Search tips
Search criteria 


Logo of iowaorthjLink to Publisher's site
Iowa Orthop J. 2010; 30: 94–98.
PMCID: PMC2958278


Ali Bakir Al-Hilli, F.I.B.M.S., F.I.C.S.* and Dheyaa Saeed Salih, F.R.C.S.Ed**



Compound limb fractures due to high-velocity missiles are complex and usually associated with multiple other injuries. These can occur in both military and civilian settings. Highvelocity missiles are presently used by terrorists worldwide. Early surgical debridement and skeletal fixation are the gold standards in managing these injuries, but data supporting these recommendations are lacking.

Aim of the study

Our aim was to determine the relationship between time (the time of injury to the time of surgical treatment) and the rate of deep infection in patients treated in Medical City, Baghdad, Iraq due to terrorist activity from 2004-2008.


This is a retrospective review of a series of open limb fractures.

Patients and method

A total of 102 civilian patients with 114 limb fractures due to high-velocity missile injuries were selected for this study from Medical City records. Patients were followed in the outpatient department in Medical City Teaching Complex both clinically and radiologically.


Surgical treatment was accomplished in less than six hours from time of injury in group A (55 fractures, 48.4%) and more than six hours in group B (59 fractures, 51.7%). The infection rate for group A was 30.9% and group B was 23.7%.


A very high infection rate was noted for these injuries, and there was no increase in the rate of deep infection in patients treated more than six hours after the injury.


Open fractures due to high-velocity missile injuries (bullets and shells) are very extensive injuries; there has been an increase in the number of these injuries in civilian sectors due to terrorism. The injuries concomitant with the open fractures have long been considered surgical emergencies.

Most texts recommend surgical debridement within six to eight hours of injury for any open fracture. The American College of Surgeons Committee on Trauma, in its Resources for Optimal Care of Injured Patients, indicates six hours is the benchmark time from injury to debridement of open fractures in trauma centers.12

Missiles used in Iraq may be solid, such as those from pistol or rifle bullets, but they may also be fragments of shells, land mines or grenades. Missiles can be high-, medium-, or low-velocity. Medium- and high-velocity missiles produce almost the same pattern of injury: damage to the body by laceration, crushing, shock waves and cavitation. Low-velocity missiles damage by laceration and crushing only. In land mine injuries the damages are produced primarily by a blast effect, secondarily by fragments entering the body, and thirdly by whole-body propulsion and burns. In addition to all of these pathophysiologic effects, psychological trauma must be considered.3

Management of open limb fractures involves patient resuscitation, wound and limb assessment, fracture classification, intravenous antibiotics and administration of tetanus toxiod.4 Best practices suggest urgent debridement of the wound and stabilization of the fracture using a range of techniques.5,8 Others have said that a delay in surgical management of open fractures does not significantly increase infection rates.4,9,10,11,12

There are many complications with missile injuries such as infection, nonunion and malunion in addition to social, economic and psychological factors. Most of these injuries require long-term treatment protocols and care from many medical specialties to allow the patient return to a normal or near-normal life.

There is a lot of literature showing that six hours is the gold standard for management of open fractures from multiple causes (including injuries from missiles).13,14,15 However, most of these authors collected data from patients with open fractures due to causes other than missile injuries.

A large number of injuries occur in Iraq from both high- and low-velocity missiles, and many patients arrive in Medical City and at other medical facilities more than six hours post injury. Our medical staff has performed many operations on patients who presented many days after their injuries. However, all of them received antibiotic prophylaxis, and we collected data from them for follow-up so we might discover the effects of delayed surgical management of missile injuries on the rate of infection.


We collected data from patients who were victims of high-velocity missile injuries in Baghdad and who were treated in Medical City (a tertiary center) for the time period between 2004 and 2008. We selected 102 patients with 114 open limb fractures (Table 1) and they were followed in the outpatient department in Medical City for a minimum of one year after treatment. We depended on Medical City data and direct patient questionnaires in addition to medical and radiological follow-ups. Patient selection depended on what surgery was done. We excluded patients with head injuries and patients with extensive limb injuries that required amputation. All our patients were victims of high-velocity missile injuries only (61 blast injuries and 53 bullet injuries).

