Operative Fracture Care Research Articles

Predictors of quality of life, economic impact, and loss to follow-up after open tibial shaft fractures in Ghana.

Open tibia fractures are associated with substantial morbidity and impact on quality of life. Despite increasing incidence in low-resource settings, most open tibia fracture research comes from high-resource settings. This study aimed to assess the impact of socioeconomic status on treatment modality and evaluate predictors of health-related quality of life following open tibia fractures in Ghana. A single-center prospective observational study was conducted in Kumasi, Ghana, from May 2020 to April 2022. Adults with open tibial shaft fractures presenting within 2 weeks of injury were eligible. Demographics, comorbidities, socioeconomic factors, and hospital course were collected at enrollment. Follow-up was scheduled at 8, 12, 26, and 52 weeks. A telephone survey assessing reasons for loss to follow-up was initiated on enrollment completion. A total of 180 patients were enrolled. Most patients were employed before injury (79.9%), had government insurance (67.2%), and were from rural areas (59.4%). Fracture classification was primarily Gustilo-Anderson type 3A (49.1%). No relationship between socioeconomic predictors and treatment modality was identified. The largest barriers to follow-up were preference for bonesetter treatment (63.1%), treatment cost (48.8%), and travel cost (29.8%). Of the lost to follow-up patients contacted, 67 (79.8%) reported receiving traditional bonesetter care. Reasons for seeking traditional bonesetter care included ease of access (83.6%), lower cost (77.6%), and familial influence (50.7%). No association was identified between socioeconomic predictors and choice of treatment. Bonesetter treatment plays a substantial role in the care of open tibia fractures in Ghana, largely because of ease of access and lower cost.

Bridging the Gap: Enhancing Open Fracture Care in Emergency Nursing

This study assesses the knowledge and practices of emergency department nurses regarding the care of open fractures, highlighting significant disparities in competence. Conducted across five hospitals, the descriptive, cross-sectional survey included 103 nurses, analyzed using SPSS with results expressed through frequencies, percentages, and Chi-squared tests. Findings reveal that 42.7% of nurses, predominantly females, lack adequate knowledge and care skills, whereas 57.3%, mostly males, are proficient. The study suggests an urgent need for focused training programs to standardize and elevate emergency care for open fractures, aiming to improve patient outcomes through enhanced nursing education. Highlights: Discrepancy in Knowledge: Significant variations in the knowledge and care practices for open fractures among emergency nurses, with nearly 43% lacking sufficient skills. Gender Differences: A notable gender-based disparity in knowledge, with a higher proficiency observed among male nurses compared to female nurses. Need for Training: The urgent requirement for specialized training programs to address gaps and improve overall patient care in emergency situations. Keywords: Open Fractures, Emergency Nursing, Knowledge Gap, Nurse Training, Patient Outcomes

The Epidemiology, Management, and Outcomes of Civilian Gunshot Wounds to the Upper Extremity at an Urban Trauma Center.

Gunshot wounds (GSWs) create significant morbidity in the United States. Upper extremity (UE) GSWs are at high risk of combined injuries involving multiple organ systems and may require variable treatment strategies. This study details the epidemiology, management, and outcomes of civilian UE GSWs at an urban level 1 trauma center. Using the University of Pennsylvania Trauma Registry, all adult patients with UE GSWs from 2015 to 2020 who were at least 6-months postinjury were studied for demographics, injury pattern, operative details, and postoperative outcomes. Fisher exact and Wilcoxon rank sum tests were used to determine differences in treatment modalities and outcomes. In 360 patients, the most common victim was young (x̄ = 29.5 y old), African American (89.4%), male (94.2%), and had multiple GSWs (70.3%). Soft tissue-only trauma (47.8%) and fractures (44.7%) predominated. Presence of fracture was independently predictive of neurologic, vascular, and tendinous injuries (P < 0.001). Most soft tissue-only injuries were managed nonoperatively (162/173), whereas fractures frequently required operative intervention (115 of 161, P < 0.001). Despite a prevalence of comminuted (84.6%) and open (43.6%) fractures, hardware complications (7.5%) and wound infection (1.1%) occurred infrequently. Civilian GSWs to the UE with only soft tissue involvement can often be managed conservatively with antibiotic administration, bedside washout, and local wound care. Even with combined injuries and open fractures, single-stage operative debridement and fracture care with primary or secondary closure often prevail. As civilian ballistic trauma becomes more frequent in the United States, these data help inform patient expectations and guide management.

