From the Guidelines
For an open fracture of the finger that has failed to close 10 days after initial repair, the recommended treatment is surgical debridement followed by appropriate wound closure techniques. The patient should undergo thorough wound debridement to remove any necrotic tissue, foreign material, or infection, followed by either delayed primary closure, skin grafting, or local flap coverage depending on the wound characteristics. Intravenous antibiotics should be administered, typically a combination of a first-generation cephalosporin like cefazolin (1-2g IV every 8 hours) plus gentamicin (5mg/kg IV daily) for broad-spectrum coverage, continuing for at least 48-72 hours after closure, then transitioning to oral antibiotics for 7-10 days total, as recommended by 1 and 1. Immobilization with appropriate splinting should be maintained to protect the fracture while allowing for wound assessment. Regular wound care with sterile dressing changes and monitoring for signs of infection is essential. This aggressive approach is necessary because persistent open fractures risk osteomyelitis, non-union, and long-term functional impairment. The combination of surgical debridement, appropriate antibiotic therapy, and proper wound closure techniques addresses both the infection risk and promotes bone healing, which is critical for restoring hand function. Negative pressure wound therapy may not be beneficial in this case, as stated in 1. The management of fracture-related infection should consider the pathogenesis and the role of biofilm formation, as discussed in 1 and 1. Key considerations include:
- The importance of timely and thorough debridement
- The selection of appropriate antibiotics, considering the potential for biofilm formation and antibiotic resistance
- The need for stable fracture fixation and soft tissue coverage to promote healing and prevent further infection. Overall, the goal of treatment is to achieve wound closure, promote bone healing, and restore hand function, while minimizing the risk of complications such as osteomyelitis and non-union.
From the Research
Treatment Options for Open Fracture of the Finger
- The management of open fractures involves a combination of antibiotic therapy, surgical débridement, and fracture fixation, with the goal of preventing infection and promoting fracture healing 2, 3.
- In cases where the wound fails to close after initial repair, negative pressure wound therapy (NPWT) may be a useful adjunct to promote wound healing and reduce the risk of infection 4, 5.
- NPWT has been shown to be effective in removing infectious material, managing wounds pending soft tissue reconstruction, and promoting wound healing in complex open fracture wounds 4.
- The use of antibiotic bead pouch and vacuum-assisted wound closure may also help reduce the risk of secondary and nosocomial contamination and subsequent infection 2.
- The selection of fracture fixation depends on the fractured bone, the location of the fracture, the extent of soft-tissue injury and contamination, and the physiologic status of the patient, and may involve the use of locking compression plates or other fixation methods 2, 5.
- The formulation of a soft-tissue treatment plan should occur during the initial wound assessment and the initial fixation of an open fracture, and may involve consultation with a soft-tissue surgeon 2.
Considerations for Treatment
- The time to surgical débridement and the use of antibiotics should be considered in the treatment plan, with the goal of preventing infection and promoting fracture healing 2, 3.
- The use of bone grafting and/or biologics may be considered to achieve bony union in patients with an acute open fracture or delayed union or nonunion 2.
- The patient's nutritional status and overall health should be taken into account when developing a treatment plan, as these factors can impact fracture healing and wound recovery 2.