What is the initial Emergency Department (ED) treatment for an open phalangeal fracture?

From the Guidelines

The initial emergency department treatment of an open phalangeal fracture should prioritize prompt wound irrigation with sterile normal saline, administration of broad-spectrum antibiotics, tetanus prophylaxis, fracture stabilization, and early hand surgery consultation. Begin with thorough irrigation using sterile normal saline (at least 3 liters) to remove debris and contaminants from the wound, as recommended by the American Academy of Orthopaedic Surgeons 1. Administer broad-spectrum antibiotics immediately, typically a first-generation cephalosporin such as cefazolin 1-2g IV for adults (25-50 mg/kg for children), with addition of gentamicin 5 mg/kg IV and penicillin G 4 million units IV for heavily contaminated wounds, as suggested by the guidelines 1. Provide tetanus prophylaxis if needed (Td or Tdap 0.5 mL IM if immunization is outdated or unknown). Apply a sterile dressing after irrigation and stabilize the fracture with a splint in the position of function. Pain management should include appropriate analgesics such as morphine 0.1 mg/kg IV or hydromorphone 0.015 mg/kg IV. Obtain radiographs in two planes to assess fracture pattern and displacement. Early hand surgery consultation is essential, as most open phalangeal fractures require operative debridement and definitive fixation within 24 hours, and the use of perioperative and postoperative systemic antibiotics for open fractures is strongly recommended 1. Avoid wound closure in the ED as this should be performed in the operating room after thorough debridement. This approach minimizes infection risk while preserving hand function, which is critical given the complex anatomy and functional importance of the fingers. The guidelines also emphasize the importance of early delivery of antibiotics to lower the risk of deep infection in the setting of open fracture in major extremity trauma 1.

Some key points to consider in the management of open phalangeal fractures include:

• The use of simple saline solution (without additives) for initial wound management, as recommended by the American Academy of Orthopaedic Surgeons 1
• The importance of early antibiotic administration, with a strong recommendation for the use of perioperative and postoperative systemic antibiotics for open fractures 1
• The need for early hand surgery consultation and operative debridement and definitive fixation within 24 hours
• The use of negative pressure wound therapy (NPWT) may not be beneficial for open fractures, as suggested by the guidelines 1
• The role of local antibiotic strategies as an adjunct to systemic antibiotics, with a moderate strength recommendation for the use of vancomycin powder, tobramycin-impregnated beads, and gentamicin-covered nails 1.

From the Research

Initial ED Treatment of Open Phalangeal Fracture

• The initial treatment of open phalangeal fractures involves prevention of infection, union of the fracture, and restoration of function 2.
• Tetanus prophylaxis and intravenous antibiotics should be administered immediately, with local antibiotic administration being a useful adjunct 2.
• The open fracture wound should be thoroughly irrigated and debrided, although the optimal method of irrigation remains uncertain 2, 3.
• Normal saline solution appears to be the optimal irrigation agent, but the optimal timing and volume are often determined by the surgeon 3.

Antibiotic Prophylaxis

• Antibiotic prophylaxis is crucial in the management of open fractures, with different classes of antibiotics being used to guide prophylactic therapy 4.
• Cefazolin and ceftriaxone are two commonly used antibiotics, with ceftriaxone offering a broader coverage and a decreased frequency of administration 5.
• There is no statistically significant difference in outcomes between cefazolin and ceftriaxone, but ceftriaxone is a safe and effective alternative for open fracture management 5.

Fracture Stabilization

• The technique of fracture stabilization depends on the anatomic location of the fracture and characteristics of the injury 2.
• For phalangeal fractures, the type of fixation method can range from percutaneous pinning to open reduction and internal fixation 6.
• Operative intervention may be required for unstable fracture patterns and those involving the articular surface, with the goal of optimizing patient goals and range of motion 6.