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The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children
David L. Skaggs, MD1; Lauren Friend, MD1; Benjamin Alman, MD2; Henry G. Chambers, MD3; Michael Schmitz, MD4; Brett Leake, MD1; Robert M. Kay, MD1; John M. Flynn, MD5
1 Division of Orthopedic Surgery, Childrens Hospital Los Angeles, MS# 69, 4650 Sunset Boulevard, Los Angeles, CA 90027
2 Hospital for Sick Children, 555 University Avenue, Toronto, ON M5G 1X8, Canada
3 Pediatric Orthopedic and Scoliosis Center, 3030 Children's Way, Suite 410, San Diego, CA 92123-4208
4 Children's Orthopaedics of Atlanta, 5545 Meridian Mark Road, Suite 250, Atlanta, GA 30342
5 The Children's Hospital of Philadelphia, 34th and Civic Center Boulevard, Wood Building, 2nd Floor, Philadelphia, PA 19104
View Disclosures and Other Information
The authors did not receive grants or outside funding in support of their research or preparation of this manuscript. They did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.
Investigation performed at Childrens Hospital Los Angeles, Los Angeles, California

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2005 Jan 01;87(1):8-12. doi: 10.2106/JBJS.C.01561
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Background: Traditional recommendations hold that open fractures in both children and adults require urgent surgical débridement for a number of reasons, including the preservation of soft-tissue viability and vascular status as well as the prevention of infection. Following the widespread use of early administration of antibiotics, a number of single-institution studies challenged the belief that urgent surgical débridement decreases the risk of acute infection.

Methods: We performed a retrospective, multicenter study of open fractures that had been treated at six tertiary pediatric medical centers between 1989 and 2000. The standard protocol at each medical center was for all children to be given intravenous antibiotics upon arrival in the emergency department. The medical records of all children with open fractures were reviewed to identify the location of the fracture, the interval between the injury and the time of surgery, the Gustilo and Anderson classification, and the occurrence of acute infection.

Results: The analysis included 554 open fractures in 536 consecutive patients who were eighteen years of age or younger. The overall infection rate was 3% (sixteen of 554). The infection rate was 3% (twelve of 344) for fractures that had been treated within six hours after the injury, compared with 2% (four of 210) for those that had been treated at least seven hours after the injury; this difference was not significant (p = 0.43). When the fractures were separated according to the Gustilo and Anderson classification system, there were no significant differences in the infection rate between those that had been treated within six hours after the injury and those that had been treated at least seven hours after the injury. Specifically, these infection rates were 2% (three of 173) and 2% (two of 129), respectively, for type-I fractures, 3% (three of 110) and 0% (zero of forty-four), respectively, for type-II fractures, and 10% (six of sixty-one) and 2% (two of thirty-seven), respectively, for type-III fractures (p > 0.05 for all three comparisons).

Conclusions: In the present retrospective, multicenter study of children with Gustilo and Anderson type-I, II, and III open fractures, the rates of acute infection were similar regardless of whether surgery was performed within six hours after the injury or at least seven hours after the injury. The findings of the present study suggest that, in children who receive early antibiotic therapy following an open fracture, surgical débridement within six hours after the injury offers little benefit over débridement within twenty-four hours after the injury with regard to the prevention of acute infection.

Level of Evidence: Therapeutic Level III. See Instructions to Authors for a complete description of levels of evidence.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    David L. Skaggs
    Posted on November 20, 2005
    Dr. Skaggs responds to Dr. Rodop
    Childrens Orthopaedic Center, Childrens Hospital of Los Angeles, Los Angeles, CA 90027

    Thank you for your letter. I will respond to each of your points:

    1. Thank you for the additional references.

    2. In the methods section it states that fractures were consecutive, excluding only those children who died or had gunshot wounds. Thus, all other types of fractures were included in this study.

    3. This point is correct, the reader could miss this sentence. I am not certain, however, that it would be good writing to repeat sentences in case the reader misses it the first time.

    4. Along with the type of antibiotic given, there are many other factors not fully investigated in this study. This study was focused to answer one question as stated.

    5. We share your concern.

    Osman Rodop
    Posted on October 27, 2005
    Surgical Delay in Treating Open Fractures in Children
    GATA Haydarpasa Training Hospital, Istanbul, TURKEY

    To the Editor:

    We would like to thank Drs. Skaggs and colleagues for this study but we have several objections:

    1. The authors state that there are no previous articles about the advantages of early surgical debridement; however, we would note that there are several studies in the literature (1,2,3,4).

    2. The authors have not stated the nature of the open wounds. It is not certain in the text whether highly contaminated injuries like barnyard injuries or lawn mover injuries, are included in the study.

    3. Gunshot wounds, which constitute a considerable number of open fractures in the States, are not included in the study. This is mentioned in only one sentence in the text and the reader can easily miss this important detail.

    4. The type of antibiotics used is not given in the text. The antibiotic selection can affect the course of treatment and early debridement decreases the need for broad-spectrum antibiotics especially for anaerobic bacteria, which could be quite costly.

    5. We are concerned that this article can easily mislead young orthopedic surgeons to treat open fractures only with early antibiotics and delay debridement for more than 24 hours, a treatment regimen which we feel could be detrimental to a child’s health especially in highly contaminated open fractures.


    1. Infections caused by lawn mower injuries in children Richard Sadovsky. American Family Physician. Kansas City: Aug 15, 2001.Vol.64, Iss. 4; pg. 674, 2 pgs

    2. Open fracture of the tibia in children. Cullen MC, Roy DR, :. Crawford J Bone Joint Surg Am. 1996 Jul;78(7):1039-47AH, Assenmacher J, Levy MS, Wen D.

    3. Pediatric orthopedic trauma: Principles in management Douglas S. Musgrave, MD; Stephen A. Mendelson, MD Crit Care Med 2002 Vol. 30, No. 11 (Suppl.)

    4. The Effect of Time to Definitive Treatment on the Rate of Nonunion and Infection in Open Fractures Brian J. Harley, Lauren A. Beaupre, C. Allyson Jones, Sukhdeep K. Dulai, and Donald W. Weber Journal of Orthopaedic Trauma Vol. 16, No. 7, pp. 484–490 © 2002 Lippincott Williams & Wilkins, Inc., Philadelphia.

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