Open Distal Radius Fractures: Timing and Strategies for Surgical Management

Association of Timing With Postoperative Complications in the Management of Open Distal Radius Fractures

BACKGROUND

This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours.

METHODS

Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion.

RESULTS

One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours.

CONCLUSION

Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner.

LEVEL OF EVIDENCE

Level IV.

Epidemiology of distal radius fractures: Elucidating mechanisms, comorbidities, and fracture classification using the national trauma data bank

BACKGROUND

An update on the epidemiology of distal radius fractures in the United States is necessary, particularly as the elderly population grows. Additionally, age and frailty have been associated with complications following surgical fixation of DRFs. Herein, we utilize the National Trauma Data Bank, a robust nationwide resource, to investigate the relationship between demographics, comorbidities, injury and fracture characteristics, and admission details.

METHODS

Patients with isolated distal radius fractures were identified from the National Trauma Data Bank (2016-2019) according to ICD-10 codes. Univariate and multivariate regressions were conducted to determine independent risk factors for bilateral fractures, displaced fractures, open fractures, as well as length of hospital stay and adverse discharge disposition for patients undergoing inpatient surgical fixation.

RESULTS

The incidence of DRFs was 3.6/1,000 trauma-related emergency department visits and 10.8/1,000 upper extremity traumas. Trauma mechanism was significantly associated with displaced and open fractures. Age (OR 1.01, 95% CI 1.01-1.01), BMI (OR 1.02, 95% CI 1.01-1.02), smoking (OR 1.34, 95% CI 1.15-1.57), and alcohol level (trace: OR 2.18, 95% CI 1.41-3.29; intoxicated: OR 2.20, 95% CI 1.63-2.95) were significantly associated with open fractures. Machinery (β=2.04, 95% CI 1.00-3.08) and MVT (β=0.39, 95% CI 0.08-0.69) mechanisms were independent risk factors for longer length of stay. mFI-5 was an independent risk factor, in a stepwise fashion, for both length of stay and adverse discharge disposition.

CONCLUSIONS

High-energy mechanisms and risk factors for poor skin quality were significantly associated with open fractures. mFI-5 was an independent risk factor for longer length of stay and non-routine discharges in patients of all ages, despite controlling for other comorbidities, unrelated complications, and mechanism of injury. Trauma mechanism was an independent risk factor for prolonged length of stay only, particularly in patients younger than 65 years of age.

Open fractures of the upper limb - do the BOAST guidelines need an update?

AIMS

This scoping review aims to explore the published literature on the current management strategies and outcomes of open upper limb injuries using the BOAST 4 guidelines as a structure.

MATERIALS AND METHODS

A comprehensive search of the MEDLINE, EMBASE, Cochrane and OrthoSearch computerised literature databases (from January 2012 through April 2022) was performed. The medical subject headings used were "open fracture"/ "Gustilo Anderson" and "forearm" or "radius" or "ulna" or "elbow" or "humerus" or "clavicle" or "shoulder" or "scapula". Abstract titles were reviewed for relevance. If the article was deemed eligible, the article was retrieved and reviewed in full.

RESULTS

The literature reveals lower rates of infection for upper limb injuries compared to their lower limb counterparts. Early antibiotic administration remains a key component of their management. Those without significant soft tissue injury (Gustilo Anderson 1) can often be treated as per their closed counterparts and timing to definitive fixation can be safely delayed in selected cases.

DISCUSSION

There is limited high quality evidence available on the management of open upper limb injuries with guidelines built on borrowed principles from the more studied open tibia fractures. What the available evidence does show is that with lower infection rates and a more forgiving soft tissue envelope it may be safe to diverge from the current BOAST guidelines in certain cases. This has relevance in complex fracture patterns requiring specialist input where it is not possible to achieve definitive fixation in 72 h and when there are other life threatening injuries to manage. Despite this early antibiotic administration and debridement within 24 h remains a key component of the early management.

Outcomes of Type I Open Distal Radius Fractures: A Comparison of Delayed and Urgent Open Reduction Internal Fixation

BACKGROUND

Type I open distal radius fractures treated with open reduction internal fixation (ORIF) have demonstrated minimal risk of infection. For this reason, they may not require urgent surgical treatment. The purpose of this study was to evaluate the outcomes of patients with type I open distal radius fractures treated with delayed ORIF compared with urgent ORIF.

