CASE STUDY: INFECTION IN OPEN CRURIS FRACTURE GRADE III

A-B THAT TREATED BY EXTERNAL FIXATION AFTER GOLDEN

PERIOD AT DR. MOEWARDI GENERAL HOSPITAL IN SURAKARTA
Johanes RM Marpaung , dr .1 Udy Herunefi , dr , Sp.B , Sp.OT2
1
General Surgery Resident, FK-UNS / RS Dr. Moewardi Surakarta
2
Orthopedic Consultants and Traumatology Sub-Pediatric Dr. FK-UNS / RS
Moewardi Surakarta
SMF Surgery FK UNS / RS Dr. Moewardi Surakarta 2018

ABSTRACT
Background : Infections in patients with open cruris fracture open after golden
period often occur. There are many risk factors can affect it.

Objective : To determine the incidence rate of infection in patients with open cruris
fracture that treated by external fixation after golden period at Dr. Moewardi
General Hospital during January to December 2018.

Methods : The characteristics data of patients were observed by retrospective from

medical record of patients that diagnosed open cruris fracture after golden period
during January to December 2018.

Results : In the period of January 2018 to December 2018 there were 55 open cruris
fracture with infection incidence rates 72.7% and the most culture result were
staphylococcal.

Conclusion : the high incidence rates of infection was found in patients with open
cruris fractures, therefore, it requires treatment as soon as posible berfore the
golden period.

Words key : Open fractures, Fraktur of cruris, Infection

INTRODUCTION
Definition of open fracture is a fracture where there is an exposure of
fragment fractures to the environment, whether the tip of fragment fracture
penetrates from the inside to the surface of the skin or the skin surface which
experiences the penetration of an object from the outside to the inside.
Mostly complications of the open fractures is infection. Infection can be
derived from the normal flora of the skin or bacteria pahthogen especially bacteria
gram (-). The group of the normal flora of the skin, such as Staphylococus ,
Propionibacterium acne, Micrococus and can also Corynebacterium. Apart from the
besides normal flora of the skin , the culture results also show a pathogenic bacteria,
it depends on the exposure (contamination) of the environment when the fracture
happened.
As an example at the plantation enviroment, mostly bacteria group is
Clostridium perfringens, but it can be different at the watery environment that
mostly occurs Pseudomonas. Nosocomial infection can also be a cause of infection
in the open fracture. Staphylococcus Aureus is the most common.
Classification of open fractures by Gustilo :
1) Type I: Open fracture with skin wound of less than 1 cm and clean. Minimal
tissue damage, usually due to bone penetrating the skin from the inside.
Configuration of the fracture is simple, transverse or simple oblique .
2) Type II: Open fracture with skin wound more than 1 cm, without any soft tissue
damage, contusion or avulsion area. Configuration of the fracture is moderate
comminutive with moderate contamination .
3) Type III: Open fracture with large soft tisuue damage, severe contamination,
usually caused by severe trauma, configuration of the fracture is comminutive.
Type III fractures are divided into three, there are:
Type IIIa: Fracture segmental or a very comminutive bone closure with
adequate soft tissue.
Type IIIb: a severe trauma or a large soft tissue loss, exposure area of
periosteum and bone expose, with a severe contamination.
 Type IIIc : Open fracture with vascular damaged without regarding to soft
tissue damaged.

