title: Attempting primary closure for all open fractures: the effectiveness of an institutional protocol.
abstract: BACKGROUND
  Immediate primary closure of open fractures has been historically believed to increase the risk of wound infection and fracture nonunion. Recent literature has challenged this belief, but uncertainty remains as to whether primary closure can be used as routine practice. This study evaluates the impact of an institutional protocol mandating primary closure for all open fractures.
  
  
  METHODS
  We retrospectively reviewed all open fractures treated in a single level 1 trauma centre in a 5-year period. Prior to the study, a protocol was adopted standardizing management of open fractures and advocating primary closure of all wounds as a necessary goal of operative treatment. Patient and fracture characteristics, type of wound closure and development of infectious and bone healing complications were evaluated from time of injury to completion of outpatient follow-up.
  
  
  RESULTS
  A total of 297 open fractures were treated, 255 (85.8%) of them with immediate primary closure. Type III open injuries accounted for 24% of all injuries. Wounds that were immediately closed had a superficial infection rate of 11% and a deep infection rate of 4.7%. Both proportions are equivalent to or lower than historical controls for delayed closure. Fracture classification, velocity of trauma and time to wound closure did not correlate significantly with infection, delayed union or nonunion.
  
  
  CONCLUSIONS
  Attempting primary closure for all open fractures is a safe and efficient practice that does not increase the postoperative risk of infection and delayed union or nonunion.
authors.affiliation: Fraser Orthopaedic Institute, University of British Columbia, New Westminster, BC.
authors.forename: Farhad O
authors.initials: FO
authors.lastname: Moola
authors.affiliation: The Division of Orthopaedic Surgery, McGill University, Montréal, Que.
authors.forename: Alberto
authors.initials: A
authors.lastname: Carli
authors.affiliation: The Division of Orthopaedic Surgery, McGill University, Montréal, Que.
authors.forename: Gregory K
authors.initials: GK
authors.lastname: Berry
authors.affiliation: The Division of Orthopaedic Surgery, McGill University, Montréal, Que.
authors.forename: Rudolf
authors.initials: R
authors.lastname: Reindl
authors.affiliation: The Royal Jubilee Hospital, Victoria, BC.
authors.forename: Duncan
authors.initials: D
authors.lastname: Jacks
authors.affiliation: The Division of Orthopaedic Surgery, McGill University, Montréal, Que.
authors.forename: Edward J
authors.initials: EJ
authors.lastname: Harvey
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002985:Clinical Protocols; D005260:Female; D005500:Follow-Up Studies; D005592:Fracture Fixation / Q000379:methods / Q000592:standards*; D005597:Fractures, Open / Q000601:surgery*; D005599:Fractures, Ununited / Q000453:epidemiology / Q000209:etiology; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D013530:Surgical Wound Infection / Q000453:epidemiology / Q000209:etiology; D013997:Time Factors; D014193:Trauma Centers / Q000592:standards*; D016896:Treatment Outcome; D058106:Wound Closure Techniques; D014945:Wound Healing; D055815:Young Adult