15.1 Introduction

Management of open fractures remains a challenge due to the combination of bone and soft tissue injuries in different magnitudes. Contamination and tissue damage predispose to a higher risk of infection. About 25% of polytrauma patients have injuries to the wrist and hand. ¹ According to Schädel-Höpfner and Siebert, ¹ and Ciclamini et al, ² uncomplicated hand or wrist fractures are the most common form of injury (2–16%), followed by soft tissue lesions (2–11%). Severe combined lesions and amputations are rare (0.2–3%). These lesions have a large incidence in young individuals (between 20 and 40 years of age), with increased incidence of hand trauma due to motorcycle accidents. ² In polytraumatized patients, it is frequent that injuries to the wrist or hand go unnoticed or are underdiagnosed. ²

Orthopaedic approach must be based on the advanced trauma life support protocol, ³ with immediate attention to restore airway, breathing, and circulation. Similarly, orthopaedic, trauma, and hand surgeons should consider each patient and his/her clinical situation as unique and plan treatment based on individualized evaluation. High-energy injury induces local and systemic release of proinflammatory cytokines, which often results in a systemic inflammatory response syndrome. ^{4 , 5}

Procedures for damage control are based on minimizing surgical trauma in a critical period for the patient, reducing surgical time, blood loss, and tissue damage. For damage control in more severe patients, fractures should be stabilized with external fixators. ⁶ In open fractures, the mechanism and energy of trauma must always be considered. Meticulous clinical examination is critical and challenging in the unconscious patient. Image exams should be performed in the emergency room. Life-threatening injuries should be a priority, and the multidisciplinary care team should define the timing and approach of open fractures according to the following principles: preserve life, preserve tissue, and preserve and restore function. ⁷

The principles of local treatment include irrigation, debridement, soft tissue repair or reconstruction, skeletal stabilization with reduction and fixation of fractures, and treatment of segmental bone loss. Early and adequate debridement decreases contamination and risk of infection. Very few structures in the hand and wrist can be debrided and sacrificed without predictable functional impairment; therefore, the surgeon must decide between how much to debride and preserve according to each situation.

Primary and early repair or reconstruction of soft tissue (muscles, tendons, peripheral nerves) provides the best functional results. Small bone segmental loss (less than 6 cm) in well-vascularized recipient beds can be treated with conventional bone graft. Large segmental losses (more than 10 cm) and hypovascular recipient areas are best treated with vascularized bone graft.

There is no consensus on how to define and classify open fractures of the hand and wrist. From the clinical point of view, it is possible to consider that open fractures of the wrist or hand have similar behaviors because of the similar anatomy. Gustilo and Anderson ⁸ published the most commonly used classification for open fractures. This classification is based mainly on the size and contamination of the wound:

• 
  

  Type I: wound less than 1 cm, little soft tissue damage with no crushing. Type I fractures usually occur by mechanism from the inside to outside, when a misaligned bone fragment pierces the skin.

  
  
• 
  

  Type II: wound more than 1 cm in length, slight or moderate crushing injury, moderate fracture fragmentation and moderate contamination. There is no extensive soft tissue damage.

  
  
• 
  

  Type III: wound with extensive soft tissue damage with a high degree of contamination and caused by high-energy trauma. There is a severe bone fragmentation and instability. There are three subtypes:

  
  
  
  
  • 
    

    III-A: soft tissue preserved despite extensive laceration.

    
    
  • 
    

    III-B: loss of soft tissue. After surgical irrigation and debridement, there is an exposed bony segment, which imposes the need for a flap (cutaneous, muscular, or muscle-cutaneous).

    
    
  • 
    

    III-C: open fracture associated with arterial laceration. Arterial repair is necessary regardless of the degree of soft tissue injury.

Swanson et al ⁹ classified open fractures of the hand based on wound size, degree of contamination, and host factors. The authors recommended fracture stabilization based on fracture classification or instability, and primary wound closure for type I and delayed for type II:

• 
  

  Type I: clean wound and no systemic factors.

  
  
• 
  

  Type II: contaminated wound, delay in treatment greater than 24 hours, or significant systemic illness.

McLain et al ¹⁰ and Duncan et al ¹¹ modified the classification by Gustilo and Anderson ⁸ for open hand fractures. McLain et al ¹⁰ classification:

• 
  

  Type I: laceration less than 1 cm, no signs of contamination, crush or fracture fragmentation.

  
  
• 
  

  Type II: laceration greater than 1 cm, no contamination, crush or fracture fragmentation.

  
  
• 
  

  Type III: laceration greater than 10 cm, contamination, crush, comminuted/segmental fractures, blast injuries, and all farm injuries.

Duncan et al ¹¹ classification: the philosophy of this classification was to downscale the wound size of Gustilo–Anderson classification to apply to the open fractures of the hand:

• 
  

  Type I: clean laceration less than 1 cm (puncture wound), no crush or tissue loss.

  
  
• 
  

  Type II: clean laceration from outside less than 2 cm, no crush or tissue loss.

  
  
• 
  

  Type III-A: laceration greater than 2 cm, soiled wound, and penetrating or puncturing projectile wound.

