The Importance of Early Operative Treatment in Open Fractures of the Fingers

Low-caliber gunshot wounds in the hand a report of three cases

Introduction

Low-caliber gunshot wounds (GSW) to the hand are common and their incidence is increasing. Most low-caliber GSW's are treated in the emergency department (ED) with washout, intravenous antibiotics and any further follow-up treatment usually performed in an outpatient capacity. Treatment of these injuries specifically to the hand may be controversial in terms of timing and extent of washout, debridement, and fixation. Currently, the literature lacks a concise treatment algorithm, and this report aims to provide clinical scenarios that may educate management decision-making for patients with these injuries.

Methods

We discuss three cases that failed this initial treatment presenting as an infected nonunion. Each patient underwent irrigation, stabilization, and received antibiotics, yet showed no evidence of interval healing at follow-up. One of the patients demonstrated evidence of infection only one week following the injury.

Results

Cultures were positive in all cases and a surgery for debridement, fixation as well as antibiotic treatment was necessary. Only one patient followed up as recommended by the treating surgeon, yet two of three of the patients demonstrated clinical improvement after surgical intervention.

Conclusions

Despite being low caliber, this type of GSW to the hand likely causes more damage than to a larger part of the upper or lower extremity given the proximity of vital anatomic structures in the hand. We suggest considering a more aggressive initial treatment in the emergency room, especially for fracture patterns that could otherwise be treated non-operatively and in a particularly nonadherent population.

Management of Open Fractures of the Extremities and Pediatrics

The modern management of open fractures was established after the foundational work of Gustilo and Anderson, but we continue to strive to determine the optimal treatment of open fractures to diminish the risk of infection. The ideal timing of antibiotics, presentation to the operating room, and timing of procedures such as flap coverage continue to be investigated with incremental changes recommended over the years. This article aims to provide the most recent review of the literature regarding the timing and management of both upper and lower extremity open fractures, pediatric open fractures, current topics of controversy, and the data supporting current treatment recommendations.

[Open Fractures of the Hand: is there No Alternative to Definitive Osteosynthetic Treatment in an Emergency Situation?]

There is an emergency indication for the treatment of open fractures. Fracture stabilisation and soft tissue care are equal prerequisites for an uncomplicated course of treatment and a good functional result. However, challenges arise in cases of extensive wound contamination and compromised perfusion, limiting options for stable osteosynthesis in emergency situations. Furthermore, resource constraints may pose a challenge to adhering strictly to the six-hour time window. This prompts deliberations on whether, under certain circumstances, a deviation from the conventional approach is feasible by exploring the possibility of prioritising immediate surgical wound care during emergencies, with definitive fracture care deferred to a later point in time. Between 2019 and 2021, 301 patients with open fractures of the hand skeleton were treated (median age 44 years, 85% male, 15% female). Definitive treatment was carried out as a primary emergency procedure in 215 patients (group A), whereas it was performed at an interval after an average of 3 days in 86 patients (group B), who had received surgical wound care, splint placement, and antibiotic coverage on the day of the injury. In a retrospective study, the following criteria were analysed: comorbidities, injury patterns, injury location, timing of treatment, number of follow-up procedures, infection rate, and duration of hospitalisation. The course was complicated by infection in six patients (1.9%). Five of these patients were in group A (infection rate 2.3%), and only one patient was in group B (infection rate 1.1%). All six infections occurred after crush injuries, all at the fingertip or end joint. These numbers underscore the relevance of soft tissue trauma and primary stump formation. Comorbidities were not statistically significant in our study with a view to the occurrence of infection. In conclusion, it can be stated that, with antibiotic protection, definitive treatment of an open fracture in an interval is possible if it is preceded by initial emergency surgical wound care with subsequent immobilisation.

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.

Open hand fractures: a prospective analysis of functional outcomes and risk factors for infection after initial management in the emergency department

PURPOSE

Open hand fractures are common orthopaedic injuries, historically managed with early debridement in the operating room. Recent studies suggest immediate operative treatment may not be necessary but have been limited by poor follow-up and lack of functional outcomes. This study sought to prospectively evaluate these injuries treated initially in the emergency department (ED), without immediate operative intervention, to determine long-term infectious and functional outcomes using the Michigan Hand Outcomes Questionnaire (MHQ).

