Department of Orthopaedics, Baylor College of Medicine, Houston, TX, USA.
Department of Orthopaedics, University of Arkansas for Medical Sciences, Little Rock, AR, USA.
Int Orthop. 2024 Jan;48(1):31-36. doi: 10.1007/s00264-023-05870-2. Epub 2023 Jun 19.
There is a paucity of literature on infections in civilian gunshot associated with long bone fractures with the reported rates ranging from 0-15.7%.This study aimed to investigate the rates of infection associated with long bone fractures caused by civilian gunshots. The specific objectives were to determine if certain extremities were at a higher risk for infection and to identify the types of bacteria present in these infections by analyzing culture isolates.
We conducted a retrospective review of consecutive patients aged 18-64 who sustained gunshot-associated long bone fractures at an urban Level I trauma centre from 2010 to 2017. Patient selection was based done through a institutional trauma centre database using international classification of diseases (ICD) 9 and 10 codes. We included patients who underwent surgical treatment, specifically fracture fixation, at our institution and excluded patients with fractures involving the pelvis, spine, foot, and hand. A total of 384 gunshot-associated long bone fractures in 347 patients were identified for analysis. Relevant patient-, injury-, and treatment-related variables were extracted from clinical records and radiographic reviews. Outcomes of interest included bony union, repeat operative procedures, and the development of deep infection.
347 patients with 384 long bone fractures were included. 32 fractures in 32 patients developed an infection for an incidence of 9.3% of patients and 8.3% of fractures. Gram-positive bacteria were present in 23/32 (72.0%) culture isolates, gram-negative bacteria in 10/32 (31.3%) culture isolates, and six infections were polymicrobial. Staphylococcus 16/32 (50.0%) and Enterobacter 6/32 (18.8%) species were the most common isolates. Of the Staphylococcus species, 5/16 (31.3%) were MRSA. Lower extremity fractures had a greater risk for infection compared to the upper extremity (11.7% vs 3.7% p < 0.01) and fractures that developed an infection had a larger average zone of comminution (63.9 mm vs 48.5 mm p < 0.05).
This study investigated the rates of infection associated with long bone fractures caused by civilian gunshots. The overall infection rate observed in our series aligns with existing literature. Gram-positive bacteria were the predominant isolates, with a notable incidence of MRSA in our patient population, highlighting the need for considering empiric coverage. Additionally, gram-negative organisms were found in a significant proportion of infections, and a notable percentage of infections were polymicrobial. Our findings emphasize the importance of carefully assessing highly comminuted lower extremity fractures and implementing appropriate antibiotic coverage and operative debridement for patients with gunshot-related long bone fractures. While current prophylaxis algorithms for open fractures lack specific inclusion of gunshot wounds, we propose incorporating these injuries to reduce the incidence of infections associated with such fractures.
有关民用枪支相关长骨骨折合并感染的文献相对较少，报告的发生率为 0-15.7%。本研究旨在调查民用枪支所致长骨骨折合并感染的发生率。具体目标是确定某些肢体是否更容易感染，并通过分析培养分离物确定这些感染中的细菌类型。
我们对 2010 年至 2017 年在城市一级创伤中心接受民用枪支相关长骨骨折的连续患者进行了回顾性分析。患者选择是通过机构创伤中心数据库基于国际疾病分类（ICD）9 和 10 代码完成的。我们纳入了在我们机构接受手术治疗（即骨折固定）的患者，并排除了骨盆、脊柱、足部和手部骨折的患者。共分析了 347 名患者的 384 例枪击相关长骨骨折。从临床记录和影像学检查中提取了相关的患者、损伤和治疗相关变量。感兴趣的结果包括骨愈合、重复手术程序和深部感染的发展。
347 名患者中有 384 例长骨骨折。32 例 32 例骨折发生感染，发生率为 9.3%的患者和 8.3%的骨折。23/32（72.0%）培养分离物为革兰氏阳性菌，10/32（31.3%）培养分离物为革兰氏阴性菌，6 例感染为混合感染。最常见的分离物为葡萄球菌 16/32（50.0%）和肠杆菌 6/32（18.8%）。葡萄球菌中，5/16（31.3%）为耐甲氧西林金黄色葡萄球菌（MRSA）。下肢骨折感染风险高于上肢（11.7%比 3.7%，p<0.01），感染骨折的平均粉碎区域较大（63.9 毫米比 48.5 毫米，p<0.05）。
本研究调查了民用枪支所致长骨骨折合并感染的发生率。我们系列中的总体感染率与现有文献一致。革兰氏阳性菌是主要分离物，我们患者人群中耐甲氧西林金黄色葡萄球菌（MRSA）的发生率较高，这强调了需要考虑经验性覆盖。此外，在显著比例的感染中发现了革兰氏阴性菌，并且相当比例的感染为混合感染。我们的研究结果强调了仔细评估高度粉碎的下肢骨折并为枪击相关长骨骨折患者实施适当的抗生素覆盖和手术清创的重要性。虽然目前的开放性骨折预防方案缺乏对枪击伤的具体纳入，但我们建议将这些损伤纳入其中，以降低与这些骨折相关的感染发生率。