Improving the Care of Severe, Open Fractures and Postoperative Infections of the Lower Extremities: Protocol for an Interdisciplinary Treatment Approach.

Patients with open fractures often experience complications during their injury. The treatments incur high costs. Interdisciplinary cooperation between different medical disciplines may improve treatment outcomes. Such cooperation has not yet been envisaged in the German health care system. The aim of the study is to improve the treatment of fractures with open soft tissue damage or postoperative complications in terms of duration and sustainability in a region in northwest Germany. Largely standardized diagnostics and therapy are intended to optimize processes in hospitals. In addition, a reduction in the duration of treatment and treatment costs is to be achieved. Using a digital platform, physicians from 31 hospitals present patient cases to an interdisciplinary group of experts from the fields of plastic surgery, infectiology, hygiene, and others. The group of experts from the environment of the University Hospital Münster promptly makes a joint treatment recommendation for the individual case. The plan is to examine 3300 patients with open fractures or surgical complications. As consortium partners, there are also 3 statutory health insurance companies. The extent to which the therapy recommendations are effective and contribute to cost reduction in the health care system will be empirically investigated in a stepped-wedge cluster-randomized design. In addition, medical and nonmedical professional groups involved in the project will be asked about their work in the project (in total, 248 clinic employees). The primary outcome is the complication rate of open fractures or the occurrence of postoperative complications. As secondary outcomes, the number of antibiotics administered, limb function, and quality of life will be assessed. The health economic evaluation refers to the costs of health services and absenteeism. For the work-related evaluation, workload, work engagement, work-related resources, readiness for technology, and ergonomic aspects of the new telemedical technology will be collected. In addition, clinic employees will give their assessments of the success of the project in a structured telephone interview based on scaled and open-ended questions. The project started in June 2022; data collection started in April 2023. As of mid-June 2024, data from 425 patients had been included. In total, 146 members of staff had taken part in the questionnaire survey and 15 had taken part in the interviews. Standardized treatment pathways in the standard care of patients with open fractures and postoperative infections will be established to reduce complications, improve chances of recovery, and reduce costs. Unnecessary and redundant treatment steps will be avoided through standardized diagnostics and therapy. The interdisciplinary treatment perspective allows for a more individualized therapy. In the medium term, outpatient or inpatient treatment centers specialized in the patient group could be set up where the new diagnostic and therapeutic pathways could be competently applied. German Clinical Trials Register DRKS00031308; https://drks.de/search/de/trial/DRKS00031308. DERR1-10.2196/57820.

Price for Care of Open Fractures of Limbs in the Surgical Emergency of the Brazzaville Hospital and University Center

Introduction: The aim of this work was to describe the emergency management of open fractures at the Brazzaville University Hospital (CHUB). Patients and Methods: this was a descriptive study with retrospective data collection from January 1 to December 31, 2022, in the surgical unit of the medical-surgical emergency department of the CHUB. All injured people hospitalized during the study period for recent open fractures whose initial treatment was carried out at the CHUB were included. The parameters studied were epidemiological, clinical, paraclinical and therapeutic. The GUSTILO Anderson Classification was used to assess the extent of skin lesions. Results: We collected 114 patients for 121 open fractures. There were 93 men (81.57%) and 21 women (18.43%), i.e. a sex ratio of 4.42. The average age was 32.4 ± 6.23 years, the etiologies were dominated by public road accidents (73.68%). The average consultation time was 4.45 hours. The pelvic limbs were affected in 80.99% of cases. Open fractures of both leg bones were the most frequent (75.20%). Type II fractures of the GUSTILO classification were in the majority (69.42%). There was one case of vascular involvement of the leg tripod and one case of radial nerve involvement. The average time for initial treatment was 8.36 ± 1.20 hours. Types I and II lesions required emergency suture before definitive treatment in 14.87% and 46.28% of cases respectively. The average time for definitive treatment was 22.91 hours. Osteosynthesis was performed in 86.78% of cases, cast immobilization with fenestration in 12.39% of cases and transfemoral amputation in 1 case. Internal fixation using an external fixator was the most frequent surgical indication (68.59%). Conclusion: Open leg fractures are very common traumatic injuries in our daily practice. Surgical treatment with an external fixator is the most commonly performed.