METHODS

Adult patients with open hand fractures managed initially in the ED at a Level-I trauma center were considered for inclusion (2012-2016). Follow-up and MHQ administration occurred at 6 weeks, 12 weeks, 6 months, and 1 year. Logistic regression and Kruskal-Wallis testing were used for analysis.

RESULTS

Eighty-one patients (110 fractures) were included. Most had Gustilo Type III injuries (65%). Injury mechanisms most commonly included saw/cut (40%) and crush (28%). Nearly half of all patients (46%) had additional injuries involving a nailbed or tendon. Fifteen percent of patients had surgery within 30 days. The average follow-up was 8.9 months, with 68% of patients completing at least 12 months. Eleven patients (14%) developed an infection, of which 4 (5%) required surgery. Subsequent surgery and laceration size were associated with increased odds of infection, and at one-year, functional outcomes were not significantly different regardless of fracture classification, injury mechanism, or surgery.

CONCLUSIONS

Initial ED management of open hand fractures results in reasonable infection rates compared to similar literature and functional recovery demonstrated by MHQ score improvements over time.

Principles of management of hand fractures

The optimal management of hand fractures requires a multidisciplinary approach. Initial assessment should include a thorough medical history and clinical examination, followed by appropriate radiological imaging. These are crucial in determining the appropriate management. Following joint stabilisation to allow fractures to unite, early mobilisation is needed to maximise the functional restoration of the hand. In this review, the principles of operative and non-operative management of these injuries are discussed.

Reoperation After Operative Treatment of Open Finger Fractures

BACKGROUND

Our primary aim was to develop a prediction model for return to the operating room (OR) after open finger fractures by studying the reoperation rate of open finger fractures based on patient demographics, injury mechanism, injury severity, and type of initial surgical fixation. The secondary aim was to study the predictors for secondary surgery due to nonunion, postoperative infection, and secondary amputation.

METHODS

In the retrospective chart review, 1321 open finger fractures of 907 patients were included. Demographic-, injury-, and treatment-related factors were gathered from medical records.

RESULTS

We found that open fractures involving the thumb had lower odds of undergoing secondary surgery. Crush injury, proximal phalangeal fracture, arterial injury, other injured fingers, and other injuries to the ipsilateral hand were associated with higher odds of undergoing secondary surgery. However, the associated factors we identified were not powerful enough to create a predictive model. Other injury to the ipsilateral hand, vein repair, and external fixator as initial treatment were associated with postoperative nonunion. Crush injury and proximal phalangeal fracture were associated with postoperative infection. No factors were associated with secondary amputation.

CONCLUSIONS

A quarter of open finger fractures will likely need more than one surgical procedure, especially in more severely injured fingers, due to crush or with vascular impairment. Furthermore, fractures involving the thumb have less reoperation, while fractures involving the proximal phalanx have poorest outcomes.

Can Open Hand Injuries Wait for Their Surgery in a Tertiary Hospital?

Objective  Open hand injuries are routinely admitted and planned for surgery acutely, competing with other surgical emergencies. This retrospective study aims to evaluate if a delay in timing to surgery for open hand injuries led to an increased rate of infection. Materials and Methods  All patients who sustained open hand injuries and underwent semi-emergent day surgery from January 1, 2015 to December 31, 2016 were included. Outcome of postoperative infection was analyzed against demographic data, injury details, and delay from trauma to therapy. Results  There were 232 cases (91% males) included, with 92.0% performed under local anesthesia. Deep seated postoperative infection was seen in 1.3%, which was not significantly associated with delay to surgery. Conclusion  We had comparable infection rates as compared with published literature. Delayed timing of surgical treatment in open hand injuries was not associated with increased rates of deep-seated infection. Managing open hand injuries as semi-emergent surgeries may be acceptable given the low infection rates.

Analysis of 1430 hand fractures and identifying the 'Red Flags' for cases requiring surgery: Head: Hand Fracture Treatment

BACKGROUND

Hand fractures constitute 20% of hand injury patients who apply to emergency services. Conservative approaches are satisfactory in the majority of the cases. However, the minority group in need of surgery reaches a serious number of patients considering the frequency of these injuries. Retrospective questioning of the indications of the performed surgeries is a proper way of understanding the decisional process for surgery.

