An Original Study Initial Management of Open Hand Fractures in an Emergency Department John T. Capo, MD, Michael Hall, BS, Ali Nourbakhsh, MD, Virak Tan, MD, and Patrick Henry, MD tributed to reducing infection rates, the management Abstract guidelines are based on studies of all fractures, usually We retrospectively reviewed the cases of patients with not including hand fractures. open hand fractures and/or dislocations managed at Current evidence indicates that infections that occur our institution between 2001 and 2009. The manage- after open fracture management are often caused by ment protocol consisted of irrigation and debridement, nosocomial organisms, not the initial contaminating reduction (if necessary), splinting, and antibiotics admin- 4 4 istration in the emergency department. Patients with organisms. Given the improvements in wound care, vascular compromise or severe mangling open wounds the high costs of hospital care, and the excellent blood were taken to the operating room for treatment. Data supply to the hand, it may be appropriate and desirable regarding demographics, wound size and modified to manage a select group of open hand fractures with a Gustilo–Anderson classification, and timing of interven- standardized protocol of wound care, but in the emer- tions were recorded. gency department (ED) setting. The fact that 12.5% Included in the study were 145 cases (91 class III, 41 of phalanx fractures are open5 adds to the importance class II, and 13 class I injuries). In 102 cases, definitive of defining the best management method for these and final management took place in the emergency fractures. In the study reported here, we retrospectively department; in the other 43 cases, additional manage- ment took place in the operating room. Antibiotics were evaluated the effectiveness of such a protocol in terms administered within 4 hours after injury, and irrigation of infection rates. and debridement were performed within 6 hours. Each of the 2 infections (1.4%) developed in a class III injury. MATERIALS AND METHODS In open hand fractures, particularly type I and type II We retrospectively reviewed the cases of patients with wounds, the protocol we followed can be appropriate open hand fractures and/or dislocations referred to the when the injury is not the severe mangling type and does orthopedics service at our institution between 2001 and not require acute vascular repair. 2009. We obtained institutional review board approval before beginning this study. The patients in these cases n open fracture is identified by a soft-tissue included all those admitted with open hand fractures disruption that allows the fracture site to be to the orthopedic hand service over this 9-year period. exposed to the outside environment. Open The orthopedic hand team at our institution has on-call fractures are usually severe and prone to seri- responsibilities 50% of the time. We reviewed the records Aous complications, such as infection.1 The basic compo- of these cases and recorded the data regarding sex, age, nents of injury management are function restoration, hand dominance, mechanism of injury, wound size, mod- bone union, and infection prevention.2 Management ified Gustilo–Anderson classification of wound (Table traditionally consists of irrigation and debridement I),6 timing of injury, ED arrival, antibiotics administra- (I&D) and bone stabilization in the operating room tion, and I&D. We also recorded type of antibiotic used (OR).1-3 Irrigation should be performed with copious and presence or absence of associated injuries, such as amounts of sterile saline, often combined with anti- tendon and neurovascular injuries. biotics, and debridement of nonviable tissue. Repeat The management protocol consisted of local-field, I&D may be needed in severe open hand fractures.2 digital or wrist block anesthesia combined with intra- Although all of these recommendations may have con- venous sedation; sterile draping of the extremity; irrigation with sterile saline (3 L), local wound debride- Dr. Capo is Professor, Mr. Hall is Medical Student, Dr. Nourbakhsh ment; reduction (if necessary), and splinting. These is Research Fellow, Dr. Tan is Professor, and Dr. Henry is procedures were performed in the OR in the hospital Orthopedic Resident, Department of Orthopedics, University of Medicine and Dentistry of New Jersey, Newark, New Jersey. ED by second-year or third-year orthopedic residents supervised by fellowship-trained attending orthopedic Address correspondence to: John T. Capo, MD, Department hand surgeons. Previously, these attendings had for- of Orthopedics, University of Medicine and Dentistry of New mally instructed the residents as to the specifics of the Jersey, 140 Bergen St, Newark, NJ 07103 (tel, 973-972-0763; fax, I&D procedure to ensure a consistent study protocol. 973-972-3897; e-mail, [email protected]). Stable fractures with acceptable alignment and no need Am J Orthop. 