Optimal timing and best treatment of open fractures have been debated. For certain at-risk lower-extremity fracture types, authors have advocated staged treatment protocols consisting of initial irrigation, débridement, and external fixation with definitive fixation occurring after adequate repeat débridement of necrotic or infected tissue, soft tissue recovery, and adequate resuscitation.1–8 This has also become the preferred strategy for patients with multiple traumatic injuries who are in unstable condition4,7 and for fractures with tenuous soft tissue envelopes, such as high-energy tibial plateau, pilon, and calcaneus fractures,1–3,5,6,8 with which immediate plating has led to unacceptable rates of complication and infection.
Limited data are available regarding the staged treatment of open fractures of the upper extremity. Conflicting results have been published on the use of staged treatment protocols in the fixation of fractures of the distal humerus9,10 and diaphyseal both-bone forearm fractures.11–13 Few data exist to guide clinicians regarding the best treatment of open fractures of the distal radius, and no particular treatment protocol has been agreed upon.14–18 The current study aimed to characterize the surgical and functional outcomes of open fractures of the distal radius in patients younger than 65 years.
Materials and Methods
After institutional review board approval was obtained, an 8-year retrospective review (January 2005 through December 2012) was conducted of the fracture database at the authors' level I trauma center. During that period, 195 open fractures of the distal radius were treated, 115 of which were sustained by 113 patients who were 16 to 64 years old. Consent for surgery for patients younger than 18 years was obtained from the patients' parents or legal guardian. All follow-up for minors was done in conjunction with the patients' parents or legal guardian. Open fracture was defined as fracture of the distal radius with associated open wound at the wrist (ulnar or radial). Twenty-one patients were lost to follow-up before 3 months and were excluded. The 3-month minimum follow-up time was chosen based on the Centers for Disease Control and Prevention definition of surgical site infection,19 which was the current authors' primary outcome measure. Ninety-two patients (94 fractures) met inclusion criteria and formed the study cohort. A power analysis was conducted using G*Power20 to estimate the number of fractures required to achieve a power level of 0.8 with alpha set at 0.05. The analysis revealed that to detect a small (w=0.1), medium (w=0.3), and large (w=0.5) effect size, as indicated by Cohen,21 785, 88, and 32 fractures would be required, respectively. This study was powered to detect a medium effect size. Of the 94 definitive fixation operations, 84 were performed by 2 hand fellowship-trained attending surgeons (R.A.P., W.A.E.) and 10 were performed by 2 trauma fellowship-trained attending surgeons (J.T., R.V.O.). The majority (n=74) of patients were treated by the senior author (W.A.E.).
Initial management of all fractures included anteroposterior and lateral view injury radiographs, traction radiographs,22 closed reduction, copious irrigation of the open wound with 1 L of normal saline, and splinting in the trauma resuscitation unit. Computed tomographic scans were not typically obtained. Tetanus prophylactic and cefazolin (or a suitable substitute) were immediately administered to all patients and were continued for 24 to 48 hours postoperatively. The timing of initial surgery depended on several factors, including patient stability, injury severity, and operating room availability. Efforts were made to perform the initial débridement within 24 hours after injury, with a preference for treating more severe wounds earlier if possible (Table 1). In the operating room, the zone of injury was thoroughly explored and underwent débridement and irrigation with saline. Cultures were not obtained at the time of initial débridement or at subsequent débridement procedures. The decision to proceed with definitive fixation was made based on surgeon discretion, which was determined by many factors, including associated injuries, patient stability, amount of contamination to wound, environment in which fracture occurred, and patient comorbidities.
Patients were considered to be in the staged treatment group if after the first operative débridement procedure a return to the operating room was planned for additional fixation. Twenty-nine total patients underwent staged treatment: 8 because of extensive soft tissue injury, 9 because the patient was too medically unstable to undergo definitive fixation at the time of initial débridement, 2 because of gross contamination, 7 because the attending surgeon on call was not comfortable definitively fixing the fracture at night, and 3 because they had external fixation applied at an outside hospital before being transferred for definitive fixation. All 3 patients who were transferred from an outside hospital with external fixation applied underwent definitive open reduction and internal fixation (ORIF) at the authors' institution. In addition, all patients in the immediate fixation group had definitive fixation performed at the authors' hospital. Postoperatively, patients were examined at 2 weeks and at regular intervals thereafter. In cases without external fixation, after the operative splint was removed, each patient received a cast or brace depending on soft tissue healing. Radiographs were obtained at all postoperative visits and were assessed for reduction, union, and fixation device issues.
