Delayed Surgical Debridement of Gustilo Type 1 and 2 Open Fractures of the Forearm, does not Increase the Risk for Infection

Objective:
Timing of operative debridement of open upper extremity fractures has not been shown to consistently alter infection rates, but treatment protocols continue to recommend prompt debridement of these fractures in the OR. In our medical center, treatment protocol for Gustilo type 1 and 2 open forearm fractures emphasizes prompt wound irrigation in the ED combined with intravenous antibiotic treatment for 72 hours. However, surgical treatment in some of these cases is postponed due to lack of available OR time.

Methods:
Medical charts of patients who presented to a level one trauma center with Gustilo type 1 or 2 open forearm fracture between 2017-2020 were retrospectively reviewed. Outcome measures were time to surgery, infection rate and union rate.

Results:
89 cases of open forearm fractures presented to the ED during the study period. 35 cases were excluded {5 Gustilo type 3; 5 were initially treated at another hospital; 3 were transferred to another hospital; 22 with lack of sufficient follow up (0-3 months)}, leaving 54 cases in our study group. Mean patient age was 53 ± 20, and 31 of them (57%) were males. There were 9 proximal third forearm fractures (3 both bones, 6 olecranon), 13 midshaft forearm fractures (both bones), 29 distal third fractures (16 both bones, 13 distal radius), and 3 periprosthetic fractures. 41 cases were classified as Gustilo 1, and 13 were Gustilo 2. Mean follow-up was 22 months (range 4-51 months). Surgical treatment in the OR was performed at a median time of 48 hours following presentation to the ED (range 2 hours -14 days). There were 2 (3.7%) cases of infection – one superficial wound infection successfully treated with oral antibiotics, and one deep wound infection which was already present during the initial surgery. There were 2 (3.7%) cases of nonunion, both underwent revision ORIF surgery with bone grafting, with full union at the final follow-up.

Conclusions:
Open forearm fractures (Gustilo type 1 or 2) can be safely treated with prompt wound irrigation in the ER combined with intravenous antibiotics, followed by delayed surgical treatment, with no apparent increase in infection or nonunion rates.