute compartment syndrome.  They identified that differential pressure (diastolic pressure minus compartment pressure) of 30 mmHg served as a more reliable predictor of need for fasciotomy as compared to absolute compartment pressures of either 30 or 40mmHg.

Citations - 440 (as of July 2017)

Open tibial fractures with associated vascular injuries: prognosis for limb salvage.
Lange RH, Bach AW, Hansen ST Jr, Johansen KH.
J Trauma. 1985 Mar;25(3):203-8.

Rationale for inclusion: Using a series of 23 cases of open tibial fractures, this study identified factors associated with high amputation rate (61%) including the presence of crush injuries, delay in vascular reconstruction, and segmental tibial fractures.

Citations - 332 (as of July 2017)

Problems in the management of type III (severe) open fractures: a new classification of type III open fractures.
Gustilo RB, Mendoza RM, Williams DN.
J Trauma. 1984 Aug;24(8):742-6.

Rationale for inclusion: This early series of open fractures with significant contamination or soft tissue injury recommended the improved classification of this varied injury patterns into Type IIIA, B, and C based on soft tissue coverage, contamination, and associated vascular injuries, and recommended the addition of an amino-glycoside to cephalosporin in the initial management of these patients.

Citations - 2454 (as of July 2017)

Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses.
Gustilo RB, Anderson JT.
J Bone Joint Surg Am. 1976 Jun;58(4):453-8.

Rationale for inclusion: This early case series from 1955-1968 describes the management of open long bone fractures, identifying a cephalosporin as appropriate antibiotic prophylaxis as well as documenting increasing infectious complications with increased severity of injury.

Citations - 3322 (as of July 2017)

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