Electronic documentation and radiographs were reviewed to determine patient demographics, injury characteristics, radiographic classification, treatment variables, and outcomes. Radiographic classification was determined based on the Arbeitsgemeinschaft für Osteosynthesefragen and Orthopaedic Trauma Association (AO/OTA) system.23 Gustilo open fracture classification was determined from the operative report.24 The primary surgical outcome was development of deep surgical site infection, defined by a need for repeat surgical débridement. The secondary surgical outcome was surgical complications requiring repeat operation. Complications and reoperations were recorded from the patient charts, and functional outcome was assessed based on wrist range of motion.
Statistical analysis was performed using SPSS software (IBM Corporation, Armonk, New York). Two-tailed t tests for continuous variables and 2-sided chi-square analyses for dichotomous variables were conducted.
Patient demographics and injury characteristics are summarized in Table 2. Patients were followed for an average of 30 months (range, 3–95 months). Sixty-six male and 26 female patients were included. The average patient age was 41 years (range, 16–64 years). Thirty-six patients had documented medical or psychiatric comorbidities. Sixty-nine percent of fractures were AO/OTA grade C3. In terms of soft tissue injury, 32%, 35%, and 33% of fractures were Gustilo type I, II, and III, respectively. Two of the Gustilo type III fractures were type IIIB. Forty-five (49%) of 94 fractures of the distal radius were associated with ipsilateral upper-extremity injury. Fifty-two (57%) of 92 patients had other orthopedic injuries, and 44 (48%) had accompanying nonorthopedic injuries. No differences were observed between the immediate definitive fixation group and the staged treatment group in terms of fracture classification, associated ipsilateral upper extremity, orthopedic injuries, and nonorthopedic injuries. The soft tissue injuries were more severe in the staged treatment group (Table 2).
Patient Demographics and Injury Characteristics
Fifty-four (58%) of 94 fractures underwent initial débridement within 12 hours of presentation, and 81 (87%) underwent initial débridement within 24 hours (Table 1). Five patients had been transferred to the authors' center without sufficient documentation to determine the time to initial débridement. In the staged treatment group, patients underwent an average of 3 débridement procedures before definitive fixation at an average of 4 days after initial débridement (Table 1). Definitive fixation was internal only in 51 fractures, external only in 2 fractures, and a combination of internal and external in 41 fractures (Table 1). Of the 2 fractures classified as Gustilo type IIIB, 1 received a pedicled groin flap and 1 received a free anterolateral thigh flap.25,26
The overall infection rate of open fractures of the distal radius in this study was 15% (14 infections in 94 fractures). Seven (11%) of 64 fractures in the immediate definitive fixation group developed infection compared with 7 (23%) of 30 fractures in the staged treatment group (P=.13). Infection rates increased according to type of open injury, with rates of 3%, 12%, and 32% for Gustilo types I, II, and III, respectively. Of the 14 infections, 10 were culture-negative, 2 grew methicillin-sensitive Staphylococcus aureus (osteomyelitis), 1 grew Clostridium botulinum (farm injury), and 1 grew Serratia marcescens (osteomyelitis). Eight infections were treated with intravenously administered antibiotics, 4 of them with 6 weeks of antibiotics for osteomyelitis. Six infections were treated with orally administered antibiotics, with courses typically ranging from 10 to 14 days. Regarding the authors' secondary outcome of surgical complications requiring reoperation, 21 (33%) of 64 fractures in the immediate definitive fixation group required reoperation compared with 15 (50%) of 30 in the staged treatment group (P=.11) (Table 3). Three nonunions required revision ORIF, and all had healed successfully by final follow-up. Thirteen (14%) of the 92 patients in the study group required removal of the fixation devices independent of infection.