Open fractures: Current treatment perspective.

Severe open fractures present challenges to orthopaedic surgeons worldwide, with increased risks of significant complications. Although different global regions have different resources and systems, there continue to be many consistent approaches to open fracture care. Management of these complex injures continues to evolve in areas ranging from timing of initial operative debridement to the management of critical-sized bone defects. This review, compiled by representative members of the International Orthopaedic Trauma Association, focuses on several critical areas of open fracture management, including antibiotic administration, timing of debridement, bone loss, soft tissue management, and areas of need for future investigation.

Role of single-dose intravenous iron therapy for the treatment of anaemia after orthopaedic trauma: protocol for a pilot randomised controlled trial

IntroductionOrthopaedic trauma and fracture care commonly cause perioperative anaemia and associated functional iron deficiency due to a systemic inflammatory state. Modern, strict transfusion thresholds leave many patients anaemic; managing this...

Is Time Truly of the Essence? Outcomes of Open Distal Radius Fracture Management

BACKGROUND: The standard of care of open distal radius fractures is urgent irrigation and debridement along with operative fixation. Herein, we investigate if open distal radius fractures (ODRF) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared to open distal radius fractures treated urgently. METHODS: An IRB-approved retrospective chart review was performed of all patients treated for ODRF over a 6-year period at an academic institution in a large metropolitan city. Post-operative complications included: surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, non-union, and malunion. For statistical analyses, nominal data were compared for distributional equality between complication dichotomy via Pearson chi-square or Fisher’s exact test depending on sample size distribution. Ordinal data were tested for ordinal association via exact Kendall’s tau test. Rank equivalency between complication dichotomy was determined for numeric data via Mann-Whitney U tests. All statistical tests were two-sided with p<0.05 considered statistically significant. RESULTS: Ninety-four patients were treated for ODRF with 62% female and 38% male patients included in the cohort. The mean (SD) age at time of injury was 58.6 (17.41) years. Notably, 28% of patients had a history of smoking. Overall, there were 16 patients (16.8%) with post-operative complications: 2 infections, 8 re-operations, 4 wound healing complications, 2 loss of reductions, 7 non-unions, and 1 malunion. Regarding energy and mechanism of injury, 74.4% had a low energy injury and 26.6% had a high energy injury, and this was not statistically significant for any post-operative complications (0.352). Likewise, age (p = 0.197) and fracture grade (p = 0.068) were not statistically significant factors for any surgical complications. The overwhelming majority of patients were treated with irrigation, debridement, and ORIF with volar locking plates. The mean (SD) open wound size was 1.6 (1.66) cm, ulnar sided, and did not correlate with any post-operative complications (p = 0.093). The mean (SD) time from injury presentation to the ER to the first dose of intravenous antibiotics was 4.7 (14.88) hours, and was not statistically significant for any post-operative complications (p = 0.186). The mean (SD) time from presentation to the ER to operative treatment was 19.1 (30.57) hours, and was not statistically significant for the presence of any post-operative complications (p = 0.092). There were 11 patients (11.7%) treated greater than 24 hours after presentation to the ER, which was not significantly distinct from those treated prior to 24 hours (p=1.000). CONCLUSION: Patients with open distal radius fractures treated after 24 hours did not have a greater risk of post-operative complications, including surgical site infections and non-union. Regarding factors that may influence urgent treatment, age, energy and mechanism of injury, and fracture grade were all not statistically significant for any post-operative complications in ODRF management.

Open Fractures in Pediatric Orthopaedics-Can Pathways Improve Care? A 1-Year Pre and Postimplementation Analysis.