2011;40(12):E243-E248. Copyright Quadrant for soft-tissue coverage or tendon or nerve repair were HealthCom Inc. 2011. All rights reserved. managed with appropriate antibiotics and followed www.amjorthopedics.com December 2011 E243 Initial Management of Open Hand Fractures Table I. Open Fracture Wound Classification (Modified Gustilo–Anderson) Type I Tidy laceration, <1 cm in length; no contamination, soft-tissue crush, loss, or fracture comminution Type II Tidy laceration, <2 cm in length; no contamination, soft-tissue crush, loss, or fracture comminution Type III Laceration, >2 cm; penetrating or puncturing projectile wound, soft-tissue crush, blast injury, periosteal stripping, or wound contamination Table II. Wound Sizes for Gustilo Classification Groups in Our Patient Cohort Gustilo Wound Size, cm Classification Mean SD Range P Value for t Test I 0.7 0.44 0.1-1 .003 (comparing I and II) II 2.1 0.9 1.5-5 .1 (comparing II and III) III 2.8 1.5 0.5-7 — femur, rib, mandible, cervical spine, and shoulder Table III. Mechanisms of Injury in Our Patient fractures. Other injuries included head concussion, Cohort pulmonary contusion, hemothorax, liver and renal lacerations, and median and ulnar nerve lacerations. Mechanism No. % Four patients had digital nerve injuries, and 16 had Work related 54 37% nail-bed injuries. Cefazolin (Ancef) was the first anti- Crush injury 36 25% biotic used in the ED in the majority of cases (85%). Gunshot 21 14% Assault 10 7% Cephalexin (Keflex) was the oral antibiotic (7- to Fall 7 5% 10-day course) prescribed most often (87%) by the Cut 6 4% Other (motor vehicle accident, 11 8% orthopedic team. Tables IV and V list the fracture bite, etc) locations: metacarpus or digits (4 cases had only open Total 145 dislocations). There were 99 distal phalanx fractures, 17 proximal phalanx fractures, and 9 middle phalanx until fracture healing. Unstable fractures, fractures with fractures. There were 23 metacarpus fractures and, unacceptable alignment, wounds that required skin in 5 cases, a concomitant finger fracture. In most graft, neurovascular injuries, and severe tendon injuries cases, the injured tendon was the second extensor underwent initial I&D and splinting in the ED and then tendon (Table VI). The 12 hand joint dislocations were taken to the OR for internal fixation or soft-tissue occurred most often in the proximal interphalangeal reconstruction procedures to be performed within the joints—the thumb interphalangeal joint (4 cases), the next 24 hours to 72 hours. Patients with vascular com- third proximal interphalangeal joint (3), and the fifth promise or severe mangling open wounds were taken to proximal interphalangeal joint (3). the OR for appropriate treatment on the day of presen- In 102 cases, I&D, fracture reduction, and wound tation. closure constituted definitive management and were One hundred forty-five cases matched our inclusion performed in the ED; in the other 43 cases, repeat I&D criteria. There were 119 men (82%) and 26 women (18%). and open reduction and internal fixation (with pins or Most patients (91.5%) were right-hand–dominant, and plates, and with or without nerve or tendon repair, nail- mean (SD) age was 39 (14) years. According to the modi- bed repair, or ablation) were performed in the OR after fied Gustilo–Anderson classification, most wounds (91, initial management in the ED. Of the 43 patients, 27 63%) were class III, followed by class II (41, 28%) and had a hospital stay of less than 1 day. The operations class I (13, 9%). Mean wound sizes were 0.7 cm (class performed for hand fractures and concomitant injuries I), 2.1 cm (class II), and 2.8 cm (class III) (Table II). The are summarized in Table VII. most common injuries (54, 37%) were work related, fol- Statistical analysis was performed with SPSS Version lowed by crush injuries and gunshot wounds (Table III). 16 (SPSS, Chicago, Illinois). c2 tests were used to Twelve patients had concomitant injuries, such as compare the infection rates of the wound classes as Table IV. Distribution of Metacarpal and Finger Fractures No Finger Fracture Finger Fracture Patients No. % No. % No metacarpus fracture 4 3.3% 119 96.7% Metacarpus fracture 17 77.3% 5 22.7% E244 The American Journal of Orthopedics® www.amjorthopedics.com J. T. Capo et al Table V. Distribution of Metacarpal and Table VI. Associated Tendon Injuries in Our Phalanx Fractures Patient Cohort Fracture Type No. Tendon Injury No. Metacarpus Fracture 1st extensor tendon 1 1st metacarpus 6 2nd extensor tendon 3 2nd metacarpus 6 3rd extensor tendon 1 3rd metacarpus 6 3rd & 4th extensor tendons 1 4th metacarpus 9 4th extensor tendon 1 5th metacarpus 9 5th extensor tendon 1 Total 36 2nd FDS tendon, FDP tendon 1 3rd FDP tendon 2 Phalanx Fracture No. 4th FDS tendon 1 Thumb 21 Total 12 Index finger 30 Middle finger 40 Abbreviations: FDP, flexor digitorum profundus; FDS, flexor digitorum Ring finger 26 superficialis.