Patients in the staged treatment group had an increased proportion of high-grade open injuries. To account for the presence of selection bias of worse injuries being treated in a staged fashion, the authors conducted a subgroup analysis for their primary and secondary outcomes based on soft tissue injury (Table 4). Ten percent of type II open fractures in the immediate definitive fixation group developed infection compared with 17% in the staged treatment group (P=.55). Thirty-eight percent of type II injuries in the immediate definitive fixation group required reoperation compared with 42% in the staged treatment group (P=.84). Twenty-seven percent of patients with type III injuries who underwent immediate definitive fixation developed infection compared with 31% who underwent staged treatment (P=1). Forty-seven percent who underwent immediate definitive fixation required reoperation vs 56% who underwent staged treatment (P=.59).
Complications According to Soft Tissue Injury
Range of motion data were available for 62 patients at an average of 8 months after injury. Patients maintained an average of 36° (95% confidence interval, 27° to 41°) of wrist flexion, 39° (95% confidence interval, 33° to 45°) of wrist extension, 63° (95% confidence interval, 52° to 66°) of pronation, and 63° (95% confidence interval, 57° to 74°) of supination (Table 5).
The authors aimed to characterize the surgical and functional outcomes of open fractures of the distal radius in patients younger than 65 years. These fractures have not been extensively investigated; studies have small sample sizes and widely varied outcomes. Nyquist and Stern17 noted sensory deficits, diminished range of motion, and wrist pain in 6 patients with open radiocarpal fracture dislocations. Rozental et al18 reviewed 18 injuries treated with immediate definitive fixation, yielding similarly poor outcomes; 23 complications occurred, including 8 infections and 5 nonunions. Gluek et al14 reported a 7% infection rate, with nearly one-third of the fractures treated in a staged fashion; they correlated wound contamination with development of postoperative infection. Kurylo et al16 reported no infections and 8 reoperations in 32 patients with open fractures of the distal radius; 60% of patients who underwent staged treatment required secondary surgery. The authors associated staged treatment with increased scarring and reoperation and concluded that immediate definitive ORIF is safe in the majority of cases.
The current authors prefer definitive ORIF in the management of open upper-extremity fractures if the soft tissues allow for definitive fixation. Immediate fixation often affords patients earlier mobilization and spares the need for reoperation.25 Definitive ORIF also allows less bulky dressings and definitive soft tissue coverage (either flap or skin graft) in a timelier manner. The rate of surgical site infection in the current study was 15%, which correlates well with published infection rates of 0 to 44% in other studies assessing open fractures of the distal radius.14–18 Compared with previous reports, the current authors had a high proportion of type III injuries.17,18 As expected, their infection rate showed a trend toward higher infections in more severe Gustilo types of open injury.18 Staged treatment of fractures was associated with a higher postoperative infection rate than that of the immediate definitive fixation group (23% vs 11%, respectively). Subgroup analysis examining infection rates with Gustilo fracture type in isolation revealed similar infection rates when Gustilo type II or III injuries underwent staged treatment vs immediate definitive fixation. However, the current authors had limited power to adequately perform the subgroup analysis and the data trended toward higher infection rates in the staged group. The authors' data suggest that infection in open fractures of the distal radius is driven by soft tissue injury and contamination regardless of the timing of fixation.
In the current study, reoperation was required for 33% of fractures that underwent immediate definitive fixation and 50% that underwent staged treatment. As expected, reoperation rates increased according to types of open injury. Higher energy injuries required a higher proportion of major reoperation (fusions, nonunion corrections) compared with lower energy injuries, which mostly required fixation device removal. Rozental et al18 reported a similarly high reoperation rate in their initial series of 18 patients. Kurylo et al16 reported a need for secondary surgery in only 8 of their 42 patients. However, their study population included only 11 type II and 2 type III open injuries. Sixty percent of their patients treated with a staged protocol required further surgery, predominantly for stiffness. The current authors agree with the conclusion presented by Kurylo et al that staged treatment likely leads to increased scarring and the need for further surgery.
The current patients maintained an average arc of motion of 75° of flexion-extension and 126° of pronation-supination, similar to previously reported findings.18 Functional results after open fractures of the distal radius are variable and seem dependent on initial soft tissue injury and avoidance of complications, regardless of treatment strategy.
