Tuft fractures are not considered true open fractures, so they have not been discussed.

An open fracture is a fracture in which there is a wound or break in the skin near the site of the broken bone – commonly caused by direct trauma or by the bone fragment breaking through the skin at the time of injury. A fracture with a wound in its vicinity should be considered open until proven otherwise as the wound may not be located immediately over the fracture site.¹ A similar approach should be taken with dislocations and adjacent wounds.

Open fractures and dislocations require different treatment from closed fractures and dislocations because of the high risk and potentially destructive nature of bone and joint infections.  

Epidemiology

Injuries to the hand are exceptionally common, accounting for between 5 and 10% of all A&E visits each year, 20% of acute fractures, 55% of upper limb problems and constitute 30% of all work-related injuries.^{2,3, 4} The most common bones to fracture in the hand are those of the little finger.⁵

Mechanisms differ between age groups with younger people more likely to involve higher energy causes such as sporting injuries or road traffic collisions; middle-aged people more likely to have work-related injuries and elderly people more likely to suffer injuries through falling. Men are 1.5 times more likely to experience hand fractures than women.⁶  

Assessment and Management

The aims of the assessment and management of an open fracture or dislocation are:

• Gather relevant information for eventual handover to relevant speciality:
  • History
  • Clinical Examination
  • Investigation
• Stabilise patient
  • ATLS
  • Wound first aid
  • Reduction and stabilisation of fracture or dislocation

Open fractures and dislocations of the hand should be referred to a suitable centre (with plastic or orthopaedic hand surgery expertise) for a same-day review.⁷

Always assess with an ATLS approach to ensure there are no other injuries. This is especially important in high-energy mechanisms, such as road traffic accidents (RTAs).

History:

Questions to ask regarding presenting complaint:

• When did it happen?
  • Relevant to associated time-sensitive injuries such as vascular injuries.
• Where did it happen?
  • Locations that increase the risk of infection include farmland, marine areas etc.
• What happened?
  • Events of the injury which include:
    • Mechanism (crush, sharp, penetrating, fall) gives an idea of the energy involved, the extent of injury, trapped foreign bodies and potential collateral injury to surrounding structures.
    • First aid such as irrigation, tourniquet use, reduction and splinting of fracture/dislocation.
    • Pre-hospital management including intubation, IV fluids, cardiac monitoring, analgesia etc.

Past Medical and Drug History:

• Comorbidities:
  • Helps stratify the risk of infection and impaired wound and bone healing. Common contributing conditions include diabetes and immunocompromise.^8,9
• Regular Medications:
  • Anticoagulants
  • Immunosuppressants
• Tetanus status
  • Puncture injuries and ‘dirty’ mechanisms are tetanus-prone wounds.¹⁰
• Allergies

Social History:

• Hand dominance
• Profession and hobbies
  • Could influence the operation performed in cases where the restoration of hand function is vitally important e.g. in musicians; or in cases where speed of recovery and need to work take precedence.^11,12
• Smoking status
  • Smoking has a significant detrimental impact on wound healing.^13,14   

Examination:

Documentation, of both positive and negative findings, is vitally important as litigation in hand surgery is becoming increasingly common, with most cases based around poor outcomes – documenting an injury-associated defect is therefore important.^15,16

Local anaesthetic should be avoided until neurovascular status has been assessed and re-assessed after any manipulation.

Inspection:

• General inspection
  • Where:
    • Inspect both the volar and dorsal sides of the hands.
    • Malrotation
      • Indicates a displaced fracture, see the illustration below.
    • Scissoring
      • Indicates displaced fracture. It may be exaggerated on flexion of fingers. See the illustration below.
  • Colour:
    • Pale colour may indicate arterial compromise, blue/purple may indicate venous compromise
  • Other pathologies:
    • It is important not to miss any other injuries or pre-existing pathologies e.g. Dupuytren or previous injuries and surgical scars
• Wound
  • Assess the extent of injury, degree of contamination, obvious loss of soft tissue or bone, and structures visible at the wound bed.

