OTA Annual Meeting, Dallas, October 28,1988 10:15 a.m.

The Treatment of Low Grade Open Fractures without Operative Debridement.

S. Orcutt, D. Kilgus, D. Ziner (Los Angeles, California)

PURPOSE To examine the results of 99 low grade open fractures treated without operative debridement, and to compare the results with 50 similar fractures treated with debridement.

CONCLUSION: Low grade open fractures treated with local wound care and IV antibiotics alone without operative debridement had a lower incidence of delayed union and cellulitis.

SIGNIFICANCE Operative debridement of low grade open fractures in wounds which are not grossly contaminated may not be beneficial. The associated soft tissue trauma and osseous devascularization may result in a higher incidence of delayed union and cellulitis.

SUMMARY OF METHOD, RESULTS, AND DISCUSSION: A retrospective analysis of the last 99 low grade (grades 1 & 2), low energy, open fractures treated without initial operative debridement with adequate follow-up, and the last 50 such fractures which did undergo initial operative debridement was performed. All fractures were followed to union. Hospital records and radiographs were available for all cases. Higher grade open fractures, high energy fractures, fractures which were grossly contaminated, gun shot and fingertip injuries, and human bite wounds were excluded from the study.

The 99 open fractures initially treated without debridement received local wound care (generally a betadine soaked gauze dressing) as well as IV antibiotics and plaster immobilization. 21 of these were subsequently treated with delayed ORIF

50 low grade open fractures were initially treated with formal operative debridement as well as IV antibiotics and plaster immobilization. Eleven of these received immediate ORIF six underwent delayed ORIF, and 33 received plaster immobilization.

There were three cases of cellulitis (3%) and ten delayed unions (10%), in the non-operative group. All 3 cases of cellulitis responded to antibiotics.

There were three infections (6%) (1 cellulitis, 1 infected hardware & 1 infected hematoma) and 8 delayed unions (16%) in the operatively treated group.

When evaluating open tibial fractures only, the incidence of infection was 4% in the non-operative group and 12% in the operative group. The rate of delayed union (healing time >6 mo) was 19% in the nonoperative group and 31% in the operative group.

The routine operative debridement of low grade open fractures which are not grossly contaminated resulted in a higher incidence of infection and delayed fracture union. This may be the result of increased soft tissue trauma, periosteal stripping, and osseous devascularization during debridement. The non-operative treatment of low grade open fractures should be evaluated in a well controlled, prospective study Low grade-low energy fractures which do not require internal fixation, which are not grossly contaminated, and which have not occurred in an environment where organic contamination is likely may not benefit from operative debridement. The associated soft tissue trauma and osseous devascularization may result in a higher incidence of delayed union and cellulitis.