PATIENTS/METHODS

Patients treated for hand fractures were retrospectively reviewed. Patient gender, age, finger/fingers involved, soft tissue involvement, treatment method (conservative/surgery) and if operated, devices used for fixation were noted. Plain radiographs of the patient were evaluated. Descriptive statistics of these variables and the effect of each variable on the decision for surgery were analyzed.

RESULTS

The study involved 1430 fractures of 1303 patients (1016 male and 287 female). Fifth finger was the most commonly injured digit (31%). Comminuted fractures (29%) followed by transverse fractures (29%) and spiral/oblique fractures (22%) were commonly diagnosed fracture types. Thirteen percent (13%) of the study group needed tendon/nerve/vessel repairs. Male patients, cases with soft tissue involvement, second, third and fourth finger fractures, fractures involving multiple digits, fractures with an intra-articular component, fractures with dislocation more than 4 mm and angulation more than 15° had a significantly higher rate of surgery.

CONCLUSION

Less than half of the hand fractures require surgery, and conservative treatment is usually preferred. Certain variables that indicate surgical treatment were identified with our study. These findings may help to weigh the options and choose the right path in doubtful conditions.

LEVEL OF EVIDENCE

Level 4, Case-control study.

Factors Influencing Infection Rates after Open Hand Fractures

Introduction  Open hand fractures are anecdotally reported to have lower infection rates than open long bone fractures. Although a 3-hour rule for antibiotic administration and a 6-hour rule for operative debridement have historically been upheld as ideal management for open fractures, other factors may be more influential in the development of infection. The purpose of this study was to investigate factors associated with open hand fracture infections. Materials and Methods  We retrospectively reviewed 67 patients with 107 open hand fractures between 2012 and 2017. Time from injury to antibiotic administration and operative debridement, modified Gustilo-Anderson classification, and patient characteristics including age, smoking status, and presence of chronic disease were examined for each patient. Outcome parameters were the development of infection and fracture union. Results  The overall rate of infection was 9% (6 of 67 patients). No type 1 or type 2 fractures developed infection in contrast to 12.2% of type 3 fractures. Patients who received antibiotics in less than 3 hours and underwent debridement in less than 6 hours did not have lower infection or nonunion rates than those who did not. The association between the modified Gustilo-Anderson classification and the development of infection or nonunion was statistically significant. Conclusion  Factors including time to antibiotics, time to operative debridement, smoking status, and chronic disease comorbidities were not predictive of either infection or nonunion in open hand fractures. Fracture type as defined by a modified Gustilo-Anderson classification was the factor most strongly related to the development of infection or nonunion in these fractures.

Comparison of Open and Closed Hand Fractures and the Effect of Urgent Operative Intervention

PURPOSE

To establish and compare the incidence of 30-day postoperative infection in surgically managed open and closed metacarpal and phalangeal fractures, and to determine whether open fractures treated urgently had a lower incidence of postoperative infection.

METHODS

We conducted a retrospective analysis of patient demographics, comorbidities, and 30-day infection rates of patients undergoing operative fixation of metacarpal, proximal, or middle phalanx fractures from 2008 to 2015 using the American College of Surgeons' National Surgical Quality Improvement Program database. A total of 3,506 patients were identified and patient variables and infection incidence were compared between open and closed injuries, as well as open injuries managed within 1 day of admission and those treated on an elective basis or treated more than 1 day after admission. Bivariate analysis was used to determine independent risk factors for postoperative infection.

RESULTS

Although 34.2% of open hand fractures were taken urgently to the operating room, the diagnosis of open fractures along with nonurgent surgical treatment for open fractures was associated with a low incidence of postoperative infection. In addition, smoking was a risk factor for postoperative infection although anatomic location (phalanx vs metacarpal) was not.

CONCLUSIONS

Patients undergoing surgery for metacarpal or proximal/middle phalangeal fractures are not at greater risk for infection based on the diagnosis of open fracture alone. In addition, patients with open fractures who are taken to the operating room more than 1 day from presentation did not have a higher incidence of infection. Smoking is associated with increased 30-day infection rates after surgery, and surgeons should identify these patients for preoperative risk stratification, counseling, and postoperative wound monitoring.

TYPE OF STUDY/LEVEL OF EVIDENCE

Prognostic II.