This study had several limitations. It was a retrospective review without a control group. Although the study population was substantially larger than those in previous reports, only 94 fractures were available for review, rendering subgroup analyses difficult. The subgroup analysis assessing Gustilo classification in isolation was underpowered. Although the average duration of follow-up was 30 months, the authors included all patients with more than 3 months of follow-up based on the definition of surgical site infection presented in the Centers for Disease Control and Prevention guidelines.19 Although the majority of postoperative infections and complications occur during the first 3 months, it is possible that some patients developed unobserved complications and sought treatment elsewhere.
This study had the potential for selection bias. It seemed possible that unstable patients with high-grade wounds would most likely undergo initial débridement later, be treated in a staged fashion, and suffer subsequent operative complications and decreased function. To investigate that possible bias, the authors conducted several analyses. They found that patients who were treated with acute and staged protocols had similar rates of ipsilateral upper-extremity injuries, other major orthopedic injuries, and major nonorthopedic injuries (Table 2). In addition, significantly more of the patients undergoing staged treatment had undergone initial débridement less than 12 hours after presentation, consistent with the aggressive treatment of worse wounds (Table 1). However, a greater proportion of high-grade soft tissue injuries were in the staged treatment group. The authors therefore conducted subgroup analyses within each Gustilo type and found infection rates to be similar for patients who had undergone staged treatment who had type II (17% vs 10%) and type III (31% vs 27%) injuries. These subgroup analyses, however, were underpowered.
The current data suggest that deep surgical site infections and surgical complications associated with open fractures of the distal radius are driven by soft tissue injury. Patients with high-grade open injuries can obtain functional range of motion in the short term. Larger multicenter studies with better characterization of the wound are needed to help elucidate whether immediate fixation is really comparable to staging.
- Egol KA, Tejwani NC, Capla EL, Wolinsky PL, Koval KJ. Staged management of high-energy proximal tibia fractures (OTA types 41): the results of a prospective, standardized protocol. J Orthop Trauma. 2005;19(7):448–455. doi:10.1097/01.bot.0000171881.11205.80 [CrossRef]
- Haidukewych GJ. Temporary external fixation for the management of complex intra- and periarticular fractures of the lower extremity. J Orthop Trauma. 2002;16(9):678–685. doi:10.1097/00005131-200210000-00012 [CrossRef]
- Nowotarski PJ, Turen CH, Brumback RJ, Scarboro JM. Conversion of external fixation to intramedullary nailing for fractures of the shaft of the femur in multiply injured patients. J Bone Joint Surg Am. 2000;82(6):781–788. doi:10.2106/00004623-200006000-00004 [CrossRef]
- Pape HC, Tornetta P III, Tarkin I, Tzioupis C, Sabeson V, Olson SA. Timing of fracture fixation in multitrauma patients: the role of early total care and damage control surgery. J Am Acad Orthop Surg. 2009;17(9):541–549. doi:10.5435/00124635-200909000-00001 [CrossRef]
- Parekh AA, Smith WR, Silva S, et al. Treatment of distal femur and proximal tibia fractures with external fixation followed by planned conversion to internal fixation. J Trauma. 2008;64(3):736–739. doi:10.1097/TA.0b013e31804d492b [CrossRef]
- Patterson MJ, Cole JD. Two-staged delayed open reduction and internal fixation of severe pilon fractures. J Orthop Trauma. 1999;13(2):85–91. doi:10.1097/00005131-199902000-00003 [CrossRef]
- Roberts CS, Pape HC, Jones AL, Malkani AL, Rodriguez JL, Giannoudis PV. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma. Instr Course Lect. 2005;54:447–462.
- Sirkin M, Sanders R, DiPasquale T, Herscovici D Jr, . A staged protocol for soft tissue management in the treatment of complex pilon fractures. J Orthop Trauma. 1999;13(2):78–84. doi:10.1097/00005131-199902000-00002 [CrossRef]
- Kloen P, Helfet DL, Lorich DG, Paul O, Brouwer KM, Ring D. Temporary joint-spanning external fixation before internal fixation of open intra-articular distal humeral fractures: a staged protocol. J Shoulder Elbow Surg. 2012;21(10):1348–1356. doi:10.1016/j.jse.2012.01.015 [CrossRef]
- Min W, Ding BC, Tejwani NC. Staged versus acute definitive management of open distal humerus fractures. J Trauma. 2011;71(4):944–947. doi:10.1097/TA.0b013e31820efd69 [CrossRef]
- Duncan R, Geissler W, Freeland AE, Savoie FH. Immediate internal fixation of open fractures of the diaphysis of the forearm. J Orthop Trauma. 1992;6(1):25–31.
