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

Management of Open Finger Fractures

Open finger fractures require prompt surgical management with irrigation, debridement, and appropriate fracture stabilization within 24 hours of injury to prevent infection and optimize functional outcomes. 1

Initial Assessment and Management

• Control bleeding: Apply direct pressure to control active bleeding. For severe bleeding unresponsive to direct compression, consider tourniquet application if appropriate 1
• Wound evaluation: Assess severity of soft tissue damage, check for visible bone fragments, and evaluate neurovascular status (color, temperature, capillary refill) 1
• Imaging: Obtain 3-view radiographs (PA, lateral, and oblique) to evaluate fracture pattern and displacement 1
• Wound care:
  • Thoroughly irrigate the wound with warm saline solution 1
  • Cover the open wound with a clean dressing to prevent further contamination 1
  • Immobilize the affected finger in the position found unless straightening is necessary for safe transport 1

Antibiotic Prophylaxis

• Administer antibiotics as soon as possible to lower the risk of deep infection 1
• First-line: Cefazolin IV
• For patients with beta-lactam allergies: Clindamycin 900mg IV or vancomycin 30mg/kg IV 1
• Consider adding vancomycin if MRSA risk factors are present, as Staphylococcus aureus is responsible for 35-75% of post-traumatic infections 1
• Limit prophylaxis to the operative period, with a maximum duration of 24 hours 1

Surgical Management

• Timing: Bring the patient to the operating room for debridement and irrigation ideally within 24 hours of injury 1

• Procedure:

  • Surgical exploration to assess extent of injury, remove foreign bodies and contaminants, evaluate tissue viability 1
  • Irrigation using saline without additives (strong recommendation) 1
  • Fracture stabilization based on fracture pattern and stability 1, 2
  • Wound coverage within 7 days from injury 1

• Fixation options:

  • External fixation may be used as a temporizing measure for severely comminuted fractures 1
  • Internal fixation may be considered for stable fracture patterns 3
  • Crush injuries, proximal phalangeal fractures, and those with arterial injury have higher odds of requiring secondary surgery 3

Post-operative Care

• Regular wound assessments to monitor healing and watch for signs of infection or tissue necrosis 1
• Early mobilization is crucial - a broken finger should not be immobilized for more than a month 2
• Consider rehabilitation needs based on location and extent of injury 1

Complications and Their Management

• Infection: Higher risk in patients who smoke, have diabetes, are obese, or consume significant alcohol 1

  • For established infections with retained hardware, at least 3 months of suppressive antibiotics may be required 1
  • Staphylococcal infections can be treated with appropriate antibiotics based on sensitivity 1

• Nonunion: Associated with other injuries to the ipsilateral hand, vein repair, and external fixator as initial treatment 3

• Secondary amputation: May be necessary in severely crushed or devascularized digits 3

Prognosis

• Most open finger fractures result from crush injuries or falls and require only simple operative treatments: debridement, lavage, and early mobilization 4
• Approximately 25% of open finger fractures will need more than one surgical procedure, especially in more severely injured fingers due to crush mechanism or with vascular impairment 3
• Fractures involving the thumb have lower reoperation rates, while fractures involving the proximal phalanx have poorer outcomes 3

Special Considerations

• Avoid overly aggressive debridement, as it may remove marginally viable tissue that could survive due to collateral blood flow 1
• Tetanus prophylaxis should be administered to patients without vaccination within the past 10 years 1
• Activate emergency response immediately if the extremity appears blue, purple, or pale, indicating vascular compromise 1