Factors Influencing Infection Rates after Open Hand Fractures

Open fractures of the hand: a new classification based on risk score to predict infection requiring re-debridement

We developed a classification for open hand fractures based on risk score to predict the risk of infection requiring re-debridement. A total of 846 retrospectively included patients underwent multivariable analysis with backward elimination to derive the predictive risk score from independent predictors. The incidence of infection requiring re-debridement was 4%. Independent predictors include diabetes mellitus or immunocompromised condition, injuries from a bite, fractures with comminution/bone loss, neurovascular injuries and inadequate soft tissue coverage. The area under the receiver operating characteristic curve of the prediction score was 0.79. The new classification system for open hand fractures divides patients into three groups: low-risk open fractures (Type I, score <1); moderate-risk open fractures (Type II, score 1 to 2.5); and high-risk open fractures (Type III, score >2.5), based on the risk of infection requiring re-debridement. Re-debridement and delayed primary closure are suggested for type III open fractures.Level of evidence: III.

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.