- Jones JA. Immediate internal fixation of high-energy open forearm fractures. J Orthop Trauma. 1991;5(3):272–279. doi:10.1097/00005131-199109000-00004 [CrossRef]
- Moed BR, Kellam JF, Foster RJ, Tile M, Hansen ST Jr, . Immediate internal fixation of open fractures of the diaphysis of the forearm. J Bone Joint Surg Am. 1986;68(7):1008–1017. doi:10.2106/00004623-198668070-00007 [CrossRef]
- Glueck DA, Charoglu CP, Lawton JN. Factors associated with infection following open distal radius fractures. Hand (N Y).2009;4(3):330–334. doi:10.1007/s11552-009-9173-z [CrossRef]
- Jawa A. Open fractures of the distal radius. J Hand Surg Am. 2010;35(8):1348–1350. doi:10.1016/j.jhsa.2010.06.008 [CrossRef]
- Kurylo JC, Axelrad TW, Tornetta P III, Jawa A. Open fractures of the distal radius: the effects of delayed débridement and immediate internal fixation on infection rates and the need for secondary procedures. J Hand Surg Am. 2011;36(7):1131–1134. doi:10.1016/j.jhsa.2011.04.014 [CrossRef]
- Nyquist SR, Stern PJ. Open radiocarpal fracture-dislocations. J Hand Surg Am. 1984;9(5):707–710. doi:10.1016/S0363-5023(84)80018-0 [CrossRef]
- Rozental TD, Beredjiklian PK, Steinberg DR, Bozentka DJ. Open fractures of the distal radius. J Hand Surg Am. 2002;27(1):77–85. doi:10.1053/jhsu.2002.30073 [CrossRef]
- Centers for Disease Control and Prevention. CDC/NHSN Surveillance Definition of Healthcare-Associated Infection and Criteria for Specific Types of Infections in the Acute Care Setting. Washington, DC: National Healthcare Safety Network; 2013.
- Faul F, Erdfelder E, Lang AG, Buchner A. G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences. Behav Res Methods. 2007;39(2):175–191. doi:10.3758/BF03193146 [CrossRef]
- Cohen J.Statistical Power Analysis for the Behavioral Sciences. 2nd ed. London: Routledge; 1988.
- Goldwyn E, Pensy R, O'Toole RV, et al. Do traction radiographs of distal radial fractures influence fracture characterization and treatment?J Bone Joint Surg Am.2012;94(22):2055–2062. doi:10.2106/JBJS.J.01207 [CrossRef]
- Kreder HJ, Hanel DP, McKee M, Jupiter J, McGillivary G, Swiontkowski MF. Consistency of AO fracture classification for the distal radius. J Bone Joint Surg Br. 1996;78(5):726–731. doi:10.1302/0301-620X.78B5.0780726 [CrossRef]
- Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453–458. doi:10.2106/00004623-197658040-00004 [CrossRef]
- Lister G, Scheker L. Emergency free flaps to upper extremity. J Hand Surg Am. 1988;13(1):22–28. doi:10.1016/0363-5023(88)90193-1 [CrossRef]
- Ninkovic M, Deetjen H, Ohler K, Anderl H. Emergency free tissue transfer for severe upper extremity injuries. J Hand Surg Br. 1995;20(1):53–58. doi:10.1016/S0266-7681(05)80017-8 [CrossRef]
|Characteristic||Study Fractures (N=94)||Immediate Definitive Fixation (n=64)||Staged Fixation (n=30)|
|Time to initial débridement, No. (%)|
| 0–6 h||26 (28)||11 (17)||15 (50)|