In the care of open fractures, time to antibiotic administration has been shown to be a critical factor in preventing infection. To help improve outcomes at our institution we designed and implemented an open fracture pathway with the goal of reducing the time from emergency department (ED) arrival to antibiotic administration. Here we evaluate the success of this pathway, propose improvements in the protocol, and provide a framework for initiation at other institutions. We compared a retrospective prepathway cohort with a prospective postpathway cohort for 1-year pre and postpathway implementation. First, we analyzed the number of patients from outside facilities who had received antibiotics before transfer. For patients who had not received antibiotics before arriving at our institution, we reviewed pathway metrics including time from ED arrival to the ordering and administration of antibiotics, whether the correct antibiotic type was selected, and time to surgical debridement. There were 50 patients in the prepathway cohort and 29 in the postpathway cohort. Prepathway 60.5% of transfers (23 of 38) received antibiotics before transfer, whereas post-pathway 90.0% of transfers (18 of 20) received antibiotics ( P =0.032). For patients who had not received antibiotics before arriving at our institution and were included in pathway metric analysis, there were no differences in demographics or fracture characteristics. Time from ED arrival to antibiotic order decreased from 115.3 to 63.5 minutes ( P =0.016). Time from antibiotic order to administration was similar between groups (48.0 vs. 35.7 min, P =0.191), but the overall time from ED arrival to antibiotic administration decreased from 163.3 to 99.2 minutes ( P =0.004). There were no significant differences in whether the correct antibiotic type was chosen ( P =0.354) or time from ED arrival to surgery ( P =0.783). This study provides evidence that for pediatric patients presenting with open fractures, a care pathway can successfully decrease the time from ED arrival to antibiotic administration. Therapeutic level III-retrospective comparative study.

Incidence and quality of care for open fractures in England between 2008 and 2019 : a cohort study using data collected by the Trauma Audit and Research Network.

This study estimated trends in incidence of open fractures and the adherence to clinical standards for open fracture care in England. Longitudinal data collected by the Trauma Audit and Research Network were used to identify 38,347 patients with open fractures, and a subgroup of 12,170 with severe open fractures of the tibia, between 2008 and 2019 in England. Incidence rates per 100,000 person-years and 95% confidence intervals were calculated. Clinical care was compared with the British Orthopaedic Association Standards for Trauma and National Major Trauma Centre audit standards. In total, 60% of all open fractures occurred in males; the median age was 48 years (interquartile range (IQR) 29 to 68). Between 2012 and 2019, the overall incidence in England was 6.94 per 100,000 person-years. In males, the highest incidence observed was in those aged 20 to 29 years (11.50 per 100,000 person-years); in females, incidence increased with age, peaking at 32.11/100,000 person-years at 90 years of age and over. Among those with severe open fractures of the tibia, there was a bimodal distribution in males, peaking at 20 to 29 years (3.71/100,000 person-years) and greater than 90 years of age (2.84/100,000 person-years) respectively; among females, incidence increased with age to a peak of 9.91/100,000 person years at 90 years of age and over. There has been variable improvement with time in the clinical care standards for patients with severe open fractures of the tibia. The median time to debridement was 13.0 hours (IQR 6.4 to 20.9); almost two-thirds of patients underwent definitive soft-tissue coverage within 72 hours from 2016 to 2019. This is the first time the incidence of all open fractures has been studied using data from a national audit in England. While most open fractures occurred in young males, the incidence increased with age in females to a much greater level than observed in older males. The degree of missing data in the national audit is startling, and limits the certainty of inferences drawn concerning open fracture care. Cite this article: Bone Joint J2022;104-B(6):736-746.

58 Introduction of a Basic Trauma Course and an Observational Study of Attitudes to Open Fractures in a Rural Region of Sierra Leone

Abstract Introduction Sierra Leone ranks in the bottom quartile of the ‘Least Developed Countries’ across the world. ‘Injury’ is responsible for an estimated 325,000 deaths per annum. Kambia is a rural district in the northwest of the country with an approximate population of 340,000 people. We were invited to teach the regions community health care officers (CHO) the first ever trauma skills course. Our secondary aim while in Kambia was to investigate the barriers to safe open fracture care in the region. Method A 4day teaching course was created and co-ordinated. Questionnaires examining candidate’s trauma knowledge, were utilised. Feedback sheets were collected to assess the courses local acceptability. Three senior CHOs were invite for a semi-structured interview exploring Open Fractures. This was recorded and a thematic analysis was performed on the results. Results The mean pre course questionnaire score was 9.0 (SD 3.45), and post course score 19.7(SD 3.8). This gave a mean difference of 10.7(CI 9.5 – 11.8, p value 0.01). All feedback collected was positive, with 15/23 candidates reports ‘Primary Survey’ the most useful teaching session. The reported boundaries to open fracture care included local beliefs, Lack or resources and services, Lack of finances. Conclusions Our basic trauma course provided an effective method of teaching trauma skills to the CHO’s of Kambia. It offered a widely accepted teaching structure and was enjoyed by the local medical community. We also identified barriers to optimal open fracture care in the region of Kambia, which can be targeted for further work.

