A prospective study of 245 open digital fractures of the hand

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.

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.

Cold sensitivity, functional disability and predicting factors after a repaired digital nerve injury

To investigate self-reported cold sensitivity and functional disability after a repaired digital nerve injury. We identified 3204 individuals operated with digital nerve repair in the Swedish national quality registry for hand surgery (HAKIR). Patient-reported symptoms, including cold sensitivity and perceived disability, were examined using two questionnaires (HQ-8 and QuickDASH), three and 12 months postoperatively. Patients with diabetes (n = 48; 3%) were identified in the Swedish National Diabetes Register (NDR). Cold sensitivity (scored 0-100) was the most prominent symptom among 1553 included individuals (998 men, 555 women; median age 41 [IQR 27-54] years). In the regression analysis, flexor tendon injury, hand fracture and injury to multiple structures predicted worsened cold sensitivity (6.9, 15.5 and 25.0 points; p = 0.005, 0.046 and < 0.001) at 12 months. Individuals with moderate (30-70) and severe (> 70) cold sensitivity had higher QuickDASH scores at three and 12 months postoperatively than individuals with mild cold sensitivity (6.0 and 5.5; 19.8 and 21.0 points; p = 0.001). Flexor tendon injury, injuries to multiple structures and diabetes had significant effect on QuickDASH scores at three, but not at 12, months postoperatively. Cold sensitivity is common after a digital nerve repair and impacts self-reported disability. A concomitant injury, particularly multiple injuries, predicts postoperative cold sensitivity.

Minimally Invasive Procedure for Correcting Extra-Articular Malunions of Metacarpals and Phalanges

PURPOSE

Extra-articular malunions of metacarpals and phalanges may cause palmar pain, finger scissoring, and splaying, and interfere with function. Current treatment involves open osteotomy and fixation with plates and screws. We present a minimally invasive method using cannulated headless screws for correction of malunions and examine the outcomes in a series of patients.

METHODS

Twenty malunions were operated on in 17 patients. In 16 cases, the malunion involved the metacarpal and in 4 it involved the proximal phalanx. All proximal phalanx and 3 metacarpal malunions were malrotation types, while the rest of the metacarpal malunions were dorsal angulations. The operation consisted of an opening wedge osteotomy in 8 patients; closing wedge osteotomy in 5; and a transverse osteotomy and derotation in the rest. Concomitant surgery to release tendon adhesions or contracted joints or to perform adipofascial flaps was performed in 8 cases. Fixation was achieved by means of a cannulated headless screw. Immediate range of motion was permitted in all cases.

RESULTS

Correction of the malunion and osteotomy union was achieved in all cases. One patient required manipulation of a digit that was found rotated at the first follow-up visit. Eleven fingers achieved more than 280° of total active motion. In 9 digits, the total active motion was less than 280° after the operation, yet improved 76° (range, 140°-30°) from their preoperative total active motion. The mean single-assessment numeric evaluation score for the whole group was 9.1.

CONCLUSIONS

The fixation provided by the cannulated headless screw is sufficient to permit immediate range of motion. Due to the minimal tissue disruption, this approach may be a reasonable alternative to the standard approach.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

"Bi-cortical" periarticular K-wire fixation for displaced unstable transverse extra-articular fractures of the base of the proximal phalanx of the fingers

INTRODUCTION

Management of unstable fractures of the proximal phalanx is a challenge.

OBJECTIVE

The purpose of this study is to introduce to the literature the use of "bi-cortical" periarticular K-wire fixation for displaced unstable transverse extra-articular fractures of the base of the proximal phalanx of the fingers.

PATIENTS AND METHODS

This is a retrospective study of 30 patients with such fractures treated by the author over the last 10 years. Demographic data were collected and surgical complications were documented. The outcome was considered excellent, good, fair and poor if the total active motion of the finger was >260^o, 250^o-259^o, 210^o - 249^o, and <210^o; respectively.

RESULTS

The worst outcome was seen in an elderly patient who sustained multiple fractures and concurrent flexor tendon injury. The remaining 29 patients were relatively young (mean age of 29 years, range = 19 - 42 years) and sustained an isolated single fracture from a fall or a fight. Out of these 29 patients, the outcome was excellent in 27 patients and good in the remaining 2 patients.

CONCLUSIONS

The "bi-cortical" periarticular k-wire fixation is best suited for transverse extra-articular fractures of the base of the proximal phalanx. The wire avoids all joints and hence, early post-operative mobilization is feasible. The technique is simple and obtains a favorable outcome in most patients.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Infections of Deep Hand and Wrist Compartments

The human hand is the most exposed part of the body to highest risk for injuries, loss of the skin integrity, and to the inoculation of bacteria, most commonly Staphylococcus aureus, Streptococcus β-haemolytic, and gram-negative. In case of an infection, the mobile anatomical structures and the synovial membranes in close proximity to each other may spread the pus towards deep spaces and compartments. Mild early infections without an abscess formation may respond to antibiotics, but at more advanced stage, erythema, swelling, stiffness, and severe pain may ensue. Abscess formation will cause debilitating pain, fever, systemic symptoms, and even sepsis. Necrotizing infections may threaten not only the limb, but also patient's life. Therefore, an initially "trivial" hand injury should never be neglected, as it might turn into a deep space infection, which must be treated immediately with drainage, wound debridement, and i.v. antibiotics. Delay in diagnosis and inadequate initial management might rapidly lead to abscess formation, destruction of the gliding surfaces and the normal anatomy, and irreparable functional deterioration.

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.

Infections of the hand: an overview

Infections of the hand are common entities that are frequently encountered by orthopaedic surgeons and primary care physicians.

A high clinical suspicion and a thorough medical history with information about the social and working history of the patients, correct identification of the type and cause of the infection, and prompt initiation of appropriate treatment by the infectious diseases physicians and orthopaedic surgeons are required.

Late diagnosis and inappropriate treatment may be a significant cause of morbidity for the hand and mortality for the patients. This article reviews the clinical spectrum and microbiology of the most common infections of the hand, and discusses the current concepts for their treatment. The aim is to increase the awareness of the treating physicians of the diagnosis and management of infections in the hand.

Cite this article: EFORT Open Rev 2019;4:183-193. DOI: 10.1302/2058-5241.4.180082

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.

Utility of early active motion for flexor tendon repair with concomitant injuries: A multivariate analysis

INTRODUCTION

Flexor tendon injury often occurs with concomitant injuries such as fracture, vascular injury, and extensor tendon injury. These injuries are repaired independently, without a comprehensive strategy. We aimed to identify the effect of concomitant injuries and treatment choice on the outcome of flexor tendon repair.

PATIENTS AND METHODS

We evaluated 118 fingers of 102 adult patients with zone 1-3 flexor digitorum profundus (FDP) tendon injuries who underwent primary surgery at our hospital between April 2009 and December 2017. The 2-strand pull-out, 4-strand Tsuge, 6-strand Lim & Tsai, and 8-strand cross-locked cruciate suturing techniques were used. We performed multivariate analyses, with the active range of motion (AROM) of the proximal interphalangeal (PIP) and distal interphalangeal (DIP) joints as dependent variables, and age, existence of concomitant injuries, and their treatment as independent variables.

RESULTS

The average AROM of the PIP + DIP joints was 130° at the last follow-up, and 'excellent' or 'good' function was obtained in 74 (63%) of 118 fingers by using the Strickland criteria. Old age, concomitant diaphyseal fractures, and specific methods of osteosynthesis, such as pinning, flexor digitorum superficialis injury, and immobilisation for 3 weeks, significantly worsened the results. However, wiring for osteosynthesis and early active motion protocol improved postoperative functional outcome. Although the outcome did not differ among the suture techniques, the 4-strand Tsuge procedure was performed for the two surgically confirmed ruptures of repair that occurred in our series.

DISCUSSION

We clarified the superiority of early mobilisation protocols with rigid osteosynthesis procedure, other than pinning. To minimise tendon adhesion or joint stiffness, surgeons should repair the tendon and fractured bone appropriately, to ensure early mobilisation without serious complications.

Intramedullary Percutaneous Fixation of Extra-Articular Proximal and Middle Phalanx Fractures

Multiple methods have been described for treating unstable proximal and middle phalangeal fractures. Irrespective of using an open or closed technique of fixation, stiffness and extensor lag at the proximal/distal interphalangeal joint almost always occur. This issue can be avoided by allowing the patients to mobilize the fingers out of plaster or splint as early as possible from the day of surgery. We describe a technique of intramedullary percutaneous fixation of extra-articular proximal and middle phalanx fractures allowing immediate mobilization of fingers, concurrent stabilization with progressive healing and thus preventing such complications.

Timing for Surgical Stabilization with K-wires after Open Fractures of Proximal and Middle Phalangeal Shaft

The optimal timing for surgical stabilization after open fractures of proximal and middle phalangeal shaft remained unclear. Total 147 patients with single open fracture in proximal or middle phalangeal shaft (arrived within 8 hours) who received K-wire fixation from June 2012 to June 2015 were included for analysis. The timing for surgical stabilization of fractures (immediate or delayed) was decided according to the surgeons’ preferences. The Michigan hand outcomes questionnaire (MHQ) scores, grip strength and total active motion (TAM) one year after the initial surgery were similar between the two groups. There was no significant difference in the incidence of tenosynovitis, bone nonunion. The overall infection rate in immediate fixation group was slightly but not significantly higher compared with the delayed fixation group (29.2% versus 20.7% P = 0.212). However, patients with both palmar and dorsal wounds who received immediate fixation had much higher infection rate compared with delayed fixation (52.6% versus 22.7%, P = 0.047). The immediate fixation could reduce costs and the period of hospitalization. Open fractures with both palmar and dorsal wounds should be treated with delayed fixation of K-wires otherwise stabilized immediately after injury.

Closed reduction and percutaneous "periarticular" single K-wire fixation for displaced unstable transverse fractures of the proximal phalanx in elderly osteoporotic women: A case series of five patients

•

No literature was found on fractures of the proximal phalanx in osteoporotic women.

•

We present a case series of five patients with 7 fractured fingers.

•

The results were excellent in 5 fingers and good in 2 fingers.

Introduction

A literature review did not reveal any study investigating the results of surgical management of fractures of the proximal phalanx in elderly osteoporotic women. We present a case series of five patients.

Patients and methods

Five consecutive cases with seven fractures of the shaft/base of the proximal phalanx were retrospectively reviewed. The mean age of the study group was 72.4 years (range, 70–76 years). All patients were on treatment for osteoporosis at the time of injury. All patients were treated with closed reduction and percutaneous “periarticular” single K-wire fixation followed by immediate active mobilization of all joints.

Results

Two minor complications were seen: superficial pin tract infection in one case; and slight fracture displacement after K-wire removal resulting in malunion in the other case. After a mean follow-up of 4 months, the total active motion was considered excellent in 5 fingers and good in 2 fingers.

Conclusion

We demonstrate a favorable outcome following closed reduction and percutaneous “periarticular” single K-wire fixation for displaced unstable transverse fractures of the proximal phalanx in elderly osteoporotic women.

Treatment of extra-articular proximal and middle phalangeal fractures of the hand: a systematic review

The aim of the study was to systematically review the patient reported and functional outcomes of treatment for extra-articular proximal or middle phalangeal fractures of the hand in order to determine the best treatment options. The review methodology was registered with PROSPERO. A systematic literature search was conducted in electronic bibliographic databases. Two independent reviewers performed screening and data extraction. The evaluation of quality of the included studies was performed using the Structured Effectiveness Quality Evaluation scale. The initial search yielded 2354 studies. The full text manuscripts of 79 studies were evaluated of which 16 studies met the inclusion criteria. In total, 513 extra-articular proximal and middle phalangeal fractures of the hand were included of which 118 (23%) were treated non-operatively, 188 (37%) were treated by closed reduction internal fixation (CRIF) and 207 (40%) by open reduction internal fixation. It can be recommended that closed displaced extra-articular phalangeal fractures can be treated non-operatively, even fractures with an oblique or complex pattern, provided that closed reduction is possible and maintained. Conservative treatment is preferably performed with a cast/brace allowing free mobilization of the wrist. No definite conclusion could be drawn upon whether closed reduction with extra-articular K-wire pinning or transarticular pinning is superior; however, it might be suggested that extra-articular K-wire pinning is favoured. When open reduction is necessary for oblique or spiral extra-articular fractures, lag screw fixation is preferable to plate and screw fixation. But, similar recovery and functional results are achieved with transversally inserted K-wires compared to lag screw fixation.

Type of study/level of evidence: therapeutic III.

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.

Skeletal Fixation in a Mutilated Hand

Hand fracture fixation in mutilating injuries is characterized by multiple challenges due to possible skeletal disorganization and concomitant severe injury of soft tissue structures. The effects of skeletal disruption are best analyzed as divided into specific locales in the hand: radial, ulnar, proximal, and distal. Functional consequences of injuries in each of these regions are discussed. Although a variety of implants are now in vogue, K-wire fixation has stood the test of time and is especially useful in multiple fracture situations. Segmental bone loss is quite common in such injuries, which can be safely reconstructed in a staged manner.

Prophylactic antibiotics in open distal phalanx fractures: systematic review and meta-analysis

A systematic review was conducted on 30 December 2014 to determine whether prophylactic antibiotics reduce the risk of superficial infection and osteomyelitis following open distal phalanx fractures. Four randomized controlled trials (353 fractures) were suitable for meta-analysis. There was no statistically significant difference between rates of superficial infection in the two groups. This finding persisted when only the two most recent and highest quality trials were included. There were no reported cases of osteomyelitis in the pooled dataset, despite patients with 164 fractures not receiving antibiotics. These results fail to show any effect of prophylactic antibiotics on the rate of superficial infections following open distal phalanx fractures. The focus of treatment should be on prompt irrigation and debridement rather than administration of prophylactic antibiotics.

Management of complications with hand fractures

Both operative and nonoperative treatment of hand fractures can result in numerous complications, including stiffness, malunion, nonunion, arthritis, infection, and complex regional pain syndrome. These complications are frequently encountered and are often challenging to treat. This article systematically outlines the diagnosis and treatment of each of these complications to achieve the best possible outcome for the patient's overall hand function.

Minimally invasive fixation of fractures of the phalanges and metacarpals with intramedullary cannulated headless compression screws

PURPOSE

To present the technique, indications, and outcomes of metacarpal and phalangeal fractures fixed with intramedullary cannulated headless screws (CHS).

METHODS

We retrospectively reviewed all charts of patients whose metacarpal and phalangeal fractures had been treated with intramedullary CHS in our practice. A total of 69 fractures (48 metacarpal and 21 phalangeal) were identified in 59 patients. Seventeen were open fractures. Eleven patients had multiple fractures (29 in total); of those, 21 were managed with CHS. In 4 other fractures the method was abandoned intraoperatively. The defect created by the entrance of the screw in the proximal phalanx was identified by computed tomography in 20 patients.

RESULTS

In 63 fractures a single screw was used; in 6 fractures 2 screws were used to provide stronger fixation. All patients returned to full duties or sport activities at an average of 76 days (range, 3 wk to 15 mo). At the latest follow-up (range, 5-54 mo; average, 19 mo) total active motion was on average 247° (range, 150° to 270°) for all fractures, 249° (range, 210° to 270°) for metacarpal, and 243° (range, 150° to 270°) for proximal phalangeal fractures. All fractures were healed and within acceptable radiological parameters. A comminuted basilar phalangeal fracture displaced secondarily yielding a poor functional result. Two patients required tenolysis and further procedures before the final result was achieved. The screw hole represents around 20% of the proximal phalanx distal articular surface.

CONCLUSIONS

Unstable transverse fractures in the phalanx and metacarpal are amenable to single intramedullary CHS fixation. Comminuted fractures require more complex configurations.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Metacarpal fractures: treatment and complications

Metacarpal fractures comprise between 18-44 % of all hand fractures. Non-thumb metacarpals account for around 88 % of all metacarpal fractures, with the fifth finger most commonly involved [19]. The majority of metacarpal fractures are isolated injuries, which are simple, closed, and stable. While many metacarpal fractures do well without surgery, there is a paucity of literature and persistent controversy to guide the treating physician on the best treatment algorithm. The purpose of this article is to review non-thumb metacarpal anatomy and treatment protocols for nonoperative management of stable fractures, and compare existing literature on surgical techniques for treatment of acute fractures and complications.

Open fractures of the hand with soft tissue loss

The evaluation, initial treatment, and definitive reconstruction of open fractures of the hand with associated soft tissue loss are reviewed. Specific attention is given to the literature on open fracture antibiotic prophylaxis in the hand; the timing of bone and soft tissue reconstruction; and options for soft tissue coverage, including local, regional, and distant tissue transfer. Factors that have shown association with outcomes in these injuries are also discussed, and the authors' preferred management is summarized.

Complications of hand fractures and their prevention

Regardless of the clinician's technical skill, the results of hand fracture treatment may not be optimal. Tissue planes are damaged by the initial trauma, and surgical approaches to restore bony anatomy or develop tendon gliding further violate them with scarring producing adhesions and motion deficits. Close communication with therapists may help reduce complications. Identification and prompt treatment of these complications may allow improved function. However, repeat surgery may be necessary to improve the results. It is critical to work with the patient to match expectations and to minimize frustration of both the patient and the surgeon.

Predictors of the postoperative range of finger motion for comminuted periarticular metacarpal and phalangeal fractures treated with a titanium plate

BACKGROUND

Plate and screw fixation was introduced for complex fractures of the hand. Several risk factors for a poor functional outcome have been identified, but there is a paucity of evidence regarding predictors of finger stiffness in difficult hand fractures. The purpose of this prospective cohort study was to identify independent prognostic factors of the postoperative total active motion (%TAM) in the treatment of metacarpal and phalangeal fractures.

METHODS

Seventy-two patients (62 males, 10 females; 37±15 years) with periarticular fractures involving metaphyseal comminution and displacement were evaluated at a minimum of 1 year following surgery. There were 49 phalangeal bone fractures, 30 intra-articular fractures and 20 associated soft-tissue injuries. The locations of plate placement were lateral in 42 patients and dorsal in 30. The mean duration from injury to surgery was 7.6 days (range, 0-40 days). There were eight examined variables related to patient characteristics (age, gender and hand dominance), fracture characteristics (fracture location, joint involvement and associated soft-tissue injury) and surgical variables (location of plate placement and duration from injury to surgery). Univariate and multivariate linear regression analysis were used to identify the degree to which variables affect %TAM at the final follow-up.

RESULTS

Univariate analysis indicated moderate correlations of %TAM with fracture location, associated soft-tissue injury and age. Multiple linear regression modelling including fracture location, age and associated soft-tissue injury resulted in formulae that could account for 46.3% of the variability in %TAM: fracture location (β=-0.388, p<0.001), age (β=-0.339, p<0.001) and associated soft-tissue injury (β=-0.296, p=0.002).

CONCLUSION

Phalangeal fracture, increasing age and associated soft-tissue injury were important risk factors to identify the postoperative %TAM in the treatment of comminuted periarticular metacarpal or phalangeal fracture with a titanium plate.

Extraarticular fractures of the middle phalanx with no associated tendon injury or extensive skin loss: the "soft-tissue crush" as a prognostic factor

According to Chow et al's classification, type I fractures of the middle phalanx have no associated tendon injury or extensive skin loss, which required reconstruction. Despite the favorable soft-tissue conditions, a rate of poor outcome as 25% has been observed, and the reason for this is unknown. The aim of this study is to test our hypothesis that type I fractures may be subclassified into following 2 types: type IA and type IB, based on the absence or presence of concurrent significant "soft-tissue crush," respectively. Type IB fractures are hypothesized to have a worse outcome. Significant soft-tissue crush is diagnosed clinically by the presence of severe swelling and/or superficial skin injury (not requiring reconstruction). In a prospective study, 29 type I extraarticular fractures of the middle phalanx in adult industrial workers were included and classified into the following 2 groups: type IA (n = 16 fingers) and type IB (n = 13 fingers). All were treated with closed reduction and longitudinal Kirschner wire fixation. The outcome in range of motion was measured, and time to return to work was recorded. At final follow-up, the mean total active motion of the injured fingers was 241.3 degrees in group IA and 186.9 degrees in group IB (P < 0.001 by Mann-Whitney U test). Furthermore, group A patients returned to work earlier than group B (15.1 vs. 26.8 weeks, P < 0.001 by Mann-Whitney U test). It was concluded that severe swelling and superficial skin injury significantly affect the outcome of type I extraarticular fractures of the middle phalanx treated by closed reduction and longitudinal Kirschner wire fixation.

Stainless Steel 2.0-mm Locking Compression Plate Osteosynthesis System for the Fixation of Comminuted Hand Fractures in Asian Adults

Objective

The aim of this retrospective study was to analyse the clinical outcome of the application of stainless steel 2.0-mm locking compression plate (LCP) system for the treatment of comminuted hand fractures in Asian adults.

Methods

Six patients who had comminuted hand fractures were treated by open reduction and internal fixation with the application of stainless steel 2.0-mm LCP (AO Compact Hand System; Synthes, Oberdorf, Switzerland) from December 2009 to October 2010. The total arc of motion of fingers, grip power, complications, and additional surgery were recorded.

Results

Three out of six patients eventually restored good hand functions in terms of the total arc of finger motion (>220°) and grip power. The commonest complication was skin impingement in finger region by the implant (4 cases). Another common complication was restricted range of motion (3 cases). One patient had minimal degree of malrotation of his left little finger. Additional surgery was required in all the patients for implant removal (6 cases), tenolysis (3 cases), and capsulotomy (2 cases).

Conclusions

The stainless steel 2.0-mm LCP is useful for the fixation of unstable comminuted hand fractures, especially in metacarpal bones, because of its advantage of better stability, which allows more aggressive rehabilitation. However, its design is not very versatile and, therefore, limits its use in the finger region. Its bulkiness frequently causes implant impingement. The patients must be informed about the chance of implant removal later.

Principles in the management of a mangled hand

Mangling hand injuries are high energy complex conditions that are challenging to manage. They require careful planning and meticulous execution of treatment. A clear set of anatomical and functional goals at the outset guides the planning. The first surgery is crucial to ensure good vascularity to the salvaged tissue, prevent infection and achieve bony stabilization. Re-look surgery and definitive reconstruction can then follow. Post-operative therapy is an important component of treatment. Despite best efforts, outcomes are variable in these devastating injuries. Secondary procedures and provision of prostheses will do much to improve the patient's body image and limb function. This article provides a set of principles that will guide the assessment and treatment of such injuries.

Prediction of hand strength by hand injury severity scoring system in hand injured patients

PURPOSE

Hand strength is a key component in human hand function, especially to those with strength-required jobs. To evaluate post-injury hand strength, this study was conducted to assess the predictability of hand injury severity scoring (HISS) system to hand strength after a period of recovery.

METHODS

In this retrospective study, 80 traumatic hand-injured subjects were recruited. Hand strength tests measured by dynamometers were performed by subjects in ways of palmar pinch, lateral pinch and cylindrical grip. The logistic regression models were used to evaluate the risk of poor hand strength among the severities represented by HISS scores.

RESULTS

A positive correlation exists between the differences of the strength of two hands, and the severity shown by HISS system in the poorer half of subjects. The risk to be in poorer half of palmar pinch subtest is significant in moderate subgroup of HISS severity. The risk to be in poorer half of cylindrical grip subtest is significant in major subgroup of HISS severity. The risk to be in poorer half of palmar pinch and cylindrical grip subtests is significant in skeletal component of HISS system.

CONCLUSIONS

HISS is a descriptive severity scoring system to hand injury and also a useful instrument to predict functional outcome. This study revealed the HISS system may predict post-injury hand strength after recovery.

Displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers in industrial workers: reduction and K-wire fixation leaving the metacarpophalangeal and proximal interphalangeal joints free

A series of 35 adult male industrial workers with displaced unstable transverse fractures of the shaft of the proximal phalanx of the fingers were treated with reduction and K-wire fixation leaving the metacarpophalangeal and interphalangeal joints free to move immediately after surgery. At final follow-up, the total active motion score of the injured finger was graded as excellent, good, fair, or poor if it was greater than 240°, 220-240°, 180-219°, or less than 180°, respectively. Complications were also documented. The results were compared with our previously published series of these fractures treated with two other techniques: percutaneous K-wires immobilizing the metacarpophalangeal joint and open reduction and interosseous loop wire fixation. The final TAM scores in the current study were excellent in 43%, good in 29%, fair in 14% and poor in 14%. Four out of the 35 patients (11%) had minor pin tract infection. These results were significantly better than the results following percutaneous K-wire fixation immobilizing the metacarpophalangeal joint indicating that immediate mobilization of all joints has a significant effect on the outcome.

[Algorithms for treatment of complex hand injuries]

BACKGROUND

The primary treatment strongly influences the course and prognosis of hand injuries. Complex injuries which compromise functional recovery are especially challenging. Despite an apparently unlimited number of injury patterns it is possible to develop strategies which facilitate a standardized approach to operative treatment. In this situation algorithms can be important guidelines for a rational approach.

MATERIAL AND METHODS

The following algorithms have been proven in the treatment of complex injuries of the hand by our own experience. They were modified according to the current literature and refer to prehospital care, emergency room management, basic strategy in general and reconstruction of bone and joints, vessels, nerves, tendons and soft tissue coverage in detail.

CONCLUSIONS

Algorithms facilitate the treatment of severe hand injuries. Applying simple yes/no decisions complex injury patterns are split into distinct partial problems which can be managed step by step.

Complications after the fractures of metacarpal and phalanges

Fractures of the metacarpals and phalanges represent 40% of all upper extremity fractures. Complications associated with these fractures are also prevalent, and can arise with both conservative and surgical treatment of hand fractures, making treatment of complications an essential part of caring for these injuries. In this article the treatment of complications associated with open fractures and infection are reviewed, in addition to current treatment options for malunion and stiffness.

Complications after flexor tendon injuries

Management of flexor tendon injuries is one of the most demanding tasks in hand surgery. Despite substantial improvements in surgical technique and postoperative rehabilitation protocols, functional outcomes may still be somewhat unreliable. In the present article, the authors present complications encountered after flexor tendon repair and provide their preferred methods of prevention and treatment.

Postoperative infections: prevention and management

Postoperative infections continue to be a challenging problem. The incidence of bacterial antibiotic resistance such as methicillin-resistant Staphylococcus aureus is rising. There are numerous intrinsic patient factors that should be optimized before surgery to minimize the risk of surgical site infections. When postoperative infections develop, treatment must be individualized. This article outlines the principles that can help guide treatment.

Ten years stable internal fixation of metacarpal and phalangeal hand fractures-risk factor and outcome analysis show no increase of complications in the treatment of open compared with closed fractures

BACKGROUND

: Stable internal screw/plating systems for hand fractures have evolved during the last 20 years. The improved versatility leads to the increased use of these materials in open fractures, with the benefit of early mobilization. The aim of this retrospective study is to discern whether the broadening of the indications for these implants is accompanied by increased complication rates.

METHODS

: Data from 365 patients treated during the last 10 years at our department for metacarpal or phalangeal fractures with stable internal fixation by screw or plate were gathered and analyzed.

RESULTS

: Uneventful bony consolidation was observed in 91.2% (n = 333). The functional results were excellent to acceptable in 85.2%, whereas in 14.8% (n = 54), the result was unsatisfactory, the latter group presenting with concominant soft tissue injury. There was no statistically significant difference in infection and nonunion rates when comparing open and closed fractures.

CONCLUSION

: These results confirm that most patients with open metacarpal and phalangeal fractures can be treated by stable internal fixation.

Hand infections

Hand infections are very common and must be properly diagnosed and treated to minimize the potentially devastating functional complications. Acute hand infections include felon, paronychia, deep-space infections, septic arthritis, osteomyelitis, and necrotizing fasciitis. Chronic infections are usually caused by atypical mycobacteria and fungi. There are several conditions that mimic acute hand infections, and it is important to recognize them so that the appropriate treatment can be instilled. To prevent all these complications and poor outcome, prompt diagnosis and early institution of appropriate surgical management and antibiotic treatment are crucial.

Factors associated with infection following open distal radius fractures

Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone fractures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twenty-four fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p = 0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the initial plan not based upon subsequent development of an infection.

Functional outcome after surgical treatment of phalangeal fractures in severely injured hands

We assessed functional results after treatment of phalangeal fractures in severely injured hands. Our aim was to quantify digital functional loss with (combinations of) risk factors of unsatisfactory function. Patients who had multiple phalangeal fractures necessitating operation in a 10-year time period were tested, using measurements of total active movement. Seventy-eight patients with 228 phalangeal fractures were available for follow-up. In 88 fingers, the fractures ended in amputation and were excluded from the study. In the resulting 140 fractures, 74 (53%) had a good result (movement >180degrees for fingers 2-5, and >98degrees for the thumb), and 66 (47%) in an unsatisfactory result. Associated soft tissue injury, level of injury, and arthrodesis were risk factors for diminished function. Intra-articular fractures and multiple fractures within the same finger predisposed to arthrodesis. Despite the extensive and severe injuries more than half had good results, which is comparable with reports describing hand injuries with less extensive trauma.

Prediction of hand function after occupational hand injury by evaluation of initial anatomical severity

PURPOSE

To examine the relationship between initial anatomic severity evaluated by the Hand Injury Severity Scoring (HISS) system and recovered hand function evaluated by the Purdue Pegboard after occupational hand injury.

METHOD

In the retrospective cohort study, 95 patients hospitalized between 1 January 2000 and 31 December 2003 for surgery due to occupational hand injury were recruited. The HISS scores were obtained by chart review by a surgeon. The Purdue Pegboard was performed at least 6 months after the injury by well-trained occupational therapists. The Purdue Pegboard scores were compared with the initial HISS scores by simple regression, multiple regression and logistic regression analysis.

RESULTS

The total HISS score was negatively correlated with scores of the Purdue Pegboard subtests, including injured-hand, both-hands, and assembly. The risk of having low injured-hand score (<13) was significantly increased in workers with initial major severity (HISS >or= 101), with OR 9.57 (95% CI 1.4-94.8). The risk of having low both-hands score (<10) was significantly increased in workers with initial severe and major severity (HISS of 51-100 and >or=101), with OR 4.5 (95% CI 1.1-21.8) and OR 25 (95% CI 3.5-263). The risk of having low assembly score (<25) was significantly increased in workers with initial major severity (HISS >or= 101), with OR 9.0 (95% CI 1.3-72.5).

CONCLUSION

The study showed that after occupational hand injury, initial anatomic severity evaluated by the HISS system could predict hand function after recovery.

Prospective outcomes of comminuted periarticular metacarpal and phalangeal fractures treated using a titanium plate system

PURPOSE

The purpose of this study was to prospectively evaluate clinical results for open reduction and internal fixation of unstable metaphyseal fractures of the metacarpal and phalangeal bones using a miniature titanium plate.

METHODS

Fifty-one consecutive patients with periarticular fractures with metaphyseal comminution and displacement were enrolled. Intra-articular involvement with a split or depression fracture was identified in 22 hands. Minimum follow-up was 1 year. There were 37 male and 14 female patients; average age was 38 years (range, 14-63). Of the 51 fractures, 15 were open; 8 of these had additional soft tissue injury, involving neurovascular injury in 4 and extensor tendon injury in 6. The average duration from injury to surgery was 6 days (range, 2-40 days).

RESULTS

Bone union was successfully achieved in all patients over an average period of 2.6 months. The final range of total active motion (%TAM) was excellent (>85%) for 26, good (70%-84%) for 17, fair (50%-69%) for 5, and poor (<49%) for 3. Postoperative complications occurred in 5 patients, including fracture redisplacement in 2, a collapse or absorption of the condylar head in 2, and superficial infection due to hardware exposure in one. Subsequently, 2 of these patients had malrotation deformities or osteoarthritic changes in the injured finger. Plates were removed in 30 cases, and additional surgery was required in 20 cases. Postoperative grip strength averaged 87% of the contralateral side. Statistical analysis revealed that patient age was significantly correlated with %TAM of the injured finger at 1-year follow-up (p < .01), and intra-articular (p < .05) and phalangeal bone (p < .01) involvement, as well as associated soft tissue injury (p < .05), significantly affected the range of finger motion.

CONCLUSIONS

Despite the technical demands of plating for comminuted metacarpal and phalangeal fractures, the low-profile titanium plate system was highly effective in maintaining anatomic reduction. The postoperative complication rate was relatively low, and the objective outcomes approached a reasonable level at 1-year follow-up.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic IV.

Hand fractures and their management: an international view

Fractures of the bones of the hand are among the commonest fractures in humans, but their management varies widely in the different regions of the world. This variability is due to many reasons, including availability of resources, social factors, geographic constraints, surgeon preference and experience, and local practice patterns. Developing countries are more likely to apply less expensive methods of managing hand fractures. The treatment of these injuries will fall somewhere along a continuum that parallels the historical development of hand fracture management. This paper will review the history of phalangeal and metacarpal fracture management to infer global differences in the treatment of hand fractures. An overview of how different health care systems are likely to manage these injuries will assist health care providers in choosing the most appropriate treatment method.

Cerclage-wiring-assisted fixation of difficult hand fractures

Difficult hand fractures with multiple butterfly fragments, multiple cortical splits or intraarticular extension continue to pose a challenge for optimal stable fixation that allows early postoperative mobilisation. In this study, we describe the use of cerclage-wire-assisted fixation of 17 difficult hand fractures in 16 patients. The cerclage wires helped to maintain the reduction, so providing sufficient initial stability for placement of a plate and screws. Stable fixation of the fracture was then accomplished without losing the reduction. One to three cerclages of stainless-steel wires were used for the preliminary fixation. Stable fixation was then accomplished by a bridging or neutralising plate technique. Postoperatively, the fixation was sufficiently stable to allow immediate mobilisation. With an average follow up of 44.5 months, all 17 fractures united without loss of reduction. At final follow-up, the average total active range of motion was 247 degrees (range 220-260 degrees ).