Surgical management delay by site of injury

Initially, we categorized our patients into four groups; those treated within six hours, those treated within seven to 12 hours, those treated within 13 to 24 hours and those treated after more than 24 hours. All patients were treated at the Medical City Emergency Depart-ment, resuscitated and transferred to the operating room for definitive care including generous surgical wound debridement and skeletal fixation of their fractures. For all patients, we use external fixators (AO type and Hoffman III) to stabilize the fractures.

All patients received triple antibiotics and a few received anti-tetanus injections based on availability (because of the shortage of medication in Iraq).

Superficial infection was defined as the presence of cellulitis or pus involving the soft tissues at the traumatic wound in the absence of clinical or radiological features of osteomyelitis (requiring antibiotic treatment or surgical intervention). Deep infection was defined as the development of osteomyelitis diagnosed clinically (development of chronic discharging sinus) or radio-logically, that required surgical debridement of bone. A microbiological culture was not considered essential for the diagnosis of superficial or deep infection,10 but could be used in the treatment of infection.

Finally, we divided the injuries into two groups as in Table 2.

Number of injuries by time of surgical treatment

Missile injuries were classified by the following grading system:3

Minor. Only soft tissue involvement with no bony, vascular or nerve injury, with or without retained metal (shrapnel or gunshot fragments).

Moderate: Soft tissue involvement, nondisplaced or drill fracture, no vascular or nerve injury, with or with out retention of metal.

Severe: Soft tissue injury with severely displaced, comminuted fracture, usually with retained single or multiple metallic fragments, with vascular or nerve injury or both.

Avulsive: Extensive soft tissue damage, bone loss associated vascular or nerve injury.

Thus, the elements that define severity of injury are:3

  1. The degree of soft tissue damage.
  2. Bony defect or severe comminution.
  3. Vascular or neural injury.

Injuries were moderate (84) and severe (30).


102 patients with 114 open fractures sustained between 2004 and 2008 were followed for a minimum of one year. Their ages ranged between 12 and 65 years, they were treated in the Medical City Orthopaedic department. Patients were divided in to two groups based on the time from injury to surgical treatment (less than and more than 6 hours). The deep infection rate for Group 1 was 30.9% and for group 2 was 23.7 %(table3)

Infection rate

In this group with 114 fractures, there were 31 infections (22 with moderate injuries and 9 with severe injuries), so the severity of injury was not a significant factor in our patient's infection rate, but this is not a significant conclusion because of the small number of patients. Because there was no increase in the infection rate with increasing time to treatment, a statistical analysis was not carried out.


Open fractures are a management challenge in orthopaedic surgery for the following reasons:

  1. Variability in mechanism of injury (traffic accidents, blunt trauma, blast injuries, bullet injuries, among others).
  2. The degree of contamination present.
  3. The delay in transfer of some patients to suitable medical facilities, though urgency of debridement within six to eight hours of injury seems nearly universally accepted.
  4. The different types of shock sometimes associated with these injuries. Shock management plays a major role in treatment of compound fractures.
  5. The policy for treating these injuries within six hours may not be in the patient's best interests in all cases. Emergent treatment can result in complex cases be ing performed during off-hours by relatively inexpe rienced surgeons, anesthetists and operating theatre staff, with the potential for less favorable outcomes.4
  6. Medical co-morbidities.

The primary goal in management of open fractures is the prevention of devastating infection of bone and soft tissues. To achieve this, the most widely accepted treatment protocols include emergent surgical irrigation and debridement of open fracture wounds, administration of broad-spectrum antibiotics, and stabilization of the fracture.18 Though these treatments are widely accepted and respected, what is the risk to patients if early debridement and fixation are not available for more than six hours?

This study selected 114 open limb fractures sustained from high velocity missiles between 2004 and 2008, and retrospectively reviewed and followed those patients in Medical City. We found a 30.9% rate of infection for fractures treated in less than six hours and a 23.7% rate of infection for fractures treated after more than six hours.

Unlike previously published studies,10 we believe it is important to calculate the total time between an injury and the patient's presentation to an emergency department. In our cases, some patients may have been injured for a long time before their arrival at an appropriate medical facility.

After Operation Iraqi Freedom in 2003, there was increased terrorist activity in Iraq and military-grade weapons became widely available. The country experienced an increasing number of missile injuries, especially of the high-velocity type. Medical facilities were presented with many difficult cases—missiles do not obey rules and may cause multiple injuries of varying severity. In some cases, Medical City (as a tertiary hospital) would receive patients 24 hours or more after the initial injury because of difficulty with transfers due to unsafe roads, and poor outlying medical facilities. These difficulties raised questions about the risk to patients from delayed surgical treatment of their open fractures due to missile injuries. Many papers have been written about this subject in the civilian sector, concentrating mainly on the delay factors, but the causes of injury specified were multiple, and missile injuries were not well represented in the literature.

