OPEN PELVIC FRACTURE AND FECAL DIVERSION

Background: Mandatory fecal diversion has been advocated as an appropr iate measure to prevent infection in the clinical setting of an open p elvic fracture. However, the efficacy of this practice has not been ve rified by prospective investigation and has received only inconsistent support from retrospective analyses. Objective: To determine whether fecal diversion is associated with a substantially lower incidence of abdominopelvic infectious complications in patients with open pelvic f ractures. Design: Case-control study. Setting: University-based tertia ry care, level I trauma center. Methods: The current study reviews our experience with 60 cases admitted from 1987 to 1993 to Harbor-view Me dical Center, a regional level I trauma center. Data collected on each patient included age, sex, Injury Severity Score, Glasgow Coma Scale, initial heart rate and systolic blood pressure, location and severity of wound, fracture pattern, pelvic stability, time to open reduction internal fixation or external fixation, mortality, use of fecal divers ion, and incidence and location of infection. Review of the literature produced an additional 186 patients amenable to analysis. Results: Fe cal diversion was performed in 19 patients, 5 (26%) of whom experience d subsequent abdominopelvic infectious morbidity. Of the remaining 41 patients, 7 patients (17%) experienced infectious complications. The 2 groups (diversion vs no diversion) were comparable with regard to rel evant demographic and clinical characteristics of injury severity. Com bining the present series with those reported by others gave a composi te series of 246 patients. For the composite series, diversion was per formed in 70% of patients. Infection developed in 27% of patients who underwent diversion vs 29% in patients who did not. In the present ser ies, only mechanical instability was determined by stepwise logistic r egression to be significantly associated with pelvic infection. This a ssociation was not altered by diversion status. Conclusions: Diversion of the fecal stream to protect open pelvic fractures is not associate d with a lower incidence of abdominopelvic infectious complications. D iversion may offer protection to a select group of patients with:exten sive soft tissue injury or posterior wounds. Mechanical instability wa s independently associated with infection.