6-hour Rule for Open Fractures - Roland Russell 21/8/2003

There are 15 articles on doing a medline search that directly or indirectly investigate the golden 6 hour rule. I hereby give details of 3 of the most respected entries.

1)   THE EFFECT OF TIME TO DEFINITIVE TREATMENT ON RATE OF NONUNION AND INFECTION ON OPEN#s

HARLEY/BEAUPRE/JONES/DULAI/WEBER

DIVISION OF ORTHOPAEDIC SUEGERY, UNIVERSITY OF ALABAMA HOSPITAL, EDMONTON , ALBERTA , CANADA

JOURNAL OF ORTHOPAEDIC TRAUMA VOL 16 NO 7 PG484-490

METHOD:-

Retrospective study. All open #s of long bones Jan 1996-dec 1998. Medical records reviewed.

247 open #s in 233 patients; 215 open #s included.

Operative start time of irrigation + surgical debridement noted.

All patients received:-

Iv cephalospoirin(+ gentamycin with grade 3) +/- penicillin

Soft tissue + bone debridement.

Deep infection defined as purulent drainage or osteomyelitis presenting after wound closure.

RESULTS:-

Mean time to definitive treatment= 8 hours 29 mins

<8hours group(54% patients with mean time in this group of 5 hours 51 mins)

>8hours group(46% patients with mean time to debridement=11 hours 15 mins)

1/60(2%) grade 1 # resulted in deep infection

5/90(6%) grade 2 # resulted in deep infection

14/65 (22%) grade 3 #s resulted in deep infection.

DISCUSSION:-

Time to debridement time analysed as :-

Continuous variable, dichromotous variable and logistic regression and this revealed no significant difference between time of debridement and development of deep infection up to 13 hours until debridement.

1966-1999- 9 articles looking at definitive time management:-

No difference-3 prospective+ 1 retrospective review

Is a difference- 2 recent retrospective reviews but one paediatric based and the other has 77% grade 3 injuries.

The strongest determinants for deep infection was the grade # and a lower rather than an upper extremity injury.

CRITIQUE:

215 open #s-good numbers

Retrospective review

Statistical analysis supports no increased risk of infection up to 13 hours time to debridement.