Skaggs et al.16 retrospectively reviewed 554 open fractures in children at six tertiary centers (Children's Hospital Los Angeles, Los Angeles, California) between 1989 and 2000. Standard protocol was to give intravenous antibiotics upon the patient's arrival in the emergency department. No significant difference was found in the rate of infection between injuries treated in less than six hours versus those treated after seven hours.

Open fractures may require emergent surgical treatment for reasons other than the prevention of infection, such as the preservation of soft tissue viability and vascular status.16 The findings of Skaggs et al.16 suggest that, in children who received early antibiotic therapy following an open fracture, surgical debridement within six hours after the injury offered little benefit over debridement within 24 hours after the injury with regard to the prevention of acute infection.

Khatod et al.11 in a retrospective review of 191 open fractures concluded that the Gustilo grading system of open fractures is a significant prognostic indicator for infectious complications. They found no significant difference between early (less than six hours) and late treatment but they continued to support the emergent treatment of open tibia fractures.

We have noticed that the Gustilo classification for open fractures poorly describes injuries due to missiles. Bullet- and shell-mechanism injuries are totally different from those of blunt trauma since the small skin wounds of the former usually cover extensive damage to underlying soft tissues. We consider all high-velocity missile injuries as grade III Gustilo.

Spencer et al.4 conducted a prospective audit of 142 open long-bone fractures over the five years between 1996 and 2001 at The Princess Margaret Hospital in Swindon, Great Britain. The authors could not demonstrate a significant increase in infection rates (10.1% for early wound debridement versus 10.8% for late wound debridement) and all their patients received intravenous antibiotics within four hours of injury.

Harley et al.,9 in a retrospective review of 241 open fractures at the University of Alberta Hospital, Edmonton, Alberta, Canada, concluded that the risk of developing an adverse outcome was not increased by aggressive debridement/lavage and definitive fixation up to 13 hours from the time of injury, when early prophylactic antibiotics administration and open fracture first aid were instituted.

Charalambous et al. (UK)10 in a retrospective study reviewed 383 open tibia fractures and concluded there was no difference between early and delayed treatment groups with respect to overall infections.

Sungaran et al. (Australia)12 in a retrospective review of 161 open tibia fractures found no increase in infection rate, as five infections occurred in the zero-to-six-hours treatment group and no infections in occurred when treatment was delayed by more than 12 hours. They found that infection correlates with the grade of open injury.

Yassir B. AlArabi et al. (UK)17 studied 248 open long-bone fractures and showed an infection rate of 7.8%/9.6% for less than six hours/more than six hours injuries respectively.

Time from injury to debridement did not predict infection in bivariable or multivariable analysis, suggesting that something occurring on admission to the definitive treatment center was associated with decreased infection risk. Postulated factors included antibiotic administration and aggressive resuscitation.1 These two factors need to be investigated further to define the exact cause. Gos-selin et al.19 analyzed data from 913 participants in seven studies, and concluded that the use of antibiotics had a protective effect against early infection compared with no antibiotics or placebo.

Patzakis et al.21 found that the most important factor contributing to infection in gunshot wounds was the type of missile used. Three of four infections recognized in this study of open fractures were in close-range shotgun wounds, and there was no significant difference between the infection rate of the group receiving no antibiotics and the group receiving antibiotics. They concluded that two cardinal factors influenced the infection rate in 333 open fractures:

  1. The presence or absence of pathogenic organisms in wounds when no antibiotic was given.
  2. The presence of resistant organisms in wounds when either penicillin/streptomycin combination or cephalothin was given.

There is a large gap between the conclusions of Fried-rich in 189819 that debridement of traumatic wounds is only effective if carried out within six hours of injury using experimental contamination in guinea pigs, and what we have today—highly developed modalities of resuscitation and antibiotics.


We have concluded that there is no difference in infection rates based on time (less than or more than six hours from injury to debridement) of open fractures from high-velocity missiles. We do not support delaying surgical treatment of open fractures from missile injuries. We do insist on optimal medical facilities and experienced trauma surgeons for these procedures, which may delay surgery to prevent potential harm from inexperienced surgeons, poor medical facilities or suboptimal surgical decisions for skeletal fixations. Early antibiotic administration and good resuscitation as early as possible are vital.