Perioperative Antibiotics for Clean Hand Surgery: A National Study

PURPOSE

Given that surgical site infections remain a common performance metric in assessing the quality of health care, we hypothesized that prophylactic antibiotics are overutilized in soft tissue hand surgery when antimicrobials are not indicated.

METHODS

We studied insurance claims from the Truven MarketScan Databases to identify patients who underwent 1 of 5 outpatient hand surgery procedures: open or endoscopic carpal tunnel release, trigger finger release, de Quervain release, and wrist ganglion excision between 2009 and 2015 (n = 305,946). Hospital payment claims for preoperative intravenous antibiotics and prescriptions filled for postoperative oral antibiotics were analyzed. We examined the rate and temporal trend of prophylactic antibiotics use and identified risk factors using multivariable logistic regression. We also calculated health care expenditures related to prophylaxis.

RESULTS

Prior to surgery, 13.6% (2009-2015) of patients received prophylactic intravenous antibiotics and trend analysis showed a statistically significant increase from 2009 (10.6%) to 2015 (18.3%), an increase of 72.5%. Preoperative prophylaxis was used most often prior to trigger finger release (17.5%) and least often prior to endoscopic carpal tunnel release (11.2%). Younger age, male sex, lower income, and obese patients had higher odds of receiving antibiotics. The total charge of prophylactic antibiotics medication used in this study equaled $1.6 million.

CONCLUSIONS

In 2015, prophylactic intravenous antibiotics were administered to nearly 1 in 5 patients prior to clean soft tissue hand surgery. Although consensus guidelines indicate prophylaxis is not indicated, their use has increased steadily in the United States from 2009 to 2015.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Open Fractures of the Hand: Review of Pathogenesis and Introduction of a New Classification System

Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture.

Antibiotic Management and Operative Debridement in Open Fractures of the Hand and Upper Extremity: A Systematic Review

Open fractures of the hand are thought to be less susceptible to infection than other open fractures because of the increased blood supply to the area. Current evidence for all open fractures shows that antibiotic use and the extent of contamination are predictive of infection risk, but time to debridement is not. We reviewed in a systematic review the available literature on open fractures of the hand and upper extremity to determine infection rates based on the timing of debridement and antibiotic administration. We continue to recommend prompt debridement and treatment of most open fractures of the upper extremity.

Timing of Debridement and Infection Rates in Open Fractures of the Hand: A Systematic Review

Background: Literature on open fracture infections has focused primarily on long bones, with limited guidelines available for open hand fractures. In this study, we systematically review the available hand surgery literature to determine infection rates and the effect of debridement timing and antibiotic administration. Methods: Searches of the MEDLINE, EMBASE, and Cochrane computerized literature databases and manual bibliography searches were performed. Descriptive/quantitative data were extracted, and a meta-analysis of different patient cohorts and treatment modalities was performed to compare infection rates. Results: The initial search yielded 61 references. Twelve articles (4 prospective, 8 retrospective) on open hand fractures were included (1669 open fractures). There were 77 total infections (4.6%): 61 (4.4%) of 1391 patients received preoperative antibiotics and 16 (9.4%) of 171 patients did not receive antibiotics. In 7 studies (1106 open fractures), superficial infections (requiring oral antibiotics only) accounted for 86%, whereas deep infections (requiring operative debridement) accounted for 14%. Debridement within 6 hours of injury (2 studies, 188 fractures) resulted in a 4.2% infection rate, whereas debridement within 12 hours of injury (1 study, 193 fractures) resulted in a 3.6% infection rate. Two studies found no correlation of infection and timing to debridement. Conclusions: Overall, the infection rate after open hand fracture remains relatively low. Correlation does exist between the administration of antibiotics and infection, but the majority of infections can be treated with antibiotics alone. Timing of debridement, has not been shown to alter infection rates.

Open Fractures of the Hand: Review of Pathogenesis and Introduction of a New Classification System

Open fractures of the hand are a common and varied group of injuries. Although at increased risk for infection, open fractures of the hand are more resistant to infection than other open fractures. Numerous unique factors in the hand may play a role in the altered risk of postinjury infection. Current systems for the classification of open fractures fail to address the unique qualities of the hand. This article proposes a novel classification system for open fractures of the hand, taking into account the factors unique to the hand that affect its risk for developing infection after an open fracture.