Duration of Perioperative Antibiotic Prophylaxis in Open Fractures: A Systematic Review and Critical Appraisal.

Fracture-related infection (FRI) remains a serious complication in open fracture care. Adequate surgical treatment and perioperative antibiotic prophylaxis (PAP) are key factors influencing the outcome. However, data concerning the optimal duration of PAP is scarce. The aim of this systematic review was to provide an overview of current evidence on the association between PAP duration and FRI in open fractures. A comprehensive search on 13 January 2022, in Embase, Medline, Cochrane, Web of Science and Google Scholar revealed six articles. Most studies compared either 1 day versus 5 days of PAP or included a cut-off at 72 h. Although prolonged PAP was not beneficial in the majority of patients, the variety of antibiotic regimens, short follow-up periods and unclear description of outcome parameters were important limitations that were encountered in most studies. This systematic review demonstrates a lack of well-constructed studies investigating the effect of PAP duration on FRI. Based on the available studies, prolonged PAP does not appear to be beneficial in the prevention of FRI in open fractures. However, these results should be interpreted with caution since all included studies had limitations. Future randomized trials are necessary to answer this research question definitively.

Access to care following injury in Northern Malawi, a comparison of travel time estimates between Geographic Information System and community household reports

Introduction: Injuries disproportionately impact low- and middle-income countries like Malawi. The Lancet Commission on Global Surgery's indicators include the population proportion accessing laparotomy and open fracture care, key trauma interventions, within two hours. The "Golden Hour" for receiving facility-based resuscitation also guides injury care system strengthening. Firstly, we estimated the proportion of the local population able to reach primary, secondary and tertiary facility care within two and one hours using Geographic Information System (GIS) analysis. Secondly, we compared community household-reported with GIS-estimated travel time.Methods: Using information from a Health and Demographic Surveillance Site (Karonga, Malawi) on road network, facility location, and local staff-estimated travel speeds, we used a GIS-generated friction surface to calculate the shortest travel time from all households to each facility serving the population. We surveyed community households who reported travel time to their preferred, closest, government secondary and tertiary facilities. For recently injured community members, time to reach facility care was recorded. To assess the relationship between community household-reported travel time and GIS-estimated travel time, we used linear regression to generate a proportionality constant. To assess associations and agreement between injured patient-reported and GIS-estimated travel time, we used Kendall rank and Cohen's kappa tests.Results: Using GIS, we estimated 79.1% of households could reach any secondary facility, 20.5% the government secondary facility, and 0% the government tertiary facility, within two hours. Only 28.2% could reach any secondary facility within one hour, 0% for the government secondary facility. Community household-reported travel time exceeded GIS-estimated travel time. The proportionality constant was 1.25 (95%CI 1.21–1.30) for the closest facility, 1.28 (95%CI 1.23–1.34) for the preferred facility, 1.45 (95%CI 1.33–1.58) for the government secondary facility, and 2.12 (95%CI 1.84–2.41) for tertiary care. Comparing injured patient-reported with GIS-estimated travel time, the correlation coefficient was 0.25 (SE 0.047) and Cohen's kappa was 0.15 (95%CI 0.078–0.23), suggesting poor agreement.Discussion: Most households couldn't reach government secondary care within recognised thresholds indicating poor temporal access. Since GIS-estimated travel time was shorter than community-reported travel time, the true proportion may be lower still. GIS derived estimates of population emergency care access in similar contexts should be interpreted accordingly.

Risk Factors for Delayed Hospital Admission and Surgical Treatment of Open Tibial Fractures in Tanzania.