We experienced a high percentage of infections of 27.1% (31 patients) and this figure needs to be investigated further to determine whether this type of open injury has a high infection rate or if there were defects in injury management in Medical City.


1. Pollak Andrew N., MD. Timing of debridement of open fractures. J Am Acad Orthop Surg. 2006;14:S48–S51. [PubMed]
2. American College of Surgeons Committee on Trauma: Resources for optimal care of the injured patient. Available at
3. Hamdan T. A., FRCS(Ed) Missile injuries of the limbs: An Iraqi perspective. J Am Acad Orthop Surg. 2006;14:S32–S36. [PubMed]
4. Spencer Jonathan, Smith Andrew, Woods David. The effect of time delay on infection in long bone fractures: a 5 year prospective audit from a district general hospital. Ann R Coll Surg Engl. 2004;86:108–112. [PMC free article] [PubMed]
5. Behrens F. Fracture with soft tissue injuries. In: Browner B, Jupiter J, Levine A., editors. Skeletal Trau-ma. Philadeliphia,PA: Saunders; 1992. pp. 311–36.
6. Cole J, Ansel L, Schwartzberg R. A sequential protocol for the management of severe open tibia fractures. Clin Orthop. 1995;315:84–103. [PubMed]
7. Gustilo R, Anderson J. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones. JBone Joint Surg. Am. 1976;58:453–8. [PubMed]
8. Patzakis M, Wilkins J. Factors influencing in fection rate in open fracture wounds. Clin Orthop. 1989;263:36–40. [PubMed]
9. Harley Brian J., Beaupre Lauren A., Jones C.Allyson, Dulai Sukhdeep K., Weber Donald W. The effect of time definitive treatment on the rate of non union and infection in open fractures. J. Orthop Trauma. 2002;16:484–490. [PubMed]
10. Charalambous C.P., Siddique I., Zenios M., Roberts S., Samarji R., Paul A., Hirst P. Early ver sus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union. Injury, Int J Care injured. 2005;36:656–661. [PubMed]
11. Khatod Monti, MD, Botte Michael J., MD, Hoyt David B., MD, Meyer Scott, MD, Smith Jeffrey M., Akeson Wayne H., MD Outcomes in open tibia fractures: Relationship between delay in treatment and infection. J Trauma. 2003;55:949–954. [PubMed]
12. Sungaran Jai, Harris Ian, Mourad Mohamed. The effect of time to theatre on infection rate for open tibia fractures. ANZ J Surg. 2007;77:886–888. [PubMed]
13. Kinlsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. 1995;9:121–127. [PubMed]
14. Kreder HJ, Armstrong P. A review of open tibia fractures in children. J Pediatr Orthop. 1995;15:482–488. [PubMed]
15. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop. 1989;243:36–40. [PubMed]
16. Skaggs David L., Friend Lauren, Alam Benjamin, Chambere Henry G., Schmiz Michael, Leake Brett, Kay Robert M., Flynn John M. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg Am. 2005;87:8–12. [PubMed]
17. Al-Arabi Yassir B., Nader Michael, Hamidian-Jahromi Ali Reza, Woods D.A. The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone fractures: A 9- year prospective study from a district general hospital. Injury IntJ Care Injured. 2007;38:900–905. [PubMed]
18. Lee Jackson., MD Efficacy of cultures in the man agement of open fractures. Clinical Orthopaedics and Related Research. 1997:71–75. Number 339. [PubMed]
19. Gosselin RA, Roberts I, Gillespie WJ. Antibiot ics for preventing infection in open limb fractures. Cochrane Database of systematic Reviews; 2004. Issue 1, Art. No; CD003764. DOI: 10.1002/14651858.CD003764.pub2. [PubMed]
20. Friedrich PL. Die aseptische Versorgung frischer. Wunden Arch FKlin Chir. 1898;57:288–310.
21. Patzakis Michael J., Paul Harvey J., JR, Ivler Daniel. The role of antibiotics in the man agement of open fractures. J Bone Joint Surg Am. 1974;56:532–541. [PubMed]

Articles from The Iowa Orthopaedic Journal are provided here courtesy of The University of Iowa