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

Prophylactic antibiotic use for penetrating trauma in prolonged casualty care: A review of the literature and current guidelines

ABSTRACT

Prolonged casualty care (PCC), previously known as prolonged field care, is a system to provide patient care for extended periods of time when evacuation or mission requirements surpass available capabilities. Current guidelines recommend a 7- to 10-day course of ertapenem or moxifloxacin, with vancomycin if methicillin-resistant Staphylococcus aureus is suspected, for all penetrating trauma in PCC. Data from civilian and military trauma have demonstrated benefit for antibiotic prophylaxis in multiple types of penetrating trauma, but the recommended regimens and durations differ from those used in PCC, with the PCC guidelines generally recommending broader coverage. We present a review of the available civilian and military literature on antibiotic prophylaxis in penetrating trauma to discuss whether a strategy of broader coverage is necessary in the PCC setting, with the goal of optimizing patient outcomes and antibiotic stewardship, while remaining cognizant of the challenges of moving medical material to and through combat zones. Empiric extended gram-negative coverage is unlikely to be necessary for thoracic, maxillofacial, extremity, and central nervous system trauma in most medical settings. However, providing the narrowest appropriate antimicrobial coverage is challenging in PCC because of limited resources, most notably, delay to surgical debridement. Antibiotic prophylaxis regimen must be determined on a case-by-case basis based on individual patient factors while still considering antibiotic stewardship. Narrower regimens, which focus on matching up the site of infection to the antibiotic chosen, may be appropriate based on available resources and expertise of treating providers. When resources permit in PCC, the narrower cefazolin-based regimens (with the addition of metronidazole for esophageal or abdominal involvement, or gross contamination of central nervous system trauma) likely provide adequate coverage. Levofloxacin is appropriate for ocular trauma. Ideally, cefazolin and metronidazole should be carried by medics in addition to first-line antibiotics (moxifloxacin and ertapenem, Literature Synthesis and Expert Opinion; Level V).

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.

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.

Clinical Characteristics and Treatment Patterns of Open Hand Fractures in the Pediatric Population

BACKGROUND

Open hand fractures are one of the most common injuries in the pediatric population. These injuries are at higher risk of infection, especially in cases of frank contamination. Several studies on adult hand fractures are available in the literature; however, pediatric open hand fractures have yet to be extensively studied. This study aimed to define pediatric open hand fracture's demographics, clinical characteristics, and treatment patterns.

METHODS

Using the Protected Health Information database, pediatric patients (<18 y old) with the diagnosis of open hand fracture from June 2016 to June 2018 were extracted. Demographic, treatment, and follow-up data were collected. Clinical outcomes included readmission and postoperative infection rates.

RESULTS

There were a total of 4516 patients who met the inclusion criteria; the median age was 7 years (interquartile range: 3 to 11); 60% males; 60% white. Displaced fractures occurred in 74% of patients, with the right hand (52%) and middle finger (27%) predominance. The most common mechanism of injury was a crushing injury in-between objects (56%). Associated nerve injury occurred in 78 patients (4%) and vascular injury in 43 patients (2%). Open reduction and internal fixation were performed in 30% of patients. Cephalosporins were the most commonly prescribed antibiotics (73%), followed by aminopenicillins (7%). Nine patients had complications related to surgical intervention (0.2%), and postoperative infection occurred in 44 patients (1%).

CONCLUSIONS

Pediatric open hand fractures most often occur during childhood and more frequently in males. These fractures tend to be more distal and displaced; reduction and fixation are required in one-third of the cases. Despite the absence of treatment guidelines and variability, this injury exhibits low complication rates.

LEVEL OF EVIDENCE

Level III, retrospective study.

Open fractures of the upper limb - do the BOAST guidelines need an update?

AIMS

This scoping review aims to explore the published literature on the current management strategies and outcomes of open upper limb injuries using the BOAST 4 guidelines as a structure.

MATERIALS AND METHODS

A comprehensive search of the MEDLINE, EMBASE, Cochrane and OrthoSearch computerised literature databases (from January 2012 through April 2022) was performed. The medical subject headings used were "open fracture"/ "Gustilo Anderson" and "forearm" or "radius" or "ulna" or "elbow" or "humerus" or "clavicle" or "shoulder" or "scapula". Abstract titles were reviewed for relevance. If the article was deemed eligible, the article was retrieved and reviewed in full.

