Bacterial Epidemiology of Surgical Site Infections after Open Fractures of the Lower Limb: A Retrospective Cohort Study

Open lower limb fractures are common injuries, and the occurrence of infectious complications after open fractures is a usual problem. The rate of surgical site infections (SSIs) and the nature and resistance of the germs responsible for SSIs remain poorly described. Our aim was to describe the bacterial epidemiology of SSIs after surgical management of an open lower limb fracture. We conducted a retrospective monocentric cohort study from 1 January 2012 to 31 December 2020 based on the analysis of inpatient records in a non-university hospital of Ile de France region. All patients who underwent surgery for an open lower limb fracture were included. A total of 149 patients were included. In our population, 19 (12.7%) patients developed an SSI. Of these 19 patients, the sample was polymicrobial in 9 (47.4%) patients. In 9 (45%) cases, the samples identified a group 3 enterobacteria, Enterobacter cloacae being the main one in 7 (36.9%) cases. Staphylococci were identified in 11 patients, with Staphylococcus aureus in 9 (47.4%). All Staphylococcus aureus were susceptible to methicillin, and all enterobacteria were susceptible to C3G. Among all SSI, 10 (58.8%) contained at least one germ resistant to amoxicillin/clavulanic acid (AMC). The SSIs rate was 12.7%. The main pathogens identified were Enterobacter cloacae and Staphylococcus aureus. The presence of early SSI caused by group 3 Enterobacteriaceae renders current antibiotic prophylaxis protocols inadequate with AMC in half the cases.

Wound photography for evaluation of surgical site infection and wound healing after lower limb trauma

Aims Deep surgical site infection (SSI) is common after lower limb fracture. We compared the diagnosis of deep SSI using alternative methods of data collection and examined the agreement of clinical photography and in-person clinical assessment by the Centers for Disease Control and Prevention (CDC) criteria after lower limb fracture surgery. Methods Data from two large, UK-based multicentre randomized controlled major trauma trials investigating SSI and wound healing after surgical repair of open lower limb fractures that could not be primarily closed (UK WOLLF), and surgical incisions for fractures that were primarily closed (UK WHiST), were examined. Trial interventions were standard wound care management and negative pressure wound therapy after initial surgical debridement. Wound outcomes were collected from 30 days to six weeks. We compared the level of agreement between wound photography and clinical assessment of CDC-defined SSI. We are also assessed the level of agreement between blinded independent assessors of the photographs. Results Rates of CDC-defined deep SSI were 7.6% (35/460) after open fracture and 6.3% (95/1519) after closed incisional repair. Photographs were obtained for 77% and 73% of WOLLF and WHiST cohorts respectively (all participants n = 1,478). Agreement between photographic-SSI and CDC-SSI was fair for open fracture wounds (83%; k = 0.27 (95% confidence interval (CI) 0.14 to 0.42)) and for closed incisional wounds (88%; k = 0.29 (95% CI 0.20 to 0.37)) although the rate of photographically detected deep SSIs was twice as high as CDC-SSI (12% vs 6%). Agreement between different assessors for photographic-SSI (WOLLF 88%, k = 0.63 (95% CI 0.52 to 0.72); WHiST 89%; k = 0.61 (95% CI 0.54 to 0.69)); and wound healing was good (WOLLF 90%; k = 0.80 (95% CI 0.73 to 0.86); WHiST 87%; k = 0.57 (95% CI 0.50 to 0.64)). Conclusion Although wound photography was feasible within the research context and inter-rater assessor agreement substantial, digital photographs used in isolation overestimated deep SSI rates, when compared to CDC criteria. Wound photography should not replace clinical assessment in pragmatic trials but may be useful for screening purposes where surgical infection outcomes are paramount. Cite this article: Bone Joint J 2021;103-B(12):1802–1808.

