PURPOSE: To determine how time to surgical debridement and fixation affects infection and complication rate in type I open distal radius fractures by comparing patients treated within 24 hours with those treated >24 hours post-injury. METHODS: A retrospective review identified 62 patients who sustained a type I open distal radius fracture that was treated surgically. Patients were stratified into groups based on time to surgical intervention. An additional analysis was performed on patients with an isolated type I open distal radius fracture treated as an inpatient or outpatient. The primary outcome measure was infection rate. Secondary outcome measures were complications, reoperations, and readmissions. RESULTS: Thirty-eight patients underwent surgery ≤24 hours post-injury at an average of 14 hours. Twenty-four patients underwent surgery >24 hours post-injury at an average of 72 hours. There were a total of 9 complications in 8 patients (14.5%). The overall infection rate was 1.6%, with only 1 deep infection occurring in the group treated ≤24 hours post-injury. There were 7 reoperations (11.3%) and 1 readmission (1.6%). No differences were found between groups in any outcome measure. In the 27 patients with an isolated fracture, there were no differences in any outcome measure when treated as an inpatient or outpatient. CONCLUSIONS: We suggest that type I open distal radius fractures could be safely treated surgically >24 hours post-injury without increased risk of infection.

Open fractures are often classified according to a system described by Gustilo and Anderson. However, this system was applied to open long bone fractures, which may not predict the incidence of infection in open metaphyseal fractures of the upper extremity. Other studies have found that wound contamination and systemic illness were the best predictors of infections in open hand fractures. Our study assessed infection in open distal radius fractures and identifies factors that are associated with these infections. We hypothesize that contamination, rather than absolute wound size, is the best predictor of infection associated with open distal radius fractures. A review by CPT code yielded 42 patients with open distal radius fractures between 1997 and 2002 treated at a level one trauma center. Medical records and radiographic follow-up were reviewed to assess the time to irrigation and debridement, the number of debridements in initial treatment period, the method of operative stabilization, the Gustilo and Anderson type of fracture, the Swanson type of fracture, and description of wound contamination. Forty-two patients were followed up for an average of 15 months (range 4 to 68 months). Twenty-four fractures were classified as Gustilo and Anderson type I, ten were type II, and eight were type III, 30 were Swanson type I, and 12 were Swanson type II. Five of the 42 fractures were considered contaminated. Two were exposed to fecal contamination. The others were contaminated with tar, dirt/grass, and gravel, respectively. Three of 42 (7%) fractures developed infections. All three infected cases received a single irrigation and debridement. Two of five contaminated fractures (40%) developed a polymicrobial infection. Both were exposed to fecal contamination and, therefore, considered Swanson type II fractures. They were classified as Gustilo and Anderson type II and IIIB based solely upon the size of the wound. Both required multiple debridements and eventually wrist fusions. The third infection occurred in a Gustilo and Anderson type II and Swanson type I open fracture treated with one debridement and plate fixation. Hardware removal, debridement, and antibiotics resolved the infection. Three contaminated fractures that healed uneventfully received two debridements. Statistical analysis revealed a correlation with infection and contamination (p = 0.0331). The number of initial debridements played a role in infection, but was not statistically significant. No relationship between infection and time to initial irrigation and debridement, method of fixation, Gustilo and Anderson type, or Swanson type was found. We propose that open distal radius fractures behave differently than open long bone fractures. Infection developed in 7% of the distal radius fractures in our study and was significantly associated with wound contamination. We recommend that contamination be included as factor for prognosis in open distal radius fractures. Contaminated fractures should be treated with multiple debridements as part of the initial plan not based upon subsequent development of an infection.

BACKGROUND: Type I open distal radius fractures treated with open reduction internal fixation (ORIF) have demonstrated minimal risk of infection. For this reason, they may not require urgent surgical treatment. The purpose of this study was to evaluate the outcomes of patients with type I open distal radius fractures treated with delayed ORIF compared with urgent ORIF. METHODS: We identified all Gustilo-Anderson type I open distal radius fractures that had undergone ORIF using volar plating over a 5-year period. Patients were stratified into those treated urgently within 24 hours and those scheduled for delayed surgery. Outcomes including functional scores, complications, reoperations, and radiographic measures were compared. RESULTS: Twenty-four patients (17 treated urgently and 7 treated delayed) had open type I distal radius fractures. All patients were started on empiric antibiotics at initial presentation-patients in the delayed treatment group were prescribed oral antibiotics, whereas those admitted for urgent treatment received intravenous antibiotics. There were no infections in either group and a single reoperation in each group. The mean postoperative Quick Disabilities of the Arm, Shoulder, and Hand score was 29 (range = 0-77) and did not differ significantly between delayed (mean = 19) and urgent (mean = 38) treatment. Rate of complications and radiographic measures did not differ significantly between the groups. CONCLUSIONS: Type I open distal radius fractures appear amenable to delayed outpatient ORIF provided that the wound is clean at the time of initial presentation and that antibiotics are initiated appropriately. Further prospective studies comparing delayed and urgent treatment strategies are warranted.