METHODS

We identified all Gustilo-Anderson type I open distal radius fractures that had undergone ORIF using volar plating over a 5-year period. Patients were stratified into those treated urgently within 24 hours and those scheduled for delayed surgery. Outcomes including functional scores, complications, reoperations, and radiographic measures were compared.

RESULTS

Twenty-four patients (17 treated urgently and 7 treated delayed) had open type I distal radius fractures. All patients were started on empiric antibiotics at initial presentation-patients in the delayed treatment group were prescribed oral antibiotics, whereas those admitted for urgent treatment received intravenous antibiotics. There were no infections in either group and a single reoperation in each group. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 29 (range = 0-77) and did not differ significantly between delayed (mean = 19) and urgent (mean = 38) treatment. Rate of complications and radiographic measures did not differ significantly between the groups.

CONCLUSIONS

Type I open distal radius fractures appear amenable to delayed outpatient ORIF provided that the wound is clean at the time of initial presentation and that antibiotics are initiated appropriately. Further prospective studies comparing delayed and urgent treatment strategies are warranted.

The Open-Fracture Patient Evaluation Nationwide (OPEN) study : the management of open fracture care in the UK

AIMS

The Open-Fracture Patient Evaluation Nationwide (OPEN) study was performed to provide clarity in open fracture management previously skewed by small, specialist centre studies and large, unfocused registry investigations. We report the current management metrics of open fractures across the UK.

METHOD

Patients admitted to hospital with an open fracture (excluding phalanges or isolated hand injuries) between 1 June 2021 and 30 September 2021 were included. Institutional information governance approval was obtained at the lead site and all data entered using Research Electronic Data Capture software. All domains of the British Orthopaedic Association Standard for Open Fracture Management were recorded.

RESULTS

Across 51 centres, 1,175 patients were analyzed. Antibiotics were given to 754 (69.0%) in the emergency department, 240 (22.0%) pre-hospital, and 99 (9.1%) as inpatients. Wounds were photographed in 848 (72.7%) cases. Median time to first surgery was 16 hrs 14 mins (interquartile range (IQR) 8 hrs 29 mins to 23 hrs 19 mins). Complex injuries were operated on sooner (median 12 hrs 51 mins (IQR 4 hrs 36 mins to 21 hrs 14 mins)). Of initial procedures, 1,053 (90.3%) occurred between 8am and 8pm. A consultant orthopaedic surgeon was present at 1,039 (89.2%) first procedures. In orthoplastic centres, a consultant plastic surgeon was present at 465 (45.1%) first procedures. Overall, 706 (60.8%) patients required a single operation. At primary debridement, 798 (65.0%) fractures were definitively fixed, while 734 (59.8%) fractures had fixation and coverage in one operation through direct closure or soft-tissue coverage. Negative pressure wound therapy was used in 235 (67.7%) staged procedures. Following wound closure or soft-tissue cover, 509 (47.0%) patients received antibiotics for a median of three days (IQR 1 to 7).

CONCLUSION

OPEN provides an insight into care across the UK and different levels of hospital for open fractures. Patients are predominantly operated on promptly, in working hours, and at specialist centres. Areas for improvement include combined patient review and follow-up, scheduled operating, earlier definitive soft-tissue cover, and more robust antibiotic husbandry.Cite this article: Bone Joint J 2022;104-B(9):1073-1080.

Outcomes of Primary Volar Locking Plate Fixation of Open Distal Radius Fractures

Background: Few studies have reported the outcomes of primary volar locking plate fixation in Gustilo and Anderson type II and IIIA open distal radius fractures. We report the outcomes of treatment of Gustilo and Anderson type II and IIIA open distal radius fractures using primary volar locking plate fixation. Methods: We retrospectively reviewed 24 patients with open distal radius fractures who were treated using primary volar locking plate fixation. The range of motion (ROM) and modified Mayo wrist scores were measured to assess functional outcomes. Radiological outcomes included the bone union period, radial inclination, volar tilt, radial length and ulnar variance. Results: Functional outcomes, including mean ROM in flexion (39.1°) and extension (52.5°), improved following primary volar locking plate treatment. Radiological outcomes were as follows. Mean bone union period, radial length and ulnar variance were 7.8 months, 10.4 and 0.7 mm, respectively. Two patients had superficial wound infection 2 weeks after surgery and one patient had non-union of the radius that required implant removal, autologous iliac crest bone graft and plate re-fixation. Conclusions: Primary volar locking plate fixation is a safe and reliable treatment option for Gustilo and Anderson type II and IIIA open distal radius fractures. By providing firm stabilisation and allowing early ROM exercise, primary volar locking plate fixation resulted in good functional and radiological outcomes. Level of Evidence: Level IV (Therapeutic).