Palpation:

• Neurovascular status
  • Assess proximal and distal to the site of injury.
  • A pair of nerves (digital ulnar and radial nerve) supply sensation to each digit on the respective side of the finger. Assess the sensation of both nerves.
  • Palpate capillary refill time and warmth of the digit. A pulse oximeter is a useful adjunct as no signal may indicate vascular compromise.
  • 2-point discrimination can be useful when you suspect that neuropraxia may confound the examination.
• Assess for retained foreign bodies
  • Take care to avoid injury on sharp foreign bodies.

Movement:

• Assess the range of movement of all surrounding joints to exclude other injuries
• Carefully assess the movements of the joints immediately proximal and distal to the injury
  • Have any of the structures that cross the fracture site been damaged or involved in the injury?
• Check for fracture/dislocation stability on active movement.

Comparison with the contralateral (uninjured) side can be useful, especially when assessing for shortening or malrotation.

Investigation

The purpose of the investigations is to aid in diagnosis, surgical planning and fitness for surgery.

• Fitness for surgery:
  • Blood tests (including coagulation and group and save depending on injury severity).
  • Pregnancy test as appropriate
  • Consider chest x-ray and ECG
• Surgical planning and diagnosis:
  • X-ray
    • Should have at least 2 views, preferably 3:
      • AP
      • Lateral
      • Oblique
    • Include joint above and below
  • Wound swab if appropriate

Use a systematic approach to interpreting x-rays; ensuring to review the entire radiograph and not immediately focus on any obvious abnormality, to reduce the chance of missing other injuries.

The order of interpretation is individual preference and is formed with experience. A suggested checklist includes:

• Patient identification
• Time and date of x-ray
• Review for soft tissue irregularities including foreign bodies
• Bones:
  • Edges
  • Altered trabecular pattern
  • Alignment
• Joints:
  • Congruency
  • Spaces
• Systematically review all areas:
  • Phalanges
  • Metacarpals
  • Wrist
• Have a high index of suspicion depending on the mechanism of injury, for example:
  • Boxer’s fractures
  • Gamekeeper’s thumb
  • Bennett’s fracture  

Management:

Immediate:

If there is concern regarding vascular status, or significant injuries e.g. mangled hand, seniors should be notified immediately and a referral made to the appropriate speciality (usually Plastic surgery or Orthopaedics).

• Active bleeding
  • Avoid tourniquets
  • Instead consider the three P’s (Pack, Pressure, Position – elevation)
• Jewellery:
  • Remove jewellery as it may become a point of vascular compromise as swelling occurs with the injury
• Analgesia
  • Use the WHO analgesic ladder
  • Consider the addition of Entonox or Penthrox (Methoxyflurane).
• IV antibiotics
  • As per trust policy
• Wound management
  • Local anaesthetic may be required to allow for adequate irrigation
  • This is vital to remove contamination and reduce the risk of infection.^17,18
  • A high volume of sterile 0.9% NaCl is recommended for wound washout, 500ml in the A&E or Assessment Unit setting is reasonable.
  • Dressings should consist of the following layers (the first layer representing the dressing in contact with the wound):
• Non-adhesive layer with or without antibacterial properties (e.g. Silflex, Inadine, Bactigras)
• Moisture control by absorption or promotion of liquid to the wound. Absorption is usually required in traumatic wounds and gauze is commonly used.
• Maintain dressing position and additional moisture control if required. Wool and crepe are usually used to keep dressings in place.
• Be aware that dressings can act as a tourniquet if applied too tightly.
• Fracture and dislocation management
  • Ensure that neurovascular status has been comprehensively assessed and documented before and after manipulation.   
  • Fracture and dislocation reduction is usually achieved by distraction of fracture site/dislocation and realignment, seek senior input if unsure
  • Apply appropriate splint. The position of safe immobilisation is useful for many fracture variations of the hand (see Figure 3). ¹⁹ The relevant speciality (Orthopaedics or Plastic surgery) can advise on the appropriate splint.
• Limb elevation
  • The limb should be elevated to heart level, adjuncts such as Bradford sling are useful.
  • Reduces swelling and pain
• Definitive management:
  • Referral to the appropriate speciality, usually Plastic surgery or the Orthopaedic team, should be made as soon as possible.