Open fracture treatment

The principle treatment of open fracture, ( 1 ) All the open fracture cases are
treated in an emergency. (2 ) Early assessment for another injury that are life
threatening, (3) Give appropriate and adequate antibiotics (4) Debridement and
irrigation of the wound, (5) Stabilization of the fracture, (6) Rehabilitation of the
fractured extremity.
Initial treatment of open fracture is general condition at first (life-
threatening), ie : installing IV fluids two lines, clinical examination and radiology,
laboratory examination. The most important for open fracture treatment is reducing
or preventing infection .
For open fracture, the stabilization of the fracture is useful to prevent severe
tissue damaged, make an easy access to take care of the wounds, make an easy
mobilization of the patient, and the patient can do isometric muscle exercise and
perform the movement of the joints on top of or below the fracture lines either active
or passive.
Stabilization of the open fracture is divided in the two ways, namely using
internal fixation (intramedullary nails or plate an d screw) and external fixation.
Complications
Commonly complications that occur are acute infection, osteomyelitis, non-
union , mal union and dissability. The most common complication in open fracture
is infection. Incidence of wound infection in open fracture is related to tissue
damaged.
The average infection that can occur based on open fracture classification
according to Gustilo is : (8) • Type I: 0% to 2% • Type II: 2% to 7% • Type III:
10% to 25% • Type IIIA: 7 % • Type IIIB: 10% to 50% • Type IIIC: 25% to 50%
with an average amputation 50% or more
The incidence of open fracture according to Benirscke et al in degree I: 0.8
- 7%. Degree II 1.1 - 12%, degree III 9 -55%. Patzakis et al wrote the incidence of
infection in open fractures of the cruris 10.5% and non-cruris 5.3%.
The initial diagnosis of infection in an open fracture can be established
based on signs and symptoms of inflammation . Gangrene can appear 24 to 48 hours
after infection. Gardner et al, developed a list (checklist) to describe the signs and
symptoms of clinical wound infection, there are consists of 12 signs, namely: 1)
Pain, 2) Erytheme, 3) Oedem, 4) Heat, 5) purulent exudate, 6) serous exudate with
inflammation, 7) slowly healing, 8) fragile granulation tissue, 9) Pocketing the basic
wounds, 10) Odor
Antibiotics immediately given without waiting for the culture results. Some
studies show that cephalosporin group are the right choice for many cases . After
the culture and sensitivity test result come out, give 2 gr as an initials and 1 to 2 gr
every 4 to 6 hours depend on the size of infection area. IV Antibiotics give for 4 to
6 weeks. In the case of severe infection, skeletal traction can be used temporary for
fracture stabilization. Pin or plaster of paris can be used if the material of external
fixation unavailable. Internal fixation such as plate or nailing must be avoided, and
can it be use 4-5 days after the sign of infection disappear.
Commonly patients come to Dr. Moewardi often arrives in late condition
because of some factors, so that debridement is also delays. For this reason, this
study was conducted to determine the incidence of infection that occurred after
debridement after the golden period in open cruris fractures of IIIA-B.
METHOD
The design of this research is using analytic retrospective which is intended
to analyze the infection rates of open cruris fracture III A-B with debridement and
external fixation treatment after Golden Period based on facts that have occurred
and recorded in the medical records in patient care inpatient and ambulatory way in
January 2018 to December 2018.
The inclusion criteria were the age of the patient <60 years old, normal
nutritional status, and doing a deridement and external fixation in the emergency
room of Dr. Moewardi General Hospital.
Exclusion criteria were patients who were only debrided and had DM
disease .
All medical records were assessed that had a bone infection and fatty tissue
by clinical and culture.

RESULTS
In the period January 2018 to December 2018 there were 55 patients of open
fracture with 41 patients (74.5 %) had a traffic accidents, 14 patients (25.5 %) had
a workplace accidents.
Table 1. Distribution of age and sex of open fractures of degree III AB
Age Man Woman total
0-15 2 - 2
16 - 40 28 8 36
41 - 60 12 5 17
total 42 13 55

Table 2. Sex distribution and incidence of infection in open cruris fractures

of degree III AB
Gender Infection Without infection total
Man 32 10 42
Woman 8 5 13
 total 40 15 55
% 72.7% 27.7%

Table 3 . Distribution of germs that cause infection in open cruris fractures

of degree III AB
Germ type Number of sufferers %
Proteus 12 21.8%
Pseudomonas 13 23.6%
Staphylococci 30 54.5%
total 55 100%

DISCUSSION
There were 55 patients with open cruris fracture III A-B who could have the
infection rate in patients before and after the golden period at Dr. Moewardi general
hospital for the period January - December 2018. Data from 55 patients, men 76.3%
and women 23.7 %.
The most commonly patients’ age were 16-40 y.o, 36 patients (65.4%). This
possibly is due to the age included in the age group with the most causes to traffic
accident. While the rest is due to workplace accidents.
Open fracture treatment in Dr. Moewardi general hospital is based on the
guidline, debridement and spraying physiology fluid 9L immediately, removing the
necrotizing tissue and corpus alienum then giving broad-spectrum antibiotics.
In Dr. Hospital Moewardi general hospital, there were 72.7 % of patients
with open cruris fractures III A and IIIB type who had infections. This rate is higher
than that reported by Cudle et al, which is 28%. This is due to (1) unequal
debridement by surgical residents so that the level of cleanliness may different, (2)
the interval time between the incident until the antibiotics were given are too long,
(3) the implementation of manual irrigation so that the pressure of irrigation may
different every debridement, (4) there were some hematom factor left in the
fragment fracture that can be a place for microorganisms to grow.
 The most culture result from 30 patients (54.5%) who had infections were
staphylococci. Benirschke et al reported the culture result were 45.23%
staphylococci, 16.67% pseudomonas and 9.52% enterobacter.
The conclusion of the data above is the high incidence of infection in
patients with open cruris fracture, therefore immediate treatment is required before
the golden period .

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