Treatment of Open Hand Fractures in the Emergency Department: Bedside Washout Vs Operative Washout and Infection Risk As a Correlate of Time to Definitive Operative Management

Intro:

Open fractures distal to the carpus are a common indication for hand consultation in the Emergency room[1]. There is little consensus as to the best management of these patients and data obtained from long bone injuries are often utilized in formulating surgical treatment algorithms[2].  

Question:

Is operative washout and debridement of open hand fractures superior to bedside washout and debridement in the Emergency Department (ER)? Does the interval time to definitive operative intervention correlate with infection risk?

Hypothesis:

Operative washout and debridement is not superior to bedside management in the ED. Patients treated definitively earlier will have a lower risk of infection.

Methods:

A retrospective chart review was performed on 303 open fractures distal to the carpus treated at a single institution by the plastic surgery. Patients were identified using a RedCAP trauma database. Patients with devascularizing injuries were excluded. Institutional IRB approval was obtained.

Results:

Of the 303 patients identified, 276 (91%) had a crush mechanism with the remaining either blunt or sharp. Only 3 patients (<1%) went to the operating room (OR) for a washout immediately. 300 patients underwent a bedside washout and debridement. A majority of patients were treated with IV cefazolin ( 57%) and discharged on cephalexin (84%) for an average of 7.29 days. 81 patients (27%) underwent a surgical procedure. Injury patterns for intervention were: 23 patient with distal phalanx(P3) (28%), 7 with middle phalanx (P2) (7%), 15 with proximal phalanx (P1) (19%), 8 with metacarpal (MTC) (10%), 6 with thumb fractures (7%), and 22 with multiple injuries to the hand (27%). The average time to definitive management was 11 days with a median time to surgery of 7 days. Time to surgery, average: P3 13 days, P2 6 days, P1 6 days, MTC 5 days, Thumb 3 days, Multiple 9 days. There were 15 infections in all patients (4.9%), and 10 of these were in operative patients (12% of operative fractures). The average time to surgery in a patient who developed an infection was 5.7 days (range 1-11). On logistical regression analysis there appears to be roughly a 6% increase in the risk of infection each day the patient is delayed from definitive operative management, though this did not reach significance secondary to the overall small number of infections.

Summary:

-Infection rates are similar in patients who undergo bedside washout in the ER as compared to those taken directly to the OR, though few in the study went directly to the OR.

-There appears to be an increased risk of infection the longer it takes for definitive operative management but this did not reach significance secondary to small sample size.

1. Capo J, Hall M, Nourbakhsh A, Tan V, Henry P. Initial management of open hand fractures in an emergency department. American journal of orthopedics (Belle Mead, NJ). 2011;40(12):E243-248.

2. Mauffrey C, Bailey JR, Bowles RJ, et al. Acute management of open fractures: proposal of a new multidisciplinary algorithm. 2012;35(10):877-881.