References:

1. Morris, R. et al. 2019. The use of personalised patient information leaflets to improve patients perceived understanding following open fractures. Eur J Orthop Surg Traumatol. 29. 537-543.
2. Dias, J. J., and Garcia-Elias, M. 2006. Hand injury costs. Injury. 37: 1071-1077.
3. Sorock, G. S. et al. 2001. Epidemiology of occupational acute traumatic hand injuries: a literature review. Safety Science. 38: 241-256.
4. Coyle, J. et al. 2014. Hand and Wrist. BMJ. 17. 348
5. Onselen, E. et al. 2003. Prevalence and distribution of hand fractures. J Hand surg Br. 28. 491-495.
6. Donnelly, L. et al. 2021. Hand and Wrist Fractures: the ‘SBCDS’ approach. [Online]. British Orthopaedic Association. Last Updated: 28 October 2021. Available at: https://www.boa.ac.uk/resource/hand-and-wrist-fractures-the-sbcds-approach.html [Accessed 15 August 2024].
7. BSSH. (2023). Open fractures (other than tuft fractures). [Online]. The British Society for Surgery of the Hand. Available at: https://www.bssh.ac.uk/_userfiles/pages/files/professionals/Trauma%20standards/2%20Open%20fractures% [Accessed 9 September 2024].
8. Okonkwo, U. A. 2017. Diabetes and wound angiogenesis. International journal of molecular sciences. 18. 1419.
9. Dryden, M. et al. 2015. Pathophysiology and burden of infection in patients with diabetes mellitus and peripheral vascular disease: focus on skin and soft-tissue infections. Clinical microbiology and infection: the official publication of the European society of clinical microbiology and infectious diseases. 21. S27-S32.
10. UK Health Security Agency. (2024). Guidance on the management of suspected tetanus cases and the assessment and management of tetanus-prone wounds. [Online]. Gov.uk. Last Updated: 15 March 2024. Available at: https://www.gov.uk/government/publications/tetanus-advice-for-health-professionals/guidance-on-the-m [Accessed 9 September 2024]
11. Chu, d. Y.et al. 2023. Management of common conditions of the musician: A Narrative Review for Plastic Surgeons. Journal of plastic Surgery and Hand Surgery. 58. 89.
12. Tiffanie Turnbull. (2024). Australian hockey star amputates finger to play at olympics. [Online]. BBC News. Last Updated: 26 July 2024. Available at: https://www.bbc.co.uk/news/articles/ckmg7ngkgjeo [Accessed 9 September 2024].
13. Sorensen, L. T. 2012. Wound healing and infection in surgery: the pathophysiological impact of smoking, smoking cessation, and nicotine replacement therapy: a systematic review. Annals of surgery. 255. 1069-1079.
14. Kean, J. 2010. The effects of smoking on the wound healing process. Journal of wound care. 19. 5-8.  
15. Ajwani, S. H. et al. 2018. Litigation in hand and wrist related injuries and surgery. Ortopedia Traumatologia Rehabilitacja. 20. 205-209.
16. Sasor, S. E. and Chung, K.C. 2020. Litigation in hand surgery: a 30-year review. Plastic and reconstructive surgery. 146. 430-438.
17. Crowley, D. J. et al. 2007. Irrigation of the wounds in open fractures. The journal of Bone and Joint Surgery British volume. 89. 580-585.
18. S Chatterjee, J. 2005. A critical review of irrigation techniques in acute wounds. International Wound Journal. 2. 258-265.
19. Dobson, P. et al. 2011.Safe Splinting in hand surgery. Ann R Coll Surg Engl. 93. 94. 

Figures:

• Figure 1: “Malrotation”, Van J. M. T. with the aid of artificial intelligence, 2024
• Figure 2: “Scissoring of digits”, Van J. M. T. with the aid of artificial intelligence, 2024
• Figure 3: “Position of Safe Immobilisation”, Van J. M. T., 2024.

Written by Dr. Henry Lonsdale (CT2) and reviewed by Jonathan Van (Plastic Surgery Registrar)