| 7–12 h||28 (30)||21 (33)||7 (23)|
| 13–24 h||27 (29)||26 (41)||1 (3)|
| 25–48 h||6 (6)||4 (6)||2 (7)|
| >48 h||2 (2)||1 (1.5)||1 (3)|
| Unknown||5 (5)||1 (1.5)||4 (14)|
|Débridement procedures, average no.||3|
|Time to definitive fixation, average, d||3.7|
|Definitive fixation, No. (%)|
| Internal fixation alone||51 (55)||44 (69)||7 (23)|
| External fixation alone||2 (2)||2 (3)|
| Internal and external fixation||37 (39)||14 (22)||23 (77)|
| Other||4 (4)||4 (6)|
Patient Demographics and Injury Characteristics
|Characteristic||Study Group||Immediate Definitive Fixation||Staged Fixation||P|
|Age, average (range), y||41 (16–64)||40||41||.71a|
|Male:female, No. (%)||66:26 (72:28)||45:18 (71:29)||22:7 (76:24)|
|Follow-up, average, mo||30||27||38||.08a|
|Mechanism of injury, No. (%)|
| Fall||42 (45)||29 (45)||13 (43)|
| Motor vehicle crash||41 (43)||25 (39)||16 (54)|
| Gunshot wound||8 (9)||7 (11)||1 (3)|
| Other||3 (3)||3 (5)|
|Fracture classification, No. (%)b|
| A2||2 (2)||2 (3)||-|
| A3||11 (12)||7 (11)||4 (13)|
| B1||2 (2)||1 (1)||1 (4)|
| B3||1 (1)||1 (1)||-|
| C1||1 (1)||1 (1)||-|
| C2||12 (13)||8 (14)||4 (13)|
| C3||65 (69)||44 (69)||21 (70)|
|Soft tissue classification, No. (%)c|
| I||30 (32)||28 (43)||2 (7)|
| II||33 (35)||21 (33)||12 (40)|
| IIIA||27 (29)||14 (22)||13 (43)|
| IIIB||2 (2)||-||2 (7)|
| IIIC||2 (2)||1 (2)||1 (3)|
|Associated injuries, No. (%)|
| Ipsilateral upper extremity||45 (49)||32 (51)||13 (45)||.66d|
| Other orthopedic||52 (57)||33 (52)||19 (66)||.38d|
| Nonorthopedic||44 (48)||29 (46)||15 (52)||.83d|
|Study Fractures (N=94)||Immediate Definitive Fixation (n=64)||Staged Fixation (n=30)|
|Reoperation||36 (38)||21 (33)||15 (50)||.11|
|Infection||14 (15)||7 (11)||7 (23)||.13|
|Stiffness||6 (6)||2 (3)||4 (13)|
|Fusion||3 (3)||1 (2)||2 (7)|
|Other soft tissue||9 (10)||4 (6)||5 (17)|
|Bony||6 (6)||4 (6)||2 (7)|
|Nonunion with revision open reduction and internal fixation||3 (3)||2 (3)||1 (3)|
|Fixation device removal||13 (14)||8 (13)||5 (17)|
Complications According to Soft Tissue Injury
|Injury and Complication||Study Fractures (N=94)||Immediate Definitive Fixation (n=64)||Staged Fixation (n=30)||Pa|
|Type I open fractures, No.||30||28||2|
| Reoperation, %||23||21||50||.36|
| Infection, %||3||4||-||.79|
|Type II open fractures, No.||33||21||12|
| Reoperation, %||39||38||42||.84|
| Infection, %||12||10||17||.55|
|Type III open fractures, No.||31||15||16|
| Reoperation, %||52||47||56||.59|
| Infection, %||29||27||31||1|
|Outcome||Study Fractures||Immediate Definitive Fixation||Staged Fixation||Pa|
|Time to final range of motion, average, mo||8||8||9|
|Range of motion, average (95% confidence interval), degrees|
| Wrist flexion||36 (27–41)||39 (24–43)||35 (25–45)||.47|
| Wrist extension||39 (33–45)||41 (33–50)||37 (26–44)||.29|
| Pronation||63 (52–66)||65 (50–70)||62 (45–68)||.58|
| Supination||63 (57–74)||65 (60–79)||59 (42–75)||.35|