Management of open elbow fractures: experiences and outcomes from a UK major trauma center

HYPOTHESIS AND BACKGROUND

Open fractures about the elbow are an infrequent but complex injury with limited existing literature. The aims of the study were to review the treatment strategies of open elbows fractures, functional outcome and complication rates associated with the injury, and correlate the outcome with the topography of the fracture.

METHODS

Patients (n = 21) with open elbow fractures injuries over a 2-year period were analyzed. They were assessed regarding the orthoplastic characteristics of their injury as well any other associated injuries. Outcomes were assessed objectively (achievement of bony union, range of movement, infection status, need for further procedures) and subjectively (Oxford Elbow Score, EQ-5D, EQ-VAS).

RESULTS

The commonest grade of open injury was grade 3 (43%). Associated orthopedic injuries were present in 62% and associated system injuries in 57%. Almost half of the patients were noted to have had a significantly increased presenting mortality risk as per Injury Severity Score assessment. Mean time to first wound débridement was 31 hours. There were no cases of deep or chronic infection. Complete bony union was noted in 85% of patients, and 48% of patients required removal of metalwork. Subgroup analysis of the cohort by fracture topography (single unipolar elbow bone injury vs. multiple elbow bony injuries) demonstrated no significant difference (P > .05) regarding rate of complication or final Oxford Elbow Score, EQ-5D or EQ-VAS. Patients with injuries that involved the distal humerus had the highest rate for further procedures (P < .05). The average Oxford Elbow Score, EQ-5D, and EQ-VAS scores for the whole cohort at final follow-up were 37.4, 0.54, and 62.18, respectively.

DISCUSSION

Open elbow injuries are usually from high-energy trauma and often combined with other significant injuries. As a result, the timelines to elbow surgery were often delayed. However, this did not impact the local infection rates nor did it necessitate further surgery, but made achieving all British Orthopaedic Association Standards for Trauma targets difficult. Chronic infection was not an issue in this cohort. Subgroup analysis indicates open distal humerus fractures carry the highest risk for further procedures. This is most commonly in the form of removal of metalwork and fibrinolysis. End outcomes for patients with open elbow fractures can be positive, despite the notable presenting Injury Severity Score. A subspecialist elbow and orthoplastic approach whenever possible is advocated.

Deep Infection after Distal Radius Open-reduction Internal Fixation: A Case Series

Background

Given its low incidence, the management of deep infection following distal radius open-reduction internal fixation (ORIF) has not been well reported. In an effort to expand our current understanding, the purpose of this case series is to present the treatment strategies and functional outcomes associated with deep infection after distal radius ORIF.

Methods

All patients with deep infections after distal radius ORIF over a ten-year period were identified and their treatment courses asessed.

Results

The cohort consisted of three women and one man with an average age of 55.5 ± 17.6 years. Mean time from infection presentation to irrigation and debridement (I&D) with removal of hardware (ROH) was 16 days (Range: 3 - 44 days). The identified bacterial species in all cases was Staphylococcus aureus (MRSA = 2, MSSA = 2). Three patients were treated with intravenous antibiotics, while one patient was treated with oral antibiotics. Mean time from infection presentation to final clinical follow-up was 11 months (Range: 3 - 20 months). Two patients required repeat I&D. A clinical determination of successful infection eradication was made in all cases.

Conclusion

The reported rate of deep infection after distal radius ORIF is less than 1%. There is no well-defined treatment algorithm for patients with deep infection after distal radius ORIF. However, removal of hardware and post-operative oral or intravenous antibiotic therapy appears effective, and is consistent with the standard practices of treating infection after other orthopaedic surgeries.

[External fixator of the wrist-temporary fixation]

OBJECTIVE

a) Fixed-angle bridging of the wrist between radius diaphysis and metacarpus by percutaneous or minimally invasively inserted threaded pins and a frame (fixator) placed above the skin level (external); b) retention of fracture fragments by ligamentotaxis; c) temporary stabilization after bone loss at wrist and distal forearm.

INDICATIONS

a) Initial treatment of fractures near the wrist or soft tissue injuries in multiple trauma patients; b) fractures of the distal radius and the distal ulna; c) dislocation of the carpus; d) infections of the wrist; e) instability after resection in the wrist area; f) fractures with impending or manifest compartment syndrome; g) fractures with extensive loss of soft tissues and lacking coverage of implants.