RESULTS

The literature reveals lower rates of infection for upper limb injuries compared to their lower limb counterparts. Early antibiotic administration remains a key component of their management. Those without significant soft tissue injury (Gustilo Anderson 1) can often be treated as per their closed counterparts and timing to definitive fixation can be safely delayed in selected cases.

DISCUSSION

There is limited high quality evidence available on the management of open upper limb injuries with guidelines built on borrowed principles from the more studied open tibia fractures. What the available evidence does show is that with lower infection rates and a more forgiving soft tissue envelope it may be safe to diverge from the current BOAST guidelines in certain cases. This has relevance in complex fracture patterns requiring specialist input where it is not possible to achieve definitive fixation in 72 h and when there are other life threatening injuries to manage. Despite this early antibiotic administration and debridement within 24 h remains a key component of the early management.

Outcomes of Primary Volar Locking Plate Fixation of Open Distal Radius Fractures

Background: Few studies have reported the outcomes of primary volar locking plate fixation in Gustilo and Anderson type II and IIIA open distal radius fractures. We report the outcomes of treatment of Gustilo and Anderson type II and IIIA open distal radius fractures using primary volar locking plate fixation. Methods: We retrospectively reviewed 24 patients with open distal radius fractures who were treated using primary volar locking plate fixation. The range of motion (ROM) and modified Mayo wrist scores were measured to assess functional outcomes. Radiological outcomes included the bone union period, radial inclination, volar tilt, radial length and ulnar variance. Results: Functional outcomes, including mean ROM in flexion (39.1°) and extension (52.5°), improved following primary volar locking plate treatment. Radiological outcomes were as follows. Mean bone union period, radial length and ulnar variance were 7.8 months, 10.4 and 0.7 mm, respectively. Two patients had superficial wound infection 2 weeks after surgery and one patient had non-union of the radius that required implant removal, autologous iliac crest bone graft and plate re-fixation. Conclusions: Primary volar locking plate fixation is a safe and reliable treatment option for Gustilo and Anderson type II and IIIA open distal radius fractures. By providing firm stabilisation and allowing early ROM exercise, primary volar locking plate fixation resulted in good functional and radiological outcomes. Level of Evidence: Level IV (Therapeutic).

Management of a mutilated hand: the current trends

Mutilated upper limbs suffer loss of substance of various tissues with loss of prehension. The most important factor in salvage of a mutilated hand is involvement of a senior surgeon at the time of initial assessment and debridement. A regional block given on arrival helps through assessment and investigations in a pain-free state. Infection still remains the important negative determinant to outcome and is prevented by emergent radical debridement and early soft tissue cover. Radical debridement and secure skeletal stabilization must be achieved on day one in all situations. Dermal substitutes and negative pressure wound therapy are increasingly used but have not substituted regular soft tissue cover techniques. Ability to perform secondary procedures and the increased use of the reconstructed hand with time keeps reconstruction a better option than prosthesis fitting. Toe transfers and free functioning muscle transfers are the two major secondary procedures that have influenced outcomes.

Traumatized Hand - Update at the First Visit

The hand is the segment most exposed to trauma, with a large volume of care in urgent and emergency services. Therefore, it is necessary that physicians on duty have the essential knowledge to effectively manage these injuries. In the present article, we will review the main conditions and conduct guidelines.

Postoperative Digit and Hand Replantation Protocols: A Review of the Literature

Successful replantation and revascularization of the hand and digit require a skilled team with urgent access to an operating room with microsurgical capabilities. Although careful indications and surgical techniques contribute to success, postoperative management also plays a vital role in the survival of a replanted digit. Previous research has assessed surgical efficiency and techniques to conduct these procedures, but few studies evaluate postoperative protocols to care for patients undergoing these procedures. Because of the lack of high-level evidence specific to replantation, many common postoperative practices related to monitoring, anticoagulation, and diet have been inferred from elective microsurgical procedures, despite notable differences in operating conditions. The highest level of evidence pertaining to digital replantation was found with the use of peripheral nerve blockade, leeching/bleeding, and nicotine use. This review provides an in-depth evaluation of the literature and insight into the rationale and level of evidence that support each postoperative intervention. It highlights institutional variability and a paucity of high-level evidence pertaining to this topic while identifying the areas of future research.

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.

Clinical Correlation of the Orthopaedic Trauma Association Open Fracture Classification With Wound Closure and Soft-Tissue Complications in Open Upper Extremity Fractures

OBJECTIVES

To correlate domains of the Orthopaedic Trauma Association Open Fracture Classification (OTA-OFC) in open upper extremity injuries with type of definitive soft-tissue closure, complication rates, and unanticipated return to the operating room for complication.

DESIGN

Retrospective review of prospectively collected data.

SETTING

Level I trauma center.

PATIENTS

Two hundred thirty-four consecutive open upper extremity fractures.

INTERVENTION

Operative management of open upper extremity fractures.

MAIN OUTCOME MEASUREMENTS

Type of definitive closure, 90-day wound complication, and wound complication necessitating return to the operating room.

RESULTS

Two hundred eighty injuries were identified, and 234 had sufficient data for analysis. Eighty-four percent (196/234) of open wounds were closed primarily, 7% (16/234) required a skin graft, and 4% (9/234) required rotational or free flap. Thirteen percent (22/166) of those followed for 90 days had a wound complication, and 50% of those with complication required a return to the OR. All OTA-OFC classifications statistically significantly correlated with type of closure (P < 0.001), with skin having a high correlation (r = 0.79), muscle (r = 0.49) and contamination (r = 0.47) moderate correlations, and arterial (r = 0.32) and bone loss (r = 0.33) low correlations. OTA-OFC muscle classification was predictive of 90-day wound complication (OR 0.31, 95% confidence interval 0.07-0.21). OTA-OFC domains correlated variably with return to the OR.

CONCLUSION

OTA-OFC clinically correlates with definitive wound management and 90-day wound complication in open upper extremity fractures. OTA-OFC skin classification has a high correlation with the type of definitive wound closure. OTA-OFC muscle was the only domain that correlated with 90-day wound complication and was predictive of 90-day wound complication.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

The evidence base for 2017 BOAST-4 guidance on open fracture management: Are we due an update?

INTRODUCTION

Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017.

METHODS

Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018-01/02/2021. Results have been summarized and discussed.

DISCUSSION

Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus.

CONCLUSION

The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed.

Functional outcomes of internal fixation of scapula fractures due to high-velocity gunshot injuries

BACKGROUND

Open fractures of the scapula are relatively rare and only a few studies are interested in this subject. This study aims to demonstrate the results of internal fixation of open scapula fractures due to gunshot injuries.

MATERIALS AND METHODS

Eight patients who had open scapula fractures and were treated by internal fixation through the conventional Judet approach included in this study. Patients were followed up monthly in the first 6 months and every 2 months in the rest of the follow-up. Shoulder range of motion, Constant Shoulder Score, and Disabilities of the Arm, Shoulder, and Hand score were used for functional evaluation.

RESULTS

The average follow-up period was 34.6 ± 11.9 months. The average time between injuries and the surgery was 10.5 ± 5.1 days. The average shoulder abduction of the patients was 135.6 ± 18.8°, the average forward flexion of the shoulder was 160 ± 19.2°. The average internal and external rotations of the shoulders were 80 ± 14.1° and 63.1 ± 17.3°, respectively. CSS was calculated as 79.8 ± 14.4, and DASH was calculated as 14.1 ± 14.9.

CONCLUSIONS

In the treatment of open scapula fractures due to gunshot injuries, an internal fixation is a reliable option and the results were comparable with previous studies.

The Effect of a PEEK Material-Based External Fixator in the Treatment of Distal Radius Fractures with Non-Transarticular External Fixation

Objective

To explore the effect of a PEEK material‐based external fixator in the treatment of distal radius fractures with non‐transarticular external fixation.

Methods

There were 48 patients in this prospective comparative study. They were divided into two groups according to the materials used: the PEEK group and the titanium group. Wrist dorsiflexion, palmar flexion, pronation, supination, radial deviation, ulnar deviation, grip strength of the palm on the affected side, kneading force, Visual Analogue Scale/Score (VAS), Disabilities of the Arm, Shoulder, and Hand (DASH) score, operation time, frequency of fluoroscopy procedures, and X‐ray results were compared between the two groups. Functional recovery was evaluated at the last follow‐up according to the wrist joint evaluation criteria.

Results

The baseline data were comparable between the two groups, and no significant differences were found in age, sex, fracture types (P > 0.05). There was no significant difference between the two groups in the results of DASH, grip strength, and recovery of pinch force and wrist function (dorsiflexion, clavicle, ulnar deviation, deviation, pronation, and supination) (P > 0.05). Normal limb function was achieved in the two groups of patients at an average of 6 weeks after surgery, and there was no significant difference in X‐ray examination radial height (10.60 ± 1.59 vs 11.00 ± 1.53, P = 0.687), radial inclination (1.11 ± 0.24 vs 1.12 ± 0.24, P = 0.798), volar tilt (10.33 ± 2.13 vs 10.00 ± 2.08, P = 0.660), ulnar variance (20.87 ± 3.00 vs 20.38 ± 3.04, P = 0.748), and step‐off persistence (1.73 ± 0.69 vs 1.68 ± 0.72, P = 0.425) between the two groups (P > 0.05). However, the operation time (54.80 ± 12.20 vs 85.23 ± 15.14, P = 0.033) and number of fluoroscopy procedures (36.93 ± 6.89 vs 64.77 ± 9.74, P = 0.000) in the PEEK group were significantly reduced compared with those in the titanium group.

Conclusion

Compared with the traditional titanium external fixator, the PEEK composite external fixator has advantages, such as a shorter operation time and fewer fluoroscopy procedures when used to treat different types of distal radius fracture.

Effects of Stellate Ganglion Block on Healing of Fractures Induced in Rats

Objective

Sympathetic blocks are used as an adjunct for pain management in the treatment of orthopedic and traumatic conditions. Stellate ganglion (ganglion stellatum) provides sympathetic innervation of the head, neck and cervicothoracic regions, and upper extremities. No study was found in the literature investigating the effects of stellate ganglion block performed in the upper extremity, on blood supply to bone, density, vascularization, and bone metabolism. Therefore, the objective of this study was to investigate the effects of stellate ganglion block on healing of closed forearm fractures that were induced in rats. Material and Methods. A total of 42 Wistar albino rats weighing between 398 and 510 g were used in this study. The rats were randomly divided into 2 groups with one group treated with stellate ganglion and the other included as the control group. In each 2 groups, a closed forearm fracture was created, confirmed with X-ray, and then stabilized by splint application. The forearm bones were examined with X-ray views on the same day and were then decalcified.

Results

When histological findings of the fracture region were examined, predominantly cartilage and less woven bone were found in 7 rats, equally distributed cartilage and immature bone in 14 rats, and predominantly imitation bone and less cartilage formation in 21 rats. In the control group, the agreement between the 1st and 2nd orthopedists for the radiological evaluation of bone formation was moderate.

Conclusion

The group administered stellate ganglion block showed a more significant fracture healing.

Surgical Site Infection After Open Upper Extremity Fracture and the Effect of Urgent Operative Intervention

OBJECTIVES

To identify which factors are predictive of surgical site infection in upper extremity fractures, and to assess whether the timing of operative debridement influences infection risk.

DESIGN

Retrospective database review.

SETTING

Hospitals participating in the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database.

PATIENTS

Patients in the NSQIP database with fractures involving the upper extremity.

INTERVENTION

Surgical management of upper extremity fracture, including operative debridement for open injuries.

MAIN OUTCOME MEASUREMENTS

Surgical site infection, including both superficial and deep infections.

RESULTS

A total of 22,578 patients were identified, including 1298 patients with open injuries (5.7% of total). The overall wound infection rate was 0.79%. Patients with open injuries were found to have a higher incidence of infection compared with those with closed injuries (1.7% vs. 0.7%, P < 0.001). Independent risk factors for 30-day infection included open fracture diagnosis, obesity, smoking, and American Society of Anesthesiolgists class >2 (all P < 0.05). Of patients with open fractures, 79.7% were taken expediently to the operating room. The rate of infection did not differ based on whether surgery was performed expediently or not (1.8% vs. 1.1%, P = 0.431).

CONCLUSIONS

Based on an analysis of the NSQIP database, the overall risk of surgical site infection following intervention for open or closed upper extremity fractures remains low. Risk factors for infection include open injury, obesity, and cigarette smoking. There was no difference in the infection rate based on the urgency of operative debridement.

LEVEL OF EVIDENCE

Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.