  
  
• 
  

  Type III-B: III-A with periosteal elevation or stripping.

  
  
• 
  

  Type III-C: III-B with neurovascular injury.

Duncan et al ¹¹ showed an infection rate of 3.5% in Gustilo–Anderson type III hand open fractures. Capo et al ¹² showed a 1.4% infection rate, even in a series with a high proportion (91 out of 145) of Gustilo–Anderson type III open fractures of the hand. Saint-Cyr and Gupta ¹³ found a 0% infection rate with the use of bone grafting to treat more severe open fractures of the hand. A retrospective review from Bannasch et al ¹⁴ found no significant difference in infection rates between the open (133 fractures) and closed (299 fractures) hand fractures. Ketonis et al, ¹⁵ in a systematic review, found that the infection rate after open hand fracture remains relatively low. Timing of debridement has not been shown to alter infection rates and the majority of infections can be treated with antibiotics alone. We believe that open fractures of the wrist behave similarly to those of the hand.

On the other hand, in many countries, over 50% of open fractures of the wrist are caused by motorcycle or motor vehicle accidents with high level of dissipated energy resulting in severe injury to bone and soft tissues. ¹⁶ There is a loss of periosteal and intramedullary blood supply to the fractured bone. That could result in tissue necrosis, both from direct trauma and from secondary ischemia. The association of avascular bone, soft tissue damage, and contamination makes some open fractures of the wrist region a challenging treatment. Open fractures imply that wrist bones and soft tissue have been exposed to a nonsterile environment. Injuries with large skin defects or soft tissue losses can have gross wound contamination with high pathogen titers and foreign bodies. In the initial treatment of these skeletal injuries, aggressive infection control and wound management often take precedence over definitive fracture fixation. Local or systemic damage control using an external fixation device is usually indicated in more complex and severe situations.

Following a violent injury, soft tissue necrosis and contamination cause an inflammatory response composed of immune cells along with a host of molecular mediators which collectively increase soft tissue permeability and promote phagocytosis. Contaminated hematomas dissect along affected tissue, resulting in dead spaces, becoming an ideal culture medium for bacterial growth. ¹⁶

Gram-positive bacteria Staphylococcus and Streptococcus are the most frequent infectious agents in the hand and wrist open fractures. ¹⁷ Infections acquired at the hospital often involve Staphylococcus and gram-negative bacteria (Pseudomonas, Klebsiella, Acinetobacter). ¹⁷ Wounds contaminated by soil are usually infected with gram-negative and anaerobic bacterias. ¹⁷ Infections acquired in the aquatic environment often involve Aeromonas, Pseudomonas, and Mycobacterium. ¹⁸ Wounds contaminated with saliva (human bites) can be infected by Eikenella corrodens and anaerobic bacteria. ¹⁹ Animal bites can cause mixed infections, with both aerobic and anaerobic bacterias. ^{20 , 21} Cat and dog bites can cause infections associated with Pasteurella multocida. ^{20 , 21 , 22} The presence of devitalized and necrotic tissue is related to the development of clostridial gas gangrene. ²³

Empirical antibiotic therapy should be initiated as soon as possible based on the probable infectious agent and according to the nature of wound contamination until the final culture and sensitivity tests are conclusive. Intravenous antibiotics should be given before, during, and for at least 5 days after surgery. Antibiotic coverage must remaining while the wound is still open (primary closure types I and II, delayed type III). ²³

Nylén and Carlsson correlate the delay in treatment with increased risk for infection. ²⁴ Swanson et al ⁹ relate a higher incidence of infection in open fractures of the hand to the presence of wound contamination, systemic illness (malnutrition, diabetes, renal or hepatic failure, malignancy, immune deficiency, drug, alcohol, or tobacco abuse) and delay in treatment greater than 24 hours.

We do not have specific data on the importance of using antibiotics in wrist open fractures. Therefore, we use the same principles of open fracture management, but add some specific concepts for hand open fractures. Some publications report the importance of antibiotic therapy in hand injuries. Sloan et al ²⁵ indicated prophylactic antibiotic therapy to reduce the risk of infection in open fractures of the distal phalanx. However, Peacock et al ²⁶ considered that antibiotic prophylaxis is not necessary in open wounds of the hand with moderate contamination and adequate debridement. Similarly, Suprock et al ²⁷ showed no benefit of prophylactic antibiotic therapy in open fractures of fingers after irrigation and debridement. Other authors emphasize the need for debridement in the management of an open fracture and that antibiotics are not a substitute for surgical debridement. ^{28 , 29} Antibiotic prophylaxis should be recommended for Gustilo type III open fractures of the hand and wrist. ³⁰ It is our opinion that wounds with mini mal contamination can be treated with first-generation cephalosporins. Aminoglycosides should be used in more contaminated wounds. ⁵ In anaerobic infections, penicillin is the drug of choice. Prophylactic antibiotics should be used for no longer than 48 to 72 hours. ²⁵ In the management of complex open hand and wrist trauma, there seems to be little benefit in extending antibiotic treatment beyond 5 days if there is no clinical sign of infection. ^{23 , 25}