CONTRAINDICATIONS

a) Pathological changes at the site of pin application, as long as no alternative site is possible: infections, fractures, osteoporosis, tumors; b) fractures that are closed and not reduceable; c) exclusively intra-articular distal radius fractures; d) lack of compliance by the patient.

SURGICAL TECHNIQUE

Insertion of two threaded pins into the radial shaft proximal to the radiocarpal joint and two pins into the second metacarpal bone. Assembly of the fixator frame in advance of the definitive reduction. Subsequently, final reduction and fixation in the desired position by tightening of the screws on the fixator frame.

POSTOPERATIVE MANAGEMENT

Pin care and changes of wound dressing every 2-3 days RESULTS: Reliable, low complication procedure for temporary fixation of the wrist for many indications.

Influence of Smoking in the Clinical Outcomes of Distal Radius Fractures

Introduction There are various studies that reviewed the effect of cigarette smoking in fracture healing process. Nonunion, delayed union, and residual pain are the significant risk factors associated with smoking and fracture healing. Little has been known about the impact of smoking in distal radius fracture healing. We intend to explore in brief the effect of smoking in distal radius fracture healing and comparing it with nonsmokers having the same fracture fixation and analyze the outcomes with respect to fracture healing and return of function.

Materials and Methods Of the total 186 patients, 92 were included in the study with (n = male: 31, female: 61) mean age of 60.2 years. They were divided into two groups: smoking (n = 43) and nonsmoking (n = 49). All had surgical fixation of the distal radius with volar locking plate and started on early mobilization. The range of motion of the wrist, grip, visual analog scale, quick disabilities of the arm and shoulder and hand score, Mayo wrist score, and bone healing period were noted between these two groups and compared with statistical analysis.

Results The mean follow-up period was 8.7 months. There was a significant association of young age and male patients having distal radius fractures in the smoking group (p < 0.05). All fractures healed well in both groups without complications. There was no significant difference between these two groups in terms of range of motion, grasp, bone healing period, and functional outcomes.

Conclusion Despite the well-known fact that, smoking has negative implications in the fracture healing process, we found group of patients (smoking and nonsmoking) with distal radius fractures treated by volar locking plates healed well with good radiological union and excellent functional outcome There is no significant influence of smoking in distal radius fracture fixation.

Arm reconstruction

The arm is less often concerned by reconstructive surgeries than more distal parts of the upper extremity. However, when affected, the arm is frequently part of complex mutilating injuries involving composite defects. For a given traumatic or oncologic defect, there are several reconstructive options and choosing the right sequence may pose a challenge even to the most experienced surgeon. The latter must integrate not only functional and esthetic requirements, but also the surgeon's habits, especially in situations of emergency. Once life-threatening conditions are averted, wound debridement, bony stabilization, neurovascular, and cutaneous reconstruction tailored to the defects should be performed in a single-stage procedure. Functionally, prompt bony stabilization is necessary to allow early mobilization. Diaphyseal shortening of the humerus can be a salvage procedure to avoid nerve and vascular grafting, with good biomechanical tolerance up to 5cm. Restoration of adequate elbow motion sometimes requires muscle transfer and should be a main concern, as proper positioning of the hand during daily activities demands a functional elbow joint. Esthetically, the surgeon must choose the most cosmetic skin coverage option whilst limiting morbidity of the donor site area. The flaps vascularized by the sub- scapular or thoraco-dorsal vessels are the most useful flaps for arm reconstruction. This paper discusses the reconstructive sequence of complex defects of the arm and provides a review of commonly used reconstructive techniques supported with illustrative cases.

Distal radius fractures: an evidence-based approach to assessment and management

Distal radius fractures account for one in five bony injuries in both primary and secondary care. These are commonly the result of a fall on outstretched hands or high-energy trauma. On assessment, clinicians should determine the mechanism of injury, associated bony or soft tissue injuries, and neurovascular symptoms. Investigations should always include radiographs to evaluate for intra-articular involvement and fracture displacement. Owing to the heterogeneous injury patterns and patient profiles, the preferred management should consider the severity of the fracture, desired functional outcome and patient comorbidities. Non-operative management in select patients can give good results, especially in older adults. Immobilisation with or without reduction forms the mainstay of non-operative treatment. Surgical management options include closed reduction and application of a cast, percutaneous K-wires, open reduction and internal fixation with plates, or external fixation. Patients should be encouraged to mobilise as soon as it is safe to do so, to prevent stiffness. Median nerve compression is the most common complication followed by tendon rupture, arthrosis and malunion. This article outlines the British Orthopaedic Association Standards for Trauma and Orthopaedics for the management of distal radius fractures.

