What is the management for an open fracture of the finger?

Management of Open Finger Fractures

For open fractures of the finger, immediate wound cleaning, appropriate antibiotic coverage, and prompt orthopedic evaluation are essential to prevent infection and optimize functional outcomes. 1, 2

Initial Assessment and Management

• Wound Evaluation:

  • Assess for severity of soft tissue damage
  • Check for visible bone fragments
  • Evaluate neurovascular status (color, temperature, capillary refill)
  • If the fractured extremity appears blue, purple, or pale, activate emergency response immediately 1

• Immediate First Aid:

  • Control bleeding using direct pressure if severe 1
  • Cover the open wound with a clean dressing to prevent further contamination 1
  • Immobilize the finger in the position found unless straightening is necessary for safe transport 1

Antibiotic Management

• Initiate antibiotics as soon as possible (ideally within 3 hours of injury) 2, 3
• Antibiotic selection:
  • For simple open finger fractures: Cefazolin 2g IV (or clindamycin 900mg IV if beta-lactam allergy) 2
  • Duration: Limited to 24 hours post-injury in the absence of clinical signs of infection 2
  • Consider adding vancomycin if MRSA risk factors present 2

Surgical Management

• Radiographic Assessment:

  • Obtain 3-view radiographs of the affected finger (PA, lateral, and oblique) 1
  • An internally rotated oblique projection increases diagnostic yield for phalangeal fractures 1

• Wound Debridement:

  • Thorough irrigation with simple saline solution (no additives) 2
  • Surgical debridement of all devitalized tissue 2, 3
  • Remove foreign material and contaminants

• Fracture Stabilization:

  • Splinting can reduce pain and prevent further injury 1
  • Definitive fixation method depends on:
    • Fracture location (intra-articular vs. shaft)
    • Stability of fracture pattern
    • Extent of soft tissue damage 3
  • Unstable fractures or those with intra-articular extension may require operative fixation 4

Special Considerations

• Tendon Injuries:

  • Assess for associated tendon damage, especially with extensor mechanism injuries 1
  • "Mallet" injuries (extensor tendon avulsion) may require surgical fixation if:
    • More than one-third of articular surface is involved
    • Palmar displacement of distal phalanx is present
    • Interfragmentary gap exceeds 3mm 1

• Tetanus Prophylaxis:

  • Administer tetanus prophylaxis if not vaccinated within 10 years 2
  • Tdap preferred if not previously given 2

Follow-up Care

• Wound Monitoring:

  • Regular assessment for signs of infection
  • Monitor for adequate healing

• Rehabilitation:

  • Early range of motion exercises when appropriate to prevent stiffness
  • Occupational therapy referral for complex injuries

Pitfalls to Avoid

• Delayed antibiotic administration increases infection risk 3
• Inadequate debridement can lead to persistent infection and poor healing 2, 3
• Overlooking associated injuries (tendon, nerve, vascular) can result in poor functional outcomes
• Overly aggressive fixation in stable fracture patterns may cause unnecessary tissue damage 4

By following these principles, most open finger fractures can be effectively managed with good functional outcomes and minimal complications.