Open fractures, especially of the tibia, require prompt intervention to achieve optimal patient outcomes. While open tibial shaft fractures are common injuries in low- and middle-income countries (LMICs), there is a dearth of literature examining delays to surgery for these injuries in low-resource settings. This study investigated risk factors for delayed management of open tibial fractures in Tanzania. We conducted an ad hoc analysis of adult patients enrolled in a prospective observational study at a tertiary referral center in Tanzania from 2015 to 2017. Multivariable models were utilized to analyze risk factors for delayed hospital presentation of ≥2 hours, median time from injury to the treatment hospital, and delayed surgical treatment of ≥12 hours after admission among patients with diaphyseal open tibial fractures. Two hundred and forty-nine patients met the inclusion criteria. Only 12% of patients used an ambulance, 41% were delayed ≥2 hours in presentation to the first hospital, 75% received an interfacility referral, and 10% experienced a delay to surgery of ≥12 hours after admission. After adjusting for injury severity, having insurance (adjusted odds ratio [aOR] = 0.48; 95% confidence interval [CI] = 0.24 to 0.96) and wounds with approximated skin edges (aOR = 0.37; 95% CI = 0.20 to 0.66) were associated with a decreased risk of delayed hospital presentation. Interfacility referrals (2.3 hours greater than no referral; p = 0.015) and rural injury location (10.9 hours greater than urban location; p < 0.001) were associated with greater median times to treatment hospital admission. Older age (aOR = 0.54 per 10 years; 95% CI = 0.31 to 0.95), single-person households (aOR = 0.12 compared with ≥8 people; 95% CI = 0.02 to 0.96), and an education level greater than pre-primary (aOR = 0.16; 95% CI = 0.04 to 0.62) were associated with fewer delays to surgery of ≥12 hours after admission. Prehospital network and socioeconomic characteristics are associated with delays to open tibial fracture care in Tanzania. Reducing interfacility referrals and implementing surgical cost-reduction strategies may help to reduce delays to open fracture care in LMICs. Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Evolution in the Acute Management of Open Fracture Treatment? Part 2.

In the first installment of this two-part series, we explored the history of open fracture treatment focusing primarily on bacteriology and antibiotic selection/stewardship. In this follow-up segment, we will analyze and summarize the other aspects of open fracture care such as time to debridement, pulsatile lavage, and open wound management (including time to closure)-finishing with summative statements and recommendations based on the current most up-to-date literature. Therapeutic Level V. See Instructions for Authors for a complete description of levels of evidence.

Impact of the COVID-19 pandemic on the management of open fractures in a major trauma centre

IntroductionThe Coronavrius-19 (COVID-19) pandemic has presented the biggest challenge that the National Health Service (NHS) has ever seen. As one of the worst affected regions, Orthopaedic service provision and delivery in London, changed dramatically. Our hypothesis is that these restrictions adversely impacted the care of open fractures in our major trauma unit in London. MethodsThis is a prospective case control study comparing the management of patients presenting pre-COVID, to those presenting during the height of the COVID pandemic in London. The pre-COVID, control cohort presented between the 1st October and the November 30, 2019. The COVID cohort presented between the April 1, 2020 and the May 31, 2020. Data was collected that related to the 11 clinical domains of the British Orthopaedic Association Standards of Trauma (BOAST) 4 guidance, as well as early complications. ResultsOf the 11 domains, 100 % compliance was achieved in 6 components, across both groups where applicable. During pre-COVID times, the timing to initial debridement was within 12 h for High energy trauma in 16/28 (57.1 %), dropping to 7/22 (31.8 %) during COVID, (p = 0.004). Definitive soft tissue closure within 72 h If not achievable at initial debridement dropped from 9/10 (90.0%) to 4/6 (66.7 %), (p = 0.006). There was no significant difference in early complication rates. ConclusionCoronavirus has changed the landscape of healthcare worldwide and impacted open fracture care by increasing time to theatre. This had no effect on early complication rate but longer term effects remain to be seen.

Gaps in the Care of Open Fractures: An Indian Scenario.