EP.FRI.300 Equine related trauma: a 20-year district general hospital experience

Introduction Although a popular recreational and competitive sport, horse riding carries risk of injury. We aimed to characterise demographics, injury patterns and outcomes of patients with an equine-related injury over a 20-year period. Methods Patients were identified through local coding. Data relevant to the study aims were extracted. Statistical analysis was used to determine any association between patient demographic with injury pattern or outcome. Results Of the 701 patients included, 71.3% were female and the mean age was 34.9 years. Simple head injury (25.4%) and upper limb fracture (21.3%) were the commonest injuries. Abdominal visceral injury occurred in 1.6% with 2 patients requiring laparotomy and splenectomy. Overall, operations were performed in 32.8%. Open reduction and internal fixation was the commonest procedure (42.4%). 30-day mortality was 0.3% and 3.1% required transfer to a tertiary centre. Older patients were more likely to have a rib (46.3 vs 33.5 years, p = <0.05) or lower limb fracture (37.9 vs 34.5 years, p = 0.04) whilst upper limb fractures were seen in younger patients (30.3 vs 36.1 years, p = <0.05). There was no statistical difference with other injury patterns or gender. Conclusion Although mortality is rare, a significant proportion of patients sustain injury requiring surgical intervention. Given the predisposition towards orthopaedic injury, adequate rehabilitation facilities need to be available. Continued development and promotion of safety equipment are also required to reduced incidence.

Pengaruh Range Of Motion Aktif terhadap Pemulihan Kekuatan Otot dan Sendi Pasien Post Op Fraktur Ekstremitas di Wilayah Kerja Puskemas Muara Kumpeh

Fracture is a break in bone continuity and is determined according to its type and extent (Anita, 2015). Fractures caused by injuries include falls, traffic accidents and trauma to sharp or blunt objects. The trend of injury prevalence shows an increase from 7.5% in 2017 to 8.2% in 2018 (Kemenkes RI, 2018). This research is a quantitative research with pre-experimental research methods with one group pretest and posttest research design. This study was conducted to determine the effect of restoring muscle and joint strength in post-op patients with limb fracture in the working area of Muara Kumpeh puskemas. The research time is planned to be carried out on July 15, 2020 in the working area of the Muara Kumpeh Health Center. The population in this study was Post op fracture with a number of 84 people. The sample in this study was 15 people using purposive sampling method. Data collection was carried out by observing the respondents MMT (Manual Muscle Testing). research using the T-Test. The results showed that the average value of muscle and joint strength recovery in post-op limb fracture patients before therapy was 30.20 Mean while the average value of muscle and joint strength recovery in post-op limb fracture patients after being given therapy was 35.80 and the results showed The effect of restoring muscle and joint strength in post-op limb fracture patients in the working area of Muara Kumpeh Health Center with p-value (0,000) <α = 0.05. The conclusion of this study is the importance of ROOM therapy in post-op expression fracture patients. It is hoped that it can be used for patients to improve muscle strength systems and better recovery of mobilization activities

1569 Paediatric Upper Limb Fracture Manipulation in A Children’s Emergency Department: Practice Changes During The COVID-19 Pandemic

Background Trauma theatre time is valuable and previous studies reported cost of £24.77/minute. BSUH Children’s emergency department (CED) guidelines were implemented in December 2016, allowing reduction of forearm and distal radius (DR) fractures in CED using 70% nitrous (N2O) sedation. Due to COVID-19 pandemic and the risks associated with aerosol generating procedures as well as staffing levels, CED shifted to using 50%N2O with or without intranasal fentanyl. Method Relevant fractures presenting to CED from Feb-Dec 2020 were identified and compared to previous years. Demographics, treatment modality, timings, and outcomes were reviewed for 275 patients. Results In 2017-2018, 56% were manipulated in CED under 70%N2O (compared to only 3% in 2016). The main barrier identified was shortage of doctors trained in sedation to supervise use of 70%N20. In 2020, 101 patients were suitable for manipulation in CED. 64 had DR fractures, 37 midshaft fractures, 65 were male. Mean age: 10 years. 92 patients (91%) were manipulated in CED/fracture clinic. One was under 70%N2O; the rest used 50%N2O with or without intranasal fentanyl. 8 (9%) had manipulation under GA. Of those manipulated in CED, 3 were re-manipulated in clinic for cast problems. A typical MUA takes 30minutes indicating a saving of £743 per case; therefore, £68,356 over the study period. Conclusions Paediatric upper limb fracture manipulation in CED under N2O is effective and provides significant cost savings. Due to changes related to COVID-19 pandemic, considerably more patients in 2020 were safely treated in CED/clinic. Using 50%N2O improves uptake due to lower staffing requirements.