gms | German Medical Science

Objectives/Interrogation: We hypothesized that surgical debridement may be delayed up to one week from the time of injury for open fractures of the hand and carpus without increased risk of infection or secondary procedure.

Methods: We conducted a retrospective review of patients seen at our tertiary upper extremity referral center for open fractures from the carpus distally over a 6-year interval. Records were queried for patient demographic information, injury history, initial management and operative findings. The primary outcomes of interest were incidence of infection and need for additional surgery. Numerical outcomes were compared using independent t-testing and categorical outcomes with Fisher's exact testing.

Results: A total of 284 patients with a mean age of 43 ± 17 years were included. The mean BMI for the cohort was 27.1 ± 5.4 and included 79.2% males, 4.7% diabetics, 26.7% smokers, and 33.9% with associated workers' compensation claims. All patients underwent bedside irrigation and debridement at the time of their initial presentation to the emergency department. The three most common mechanisms of injury were crush (46.6%), saw (20.8%), and traumatic amputation (9.7%). The median time interval from injury to surgery was 4 days (range, 0 to 34). The three most common methods for fracture stabilization were K-wire fixation alone (50.7%), splinting (41.4%), and plate and screw fixation (4.0%).

Complications occurred in 16 patients (6%), including 4 patients (1.4%) who developed infection. Two infections required debridement and two were successfully treated with oral antibiotics. Revision of nonunion, unplanned revision amputation for wound issues, and tenolysis for stiffness were each required in 3 patients. The most common planned revision surgeries were for coverage of soft-tissue defects (skin grafting in 5, local flaps in 4). Diabetes was the lone factor predictive of complications (complication rate = 18.8% in diabetics vs. 3.9% in non-diabetics; Fisher's exact P = 0.033). Time interval from injury to initial surgery was not significantly different for the patients who developed complications (mean 4.9 ± 5.6 days) vs. those who did not (mean 5.3 ± 6.0 days; P = 0.78).

Summary: Delayed treatment of open hand/wrist fractures does not lead to increased incidence of infection or complications. Diabetics with open hand/wrist fractures are at greater risk for developing postop complications. Revision surgery is most likely to be required for issues related to wound healing and coverage.