Open fractures can be difficult to heal and have a high risk of infection. The overall infection rate for open fractures of the hand, however, is relatively low and most infections can be treated successfully with antibiotics alone, according to study data presented at the American Society for Surgery of the Hand annual meeting. Moreover, although the use of antibiotics influences infection rates in these fractures, the timing of débridement does not.

“Studies on the management of open fractures have focused almost exclusively on long bones. As a result, treatment guidelines for open fractures of the hand have not been well established. Physicians still have questions about whether or not to use antibiotics and when to débride these injuries,” said presenter Joseph Dwyer, MD.

Systematic literature review, meta-analysis
Dr. Dwyer and his fellow researchers conducted a comprehensive search of literature databases to determine infection rates and the effect of antibiotic administration and débridement timing in open fractures of the hand. Only studies in English were reviewed. The following inclusion criteria were used:

• open fractures of the carpals, metacarpals, or phalanges
• data on infections
• minimum of 25 patients
• patients older than 14 years

Animal studies, studies that combined hand and long bone open fracture data, and studies that combined open and closed fracture data were excluded.

In all, 12 clinical studies (4 prospective and 8 retrospective cohort studies) met the inclusion criteria. The studies involved 1,669 open fractures. The researchers examined the following data:

• treatment received
• antibiotic administration
• time to débridement
• number and type of infections (superficial vs deep)
• follow-up duration
• fracture grade
• associated injuries
• complications

Meta-analysis revealed that the overall infection rate was 4.6 percent (n = 77). Among the patients who were treated with preoperative antibiotics (1,391 fractures), the infection rate was 4.4 percent (n = 61), regardless of the regimen. Among the patients not treated with preoperative antibiotics (171 fractures), the infection rate was 9.4 percent (n = 16).

Six studies provided information on the severity of infections in 1,132 fractures. Most of the infections (86 percent) were superficial and resolved with oral antibiotics only.

“These findings suggest that antibiotic use is associated with lower odds of infection in open hand fractures and that infections detected early can often be treated nonsurgically,” Dr. Dwyer said.

Débridement of an open fracture within the first 6 hours of injury is a guideline traditionally followed in the treatment of long bone fractures. During their analysis, however, the researchers found that hand fractures that were débrided within 6 hours and those débrided after 6 hours had similar infection rates (3 percent and 3.6 percent, respectively). Plus, two studies that looked specifically at time to débridement showed no correlation to the incidence of infection, Dr. Dwyer noted.

“Our pooled analysis indicated that the timing to débridement does not appear to affect infection rates in open fractures of the hand,” he said.

Additional studies needed
Dr. Dwyer admitted that the study did have limitations, namely its retrospective design and the inconsistency among treatment regimens.

“The antibiotic dosing and protocol were varied across the studies,” he said. “The débridement time and setting—the emergency department or the operating room—also varied.” He added, “We believe further prospective studies are needed before treatment guidelines for open fractures of the hand can be created.”

Dr. Dwyer’s coauthors of “Timing of Débridement and Infection Rates in Open Fractures of the Hand: A Systematic Review” are Asif M. Ilyas, MD, and Constantinos Ketonis, MD, PhD.

Disclosure information: Dr. Ilyas—Integra Life Sciences, Jaypee Medical Publishers, Elsevier; Drs. Dwyer and Ketonis—no conflicts.

Maureen Leahy is assistant managing editor of AAOS Now. She can be reached at leahy@aaos.org

Bottom Line

• Few reports have analyzed the impact of antibiotics and débridement on rates of infection after open fractures of the hand.
• Results of this meta-analysis indicate that the overall infection rate for open fractures of the hand is relatively low and that most infections can be treated successfully with antibiotics alone.
• Antibiotic use is associated with lower odds of infection in open fractures of the hand.
• Timing of débridement does not alter infection rates in these fractures.