The impact of trauma centre designation on open tibial fracture management

Abstract

INTRODUCTION The British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons guidelines for the management of open tibial fractures recommend early senior combined orthopaedic and plastic surgical input with appropriate facilities to manage a high caseload. The aim of this study was to assess whether becoming a major trauma centre has affected the management of patients with open tibial fractures. METHODS Data were obtained prospectively on consecutive open tibial fractures during two eight-month periods: before and after becoming a trauma centre. RESULTS Overall, 29 open tibial fractures were admitted after designation as a major trauma centre compared with 15 previously. Of the 29 patients, 21 came directly or as transfers from another accident and emergency deparment (previously 8 of 15). The time to transfer patients admitted initially to local orthopaedic departments has fallen from 205.7 hours to 37.4 hours (p=0.084). Tertiary transferred patients had a longer hospital stay (16.3 vs 14.9 days) and had more operations (3.7 vs 2.6, p=0.08) than direct admissions. As a trauma centre, there were improvements in time to definitive skeletal stabilisation (4.7 vs 2.2 days, p=0.06), skin coverage (8.3 vs 3.7 days, p=0.06), average number of operations (4.2 vs 2.3, p=0.002) and average length of hospital admission (26.6 vs 15.3 days, p=0.05). CONCLUSIONS The volume and management of open tibial fractures, independent of fracture grade, has been directly affected by the introduction of a trauma centre enabling early combined senior orthopaedic and plastic surgical input. Our data strongly support the benefits of trauma centres and the continuing development of trauma networks in the management of open tibial fractures.

Experience of managing open fractures of the lower limb at a major trauma centre

“…However, in the most recent period, the median time between fixation and soft tissue cover remained 2.5 days, and in 62% of cases, the delay from injury to soft tissue cover exceeded 72 hours and so failed to meet the BOAST 4 targets. Patients are therefore being transferred to our centre more quickly following the introduction of the MTC, as has been shown elsewhere, 2 and are having definitive fixation performed in our centre but there remained a delay in achieving soft tissue cover in period 3. The fall in the deep infection rate may reflect reduced time to surgery.…”

“…2,3,8,10,11 However, there remains scope for expediting definitive soft tissue coverage both in our centre and in other MTCs through a process determined by local structural constraints. 12 The 'fix and flap' protocol is regarded as the gold standard for treatment.…”

“…1 These enable orthopaedic and plastic surgical teams with experience in managing such injuries to coordinate patient care, minimising delays in surgery and leading to improved outcomes. 2,3 We performed an audit of referral practice in the one year before and after the introduction of the BOA/BAPRAS guidelines, and found no evidence of change in referral practice in our region.…”

The impact of a dedicated orthoplastic operating list on time to soft tissue coverage of open lower limb fractures

“…Stammers et al report similar improvements in open fracture management in the eight-month period directly following trauma centre designation. 9 The authors observed a reduction in time to soft tissue coverage approaching statistical significance from 199 to 89 hours (p=0.06). They attribute this to increased senior surgeon input, a dedicated major trauma theatre and prioritisation of joint cases.…”

“…9 The improvements in care observed may reflect a maturation of the major trauma centre, as care protocols, staff experience and processes become more effective, which drives down delays in definitive management and improves outcomes. 10,11 We believe that the intervention studied (a dedicated orthoplastic operating list) is part of the trauma centre maturation process, and separating the individual component effects of this and other procedural improvements on the management of open fractures becomes difficult.…”