Evaluating Outcomes Following Open Fractures of the Distal Radius

PURPOSE

A paucity of evidence exists regarding the optimal treatment of open fractures of the distal radius. The purpose of this study was to compare short-term complication rates between various treatment options following open fractures of the distal radius.

METHODS

We performed a retrospective review of all open fractures of the distal radius at a single level 1 trauma center over a 10-year period. The primary outcome measure was the number of minor and major complications. Demographic and clinical characteristics of patients across treatment and outcome groups were compared and models were used to describe the relationships between outcome and treatment.

RESULTS

Ninety patients met the inclusion criteria for evaluation. An even distribution between high-energy (n = 45) and low-energy (n = 45) injuries was seen with 61 fractures Gustilo I (67%), 19 Gustilo II (22%), and 10 Gustilo III (11%). The majority of fractures were intra-articular (n = 48 AO type C vs n = 42 AO type A/B). Fractures were treated with immediate open reduction internal fixation (ORIF) in 67 cases (74%), external fixation in 12 (13%), initial external fixation followed by ORIF at a later time in 8 (9%), or closed reduction and percutaneous pinning in 3 (4%). We observed 33 complications (37%) of which 24 were major and 9 minor. Mechanism of injury and type of treatment were the only variables shown to correlate with an increased rate of complications.

CONCLUSIONS

We conclude that open fractures of the distal radius treated by immediate ORIF at the time of index debridement can result in satisfactory outcomes compared with other forms of treatment.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Hand, Wrist, Forearm, and Arm Replantation

Level of injury plays a significant role in decisions to perform replantation, with improved function, nerve regeneration, and decreased rate of reperfusion injury for injuries at the distal forearm or wrist compared with proximal injuries. The principles of a functional and sensate outcome dictate replantable parts, whereas patient comorbidity, expectations, and safety dictate patient candidacy. Vascular grafts are an expected part of the operation, and the contralateral arm or a lower extremity should be prepped into the surgical field. Despite diminished function, patient satisfaction and independence remain high after a major upper extremity replantation.

Corrective osteotomy of distal radius malunion after IIIB open fracture: Palmar approach - Case report

BACKGROUND

Despite the fact that distal radius fractures are the most common, open fractures are relatively uncommon. The aim of this study is to present the case with severe malunion of extra-articular left distal radius after open fracture grade IIIB (Gustillo). The treatment was done with open correctuve osteotomy and ostosynthesis with volar low profile plate.

CASE PRESENTATION

A 32-years old man was admitted to our departement because of severely malunited left distal radius extra-articular metaphyseal fracture after treatment of an open fracture. He was primary treated in a Regional Hospital with irrigation, debridement, antimicrobial cover, and immediate skeletal management through fixation with Kirschner's wires. No external fixator was used. He developed volar metaphyseal angulation after loss of primary reduction of K-wires fixation; therefore it required corrective surgical treatment. Because of malunion, open corrective osteotomy and bone grafting of distal radius with volar plating were done. Follow-up 20 months after surgery show deformity correction of radial volar inclination, height, and restitution of distal radioulnar joint.

CONCLUSION

This case report offers an informative overview on this uncommon case of distal radius open fracture malunion treated successfully with volar approach corrective osteotomy. Corrective surgery is the primary therapy of choice in the this case. This method have shown to be safe and effective in treatment of distal radius malunion with volar angulation.

Complications in the Management of Distal Radius Fractures: How Do We Avoid them?

PURPOSE OF THIS REVIEW

Distal radius fractures are one of the most common fractures in the upper extremity. The purpose of this review is to outline common complications that may arise when caring for distal radius fractures and to describe the treatment strategies when faced with such complications.

RECENT FINDINGS

Tendon complications are not uncommon after distal radius fractures. Recent literature highlights new plating technology for dorsal plating techniques. Moreover, new literature has outlined parameters for flexor tendon complications when using volar locking plates in an effort to avoid flexor tendon irritation and rupture. In summary, it is important to understand the various complications that can arise when treating distal radius fractures in an effort to avoid suboptimal outcomes.