Infection In Open Fractures Research Articles

Injuries caused by pigs in Papua New Guinea

Pigs are intelligent animals that can be formidable adversaries to humans because of their sharp tusks and their ability to attack swiftly. Domestic and feral pigs have an important role in the ecology of village life in Melanesia. A six-year review of all injuries that were caused by pigs that were referred from the villages in Milne Bay Province, Papua New Guinea, to the Provincial Hospital was completed. Some of the injuries that were seen among the 20 patients who were studied included: three penetrating abdominal injuries with prolapse and strangulation of the intestine; a "sucking" chest wound; bilateral pneumothoraces; two infected open fractures of the radius and the ulna; a perforating injury of the knee with septic arthritis; a hand injury with laceration of multiple tendons; an arterial injury of the wrist; injury of a tibial nerve with foot drop; and a severe scrotal injury with exposure of the testicles. Most injuries resulted from the hunting of feral pigs. Adult male hunters who used dogs and carried only one spear were injured most frequently. Wounds from injuries by pigs are deep, often involve multiple critical structures, and are grossly contaminated. Resuscitation requires the administration of fluid and often blood. Treatment includes irrigation, debridement and closure of the wound. The principles of managing such injuries, the prevention of injuries, the ecology of pigs and humans, human infections originating from pigs, and safer methods of hunting pigs are discussed.

The prevention of infection in open fractures. An experimental study of the effect of antibiotic therapy.

Using an experimental rabbit model of a contaminated open fracture of the tibia that was fixed with an intramedullary pin, we assessed the effect of a single dose of cephradine in preventing post-traumatic osteomyelitis in which the infecting organism was Staphylococcus aureus. We paid particular attention to the effect of a delay in giving the antibiotic. The frequency of osteomyelitis in the animals in a control group (no antibiotic) was 91 per cent. When a single injection of cephradine was given one hour before inoculation with the bacteria, the rate was 30 per cent, a statistically significant reduction (p less than 0.01). When cephradine was not administered until one to four hours after inoculation with the bacteria, the average rate of osteomyelitis was 51 per cent, a 40 per cent reduction compared with the rate for the control group. The effect of the antibiotic therefore persisted even when the initial dose was delayed for four hours after bacterial inoculation.

Role of internal fixation in infection of open fractures: studies with Staphylococcus aureus and Proteus mirabilis.

Studies of infections in open fractures are described. The hamster was chosen as the experimental model. Osteotomies of the femur were created with an osteotomy saw. Some osteotomies were left to heal and others were fixed with an 0.9 mm K-wire. The infection rates in fixed and unfixed fractures were compared. The first group of hamsters with fixed and unfixed osteotomies was returned to cages with open wounds. There was no difference in the infection rate at 2 weeks. The second group was deliberately contaminated with Staphylococcus aureus and then returned to cages with open wounds. In this group, the infection rate at 2 weeks was lower in the internally-fixed fractures than in the unfixed fractures. The third group was deliberately contaminated with the gram negative organism Proteus mirabilis. In these animals, the infection rate was increased in the presence of the internal fixation device. The fourth group was deliberately contaminated with both Staphylococcus aureus and Proteus mirabilis. The infection rate in these animals was very high; Proteus was recovered from those animals with internal fixation and Staphylococcus was recovered from those animals without internal fixation. These studies in the hamster document the usefulness of this animal as an inexpensive and reproducible model for studying infection of open fractures. The hamsters tolerated the procedure well, and wound and fracture healing progressed satisfactorily.

Infectious morbidity in extremity fractures.

To review infectious morbidity in extremity fractures, 265 patients with 280 open fractures and 573 patients with closed fractures requiring open reduction and internal fixation (ORIF) were reviewed. Among open fractures, 32 (11%) became infected. Significantly fewer infections occurred in open fractures secondary to gunshot wounds (p less than 0.01) and in the upper extremity regardless of cause (p less than 0.05). Preventive preoperative antibiotics did not appear to affect infection rates. Open fracture infections were consistently with hospital-acquired organisms, and these were consistently resistant to the preventive antibiotic employed. Closed fractures had only 18 (3%) infections after ORIF. Preoperative antibiotics did reduce infection rates compared to rates in patients with no preoperative systemic antibiotics (p less than 0.05). Pathogens in ORIF patients showed a greater preponderance of Staphylococci. In conclusion, preventive antibiotics were only effective in the prevention of infection in the ORIF patients. Open fracture patients consistently develop infections with hospital-acquired pathogens, suggesting that contamination after hospitalization rather than at the time of injury is a major factor.

Problems in the Management of Type III (Severe) Open Fractures

Between 1976-1979, 87 Type III open fractures (in 75 patients) were treated at the Hennepin County Medical Center. Factors leading to increased morbidity in Type III fractures were: massive soft-tissue damage; compromised vascularity; severe wound contamination; and marked fracture instability. This study demonstrates, because of varied severity and prognosis, that the current designation of Type III open fracture is too inclusive. We recommend, therefore, that Type III open fractures be divided, in order of worsening prognosis, into three subtypes. Type IIIA--Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound. Type IIIB--Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination. Type IIIC--Open fracture associated with arterial injury requiring repair. Wound sepsis in the three subtypes were: Type IIIA, 4%, IIIB, 52%; and IIIC, 42%; while amputation rates were, respectively, 0%, 16%, and 42%. Only two patients developed osteomyelitis, and 12 patients had delayed or nonunions. Five patients died, all as a result of multisystem trauma. The bacterial pathogens in infected open fractures have changed dramatically over the years. In the present series (1976-1979), 77% of infections were due to Gram-negative bacteria, compared with 24% previously (1961-1975). A change of antibiotic therapy from a first-generation cephalosporin alone to a combination of a cephalosporin and an aminoglycoside, or a third-generation cephalosporin, is currently indicated in Type III open fractures.

The prevention of infection in open fractures.

The prevention of infection in open fractures.

Staphylococcal anatoxin in prophylaxis and treatment of wound infection in open fractures

Staphylococcal anatoxin in prophylaxis and treatment of wound infection in open fractures