Factors Associated with Infection following Open Distal Radius Fractures

Abstract

Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone factures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twentyfour fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/ grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p=0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the ...

Outcomes After Volar Plate Fixation of Low-grade Open and Closed Distal Radius Fractures Are Similar

“…In fact, immediate plate fixation rarely was used in previous studies [5,21]. In a study by Rozental et al [21], immediate plate fixation was used in only two of 18 patients, and in a study by Glueck et al [5], none of the 42 patients were treated by immediate plate fixation. In a recent study by Kurylo et al [12], however, seven of 32 patients were treated by immediate plate fixation, and they [12] concluded immediate plating was probably a safe treatment option for low-grade open DRFs because no deep infection was encountered in their series.…”

“…Second, although there had been no report on major complications, such as infection and nonunion in low-grade open DRFs after plate fixation, this study was slightly underpowered for statistical analysis of the infection rate. Three studies [5,12,21] [4,16], the main treatment modality used for open DRFs is external fixation. In fact, immediate plate fixation rarely was used in previous studies [5,21].…”

“…Three studies [5,12,21] [4,16], the main treatment modality used for open DRFs is external fixation. In fact, immediate plate fixation rarely was used in previous studies [5,21]. In a study by Rozental et al [21], immediate plate fixation was used in only two of 18 patients, and in a study by Glueck et al [5], none of the 42 patients were treated by immediate plate fixation.…”

“…The infection rate was reported as 0.3% when closed DRFs were treated by volar plate fixation [23], whereas the incidence requiring a subsequent irrigation and débride-ment for infection control was reported as 17% in open DRFs [5,21]. Therefore, when we assumed the infection rate of closed DRFs was 0.3% and the proportion inequality of the infection rate in open DRF was 17%, a sample size of 20 patients in the open fracture group and 40 in the closed fracture group at 3 months postoperation would provide 66% power with a Type I error rate of 0.05.…”

“…Although several studies have reported results for treatment of open DRFs [5,12,21], these studies were case series (not comparative studies) that mainly focused on risk factors for development of deep infection. In addition, several treatment methods were used in those studies, although external fixators were used in most cases.…”