There is a distinct lack of published studies evaluating the reasons for delay in definitive treatment of open fractures. This study aimed to determine the specific factors causing delay in the timely treatment of open fractures from the time of injury and to analyse the quality of treatment performed at the pre-hospital level. In total, 250 consecutive patients with open fractures were assessed for time to surgery from injury and admission. The referred patients were analysed for distance of travel, level of referring hospital and appropriateness of care. The reasons for delay in terms of infrastructural- and patient-related factors were analysed individually and in combination. There were 37 direct patients (Group A) and 213 referred patients (Group B). Inappropriate care was present in 172 out of 213 (80.8%) referred patients. In total, 84% patients travelled more than 50 kms. The definitive surgery in referred patients was likely to be significantly delayed with regard to time from injury (29.84 vs 44.84h, p ≤ 0.02). After admission, the time to surgery was greater than 24h in 102 patients. Multivariate regression analysis determined that associated injuries and lack of fitness for surgery caused greater delay than non-availability of operation theatre or intensive care unit bed. Delayed referral, inadequate pre-hospital care and delay in surgery due to patient- and infrastructural-related issues at tertiary centre were identified as critical gaps in open fracture care in India. The importance of appropriate basic knowledge about management of open fractures should be emphasized at all structural level of care.

Orthoplastic management of open tibial fractures in children : a consecutive five-year series from a paediatric major trauma centre.

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date. Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score. The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery. The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J2021;103-B(6):1160-1167.

Prophylactic Vancomycin-PMMA Strips are an Easy-to-Use and equally effective alternative to antibiotic beads in open fracture care

Objectives: Even under ideal conditions, infection remains a risk of surgery and can be harrowing after surgical repair of compound fractures. This study aimed to assess the efficacy and convenience of local antibiotic-impregnated polymethyl methacrylate (PMMA) strips to overcome infection and functional union within a specified time after primary definitive stabilization of compound fractures. Design:We investigated patients who received PMMA-vancomycin strips during orthopedic surgical repair of open fractures. Setting: From 2017 to 2019 in a tertiary medical center. Patients: A total of 106patients with open fractures type I through IIIC were included (age range, 24–62 years). Intervention: Patients underwent profuse wound cleaning, methodical debridement, and definitive stabilization with PMMA-vancomycin strips. Main Outcome Measurements: We measured the incidence of wound healing, fracture union, and infection rate. Patients were followed for two years with infection parameters and radiographs. The efficacy of the PMMA strips in our study with that of PMMA beads in similar procedures from published studies was compared. Results: Of 106patients, five (4.7%) had a subclinical infection until implant removal. We found no osteomyelitis or non-union in any patient. A literature search confirmed comparable outcomes in infection rates between the PMMA strips used in this study and antibiotic beads used in previous studies. However, the removal of PMMA vancomycin strips is generally more convenient compared with that of beads. Conclusions: For the controversial challenge of determining the duration to keep or remove antibiotic beads, PMMA vancomycin strips present surgeons with an easy-to-use alternative with equivalent efficacy. Keywords: Vancomycin, Polymethyl methacrylate, Beads, Strip.

Efektivitas Terapi Bermain Fidget Spinner terhadap Nyeri Pasca Operasi Fraktur pada Anak

Fracture is one of the most vulnerable injuries in children. Fracture is a disconnectionin bone continuity caused by trauma or physical exertion, the management of the fracture can be done with orthopedic surgery, namely by open reduction using internal fixation. Pain is a major problem in post operative fracture care Non pharmacological techniques that can be done to ward off postoperative pain in children are by doing play therapy, one of which is by using fidget spinner therapy. This literature review aims to analyze the effect of fidget spinner therapy on postoperative fracture pain.this game can distract children and give them something soothing to release pent up energy. Methods: This research explores quantitative evidence published in electronic databases such as pubmed, garuda, and google schoolar. Using a journal search strategy, I only came up with the results of one recent and relevant journal for inclusion in the final analysis. Results: I can see a significant effect in postoperative fracture pain intensity in the child after the patient was given fidget spinner therapy. Conclusion: From the results, it can be concluded that fidget spinner therapy is a non-pharmacological therapy that can reduce the pain scale in post operative fracture patients. It is hoped that parents will use this game in the handling of fracture pain in their children