Purpose: Controversy exists on the urgency of operative treatment for low energy open distal radius fractures. Two medical centers shifted practice and no longer take all open distal radius fractures emergently to the operating for debridement. The purpose of this study is to provide preliminary data to evaluate if this is associated with unacceptably high infection rates. Methods: A retrospective chart review was performed for 55 open distal radius fractures in 54 patients at two level one trauma centers. Patients underwent irrigation and closed reduction in the emergency department followed by definitive closed treatment or operative treatment with surgical irrigation, debridement, and fixation, either within 24 hours or after discharge. The main outcome measure was infection, with secondary outcomes of complications or secondary procedures. Results: In this cohort, 4 of 55 patients experienced infections (7.2%.) There were no infections in low energy injuries. Twenty-four patients went to the operating room 2 or more days from presentation or were treated nonoperatively with only 1 postoperative infection (4.2%). All infections were in high energy mechanism injuries with at least one additional risk factor: smoking, polytrauma, or Gustilo Anderson type 2 injury. Conclusions: These data suggest that in patients with low energy injury mechanisms and type 1 injuries, delay in formal operative debridement is not associated with an elevated infection risk in this small case series. Future prospective studies with larger sample sizes are needed to definitively evaluate whether some open distal radius fracture patterns may not require emergent operative debridement. Type of study/level of evidence: Prognostic IV.

PURPOSE: To report radiographic, clinical, and patient-based functional outcomes following contemporary operative treatment of patients who sustained an open distal radius fracture and compare them to a similar group of patients treated operatively for closed distal radius fractures. METHODS: Over five years, 601 patients with a distal radius fracture presented to our academic medical center, including one Level 1 trauma hospital, and were prospectively enrolled in an upper extremity trauma database. Patients with open distal radius fractures underwent irrigation, debridement, and operative fixation within 24 hours of presentation. Closed distal radius fractures requiring operative fixation were treated electively. Retrospective review of the database identified eighteen open fractures of the distal radius (11 type I, 6 type II, 1 type IIIa). The open fracture patients were individually matched with eighteen closed distal radius fracture patients who underwent surgical fixation based on age, sex, injury to dominant extremity, fracture pattern, and method of fracture fixation. Clinical, radiographic, patient- based functional outcomes, and complications were recorded at routine postoperative intervals. RESULTS: Follow-up was greater than 77% in both groups at all time points. The open and closed groups were similar in regards to age, gender, BMI, race, tobacco use, income, employment status, hand dominance, injury to dominant extremity, mechanism of injury, fracture classification, method of fracture fixation, and presence of concomitant injury. Postoperative complications and reoperation rates were similar between the open and closed groups. Union rates and radiographic alignment one year postoperatively were similar between the open and closed fracture groups. At final follow-up, range of motion parameters, grip strengths, DASH indices, and subjective pain scores were similar between both groups. DISCUSSION: Open distal radius fractures treated with early debridement and fixation achieved similar outcomes to surgically treated closed fractures of the distal radius when followed for a year or more postoperatively.

BACKGROUND: This study investigates whether open distal radius fractures (ODRFs) treated after 24 hours from time of injury have an increased risk of infection or overall complication profile compared with those treated within 24 hours. METHODS: Retrospective review was performed of all patients treated for ODRF over a 6-year period at a single large academic institution. Postoperative complications included surgical site infections, need for revision irrigation and debridement, delayed soft tissue healing, loss of reduction, nonunion, and malunion. RESULTS: One-hundred twenty patients were treated for ODRF. Mean (SD) age at time of injury was 59.92 (17.68) years. Twenty patients (16.7%) had postoperative complications. Regarding mechanism of injury, 78 (65.0%) had a low-energy and 42 (35.0%) had a high-energy injury. Age and fracture grade were not significant factors. Mean (SD) open wound size was 1.18 (1.57) cm. Mean (SD) time from injury presentation to the emergency department (ED) and first dose of intravenous antibiotics was 3.07 (4.05) hours and mean (SD) time from presentation to the ED and operative treatment was 11.90 (6.59) hours, which did not show a significant association with postoperative complications. Twenty-four patients (20.0%) were treated greater than 24 hours after presentation to the ED, which was not significantly distinct from those treated within 24 hours. CONCLUSION: Patients with ODRFs treated after 24 hours were not associated with a greater risk of postoperative complications. Factors including age, energy and mechanism of injury, and fracture grade did not alter outcome in any statistically significant manner. LEVEL OF EