Anteroposterior radiograph of the right hand.
Photograph depicting wound sustained over the dorsum of the right hand.
A 28-year-old man presents to the office 6 days after striking a wall with his right hand. He went to an urgent care facility 4 days ago, at which time he was diagnosed with a distal fifth metacarpal fracture. Anteroposterior radiograph of the right hand was obtained (Figure 1). He was also found to have a wound over the dorsum of the fracture site (Figure 2), which was closed with a fast-acting topical adhesive during the urgent care visit.
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The patient’s hand wound is directly over the displaced metacarpal fracture, which can be assumed to be an open fracture. Fractures of the phalanges and metacarpals are common injuries seen in the emergency department and urgent care setting, and up to 5% are open fractures.1 More than 75% of open hand fractures involve phalangeal fractures.1 Few (if any) treatment guidelines for open fractures of the hand exist.
The Gustilo-Anderson classification for open fractures of the tibia has helped guide treatment of open long bone fractures.2 Compared to long bone fractures, open fractures of the hand more often present with a smaller wound size, variable mechanisms of injury, and unique soft tissue closure options.3 The widely accepted treatment of irrigation and debridement in the operating room within 24 hours for open fractures of the hand is largely based on the recommended (and widely studied) treatment of open long bone fractures. Deep infection after open metacarpal fractures treated without debridement is much more likely (estimated 11% chance) compared with a <1% chance when surgical debridement is performed.1
Open phalangeal fractures can often undergo adequate irrigation and debridement in the emergency department setting under digital block. Open metacarpal fractures require more soft tissue debridement, which requires general anesthesia in the operating room. Although the risk of infection after open metacarpal fractures is small (and less than open long bone fractures), early aggressive debridement plays the most important role in reducing this risk.
Antibiotics should be prescribed to reduce the risk of infection after debridement is performed. This case highlights the need for a high index of suspicion for open hand fractures in the urgent care setting.1-3
Dagan Cloutier, MPAS, PA-C, practices in a multispecialty orthopedic group in the southern New Hampshire region and is editor-in-chief of the Journal of Orthopedics for Physician Assistants (JOPA).
- Shobhit V. Minhas, Louis W. Catalano III. Comparison of open and closed hand fractures and the effect of urgent operative intervention [published online June 13, 2018]. J Hand Surg. doi: 10.1016/j.jhsa.2018.04.032
- 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.
- Diaz-Garcia R, Waljee JF. Current management of metacarpal fractures. Hand Clin. 2013;29:507-518.