The effect of time to definitive treatment on the rate of nonunion and infection in open fractures

Objectives: To determine the association between time to definitive surgical management and the rates of nonunion and infection in open fractures resulting from blunt trauma. To determine the association of other clinical determinants with these same adverse events. Design: Retrospective review of a consecutive series of open long bone fractures. Setting: Referral trauma center with transport times often extending beyond eight hours from the time of injury. Patients: A total of 227 skeletally mature patients with 241 open long bone fractures were treated between January 1996 and December 1998; 215 fractures were available for review at a minimum of twelve months postinjury. Intervention: Medical charts of all patients were reviewed using a standardized data collection form. All available records and radiograph reports were inspected. All cases were followed to clinical and radiographic union of the fracture or until a definitive procedure for nonunion or deep infection was carried out. Main Outcome Measures: Occurrence of deep infections or nonunions after fracture treatment. Results: The mean time to definitive treatment was eight hours and twenty-five minutes (range I hour 35 minutes to 30 hours 40 minutes). Forty patients went on to nonunion, and twenty developed a deep infection. In the final multivariate regression model, time was not a significant factor in predicting either nonunion or infection (p > 0.05). The strongest determinants for nonunion were found to be presence of infection and grade of injury (p < 0.05). The strongest predictors for the development of a deep infection were fracture grade and a lower extremity fracture (p < 0.05). Conclusions: The risk of developing an adverse outcome was not increased by aggressive debridement/lavage and definitive fixation up to thirteen hours from the time of injury when early prophylactic antibiotic administration and open fracture first aid were instituted.