Complications after treatment of flexor tendon injuries

The goals of flexor tendon repair are to promote intrinsic tendon healing and minimize extrinsic scarring in order to optimize tendon gliding and range of motion. Despite advances in the materials and methods used in surgical repair and postoperative rehabilitation, complications following flexor tendon injuries continue to occur, even in patients treated by experienced surgeons and therapists. The most common complication is adhesion formation, which limits active range of motion. Other complications include joint contracture, tendon rupture, triggering, and pulley failure with tendon bowstringing. Less common problems include quadriga, swan-neck deformity, and lumbrical plus deformity. Meticulous surgical technique and early postoperative tendon mobilization in a well-supervised therapy program can minimize the frequency and severity of these complications. Prompt recognition of problems and treatment with hand therapy, splinting, and/or surgery may help minimize recovery time and improve function. In the future, the use of novel biologic modulators of healing may nearly eliminate complications associated with flexor tendon injuries.

Low-severity metacarpal and phalangeal fractures treated with miniature plates and screws

INTRODUCTION

The results reported in the literature of metacarpal and phalangeal fractures treated with miniature plates and screws are scarce and contradictory. The aim of our study was to evaluate the functional results after low-severity metacarpal and phalangeal fractures treated by miniature plates and screws.

MATERIALS AND METHODS

We retrospectively reviewed 44 patients of a consecutive series with 56 low-severity metacarpal and/or phalangeal fractures stabilized with miniature plates and screws with a mean follow-up of 24 months to assess objective and subjective outcomes and complications. The objective assessment included measurement of the range of motion (ROM) of the involved finger, prehension, sensory function and strength. The subjective evaluation assessed the impairment and pain felt by the patient.

RESULTS

At the final check-up, average total active movement of the involved digit was 256 degrees (range 175 degrees -260 degrees ), and average score for prehension was 49.3 (range 30-50), with 41 patients with a full score. The Jamar test pointed to a significant reduction in grip strength (-5.2%) of the injured hand compared with the other hand. Average subjective impairment score for all the fractures was 15.5 (range 10-16), with 39 patients having a score between 16 and 14 (no impairment). Fracture reduction was anatomic in 42 fractures (75%), satisfactory in 11 (19.6%) and unsatisfactory in 3 (5.4%). There were no contractures, non-unions, infections or tendon ruptures. Twenty patients (45%) presented with one or more complications in 23 fractures (41.1%).

CONCLUSION

These very favourable results suggest that miniature plates and screws are a possible choice in the treatment of these fractures.

The use of prophylactic flucloxacillin in treatment of open fractures of the distal phalanx within an accident and emergency department: a double-blind randomized placebo-controlled trial

Open fractures of the distal phalanx commonly present to the Accident and Emergency Department. Controversy surrounds the use of prophylactic antibiotics in treating this injury. A double-blind, prospective, randomized placebo-controlled study was undertaken comparing the use of prophylactic flucloxacillin to placebo in addition to meticulous wound toilet. One hundred and ninety-three adult patients with an open fracture of the distal phalanx were studied. Seven patients developed superficial infections, an overall infection rate of 4%. No patient developed osteitis or a deep wound infection. There were three cases of infection in the 98 patients (3%) in the antibiotic group and four cases of infection in the 95 patients (4%) in the placebo group. A difference of proportion test confirmed no significant difference. It is concluded that the addition of prophylactic flucloxacillin to thorough wound toilet and careful soft-tissue repair of open fracture of the distal phalanx confers no benefit.

Secondary procedures following mutilating hand injuries

Mutilating hand injuries result in injury to multiple anatomic structures, which increases the possibility that secondary procedures or staged reconstruction will be necessary. Secondary procedures often are required to provide stable wound coverage, restore sensation, provide bony stability, increase range of motion, or allow prehension, all of which are performed to improve hand function. The patient, the surgeon, and the therapist must all work together to achieve the best functional result following a severe mutilating hand injury.

Fracture fixation in the mutilated hand

Early anatomic (or near anatomic; lingers do not impinge or overlap during flexion or extension) stable fracture fixation provides the foundation for successful wound management and for the repair, reconstruction, and healing of all damaged tissues in a mutilating hand injury. It also plays an instrumental role in pain control and affords an optimal opportunity for timely and favorable rehabilitation of and recovery from mutilating injuries of the hand. Kirschner or other wiring systems or mini external fixators may be used for simple fractures, in children, when rapid fracture fixation is necessary, and for provisional fracture fixation. Mini plates should be considered for fractures with comminution or loss and in instances of multiple fractures. Fingers with segmental injury of three or more tissues should be considered for early amputation to avoid prolonged and impaired recovery of the hand. Every effort should be made to preserve the thumb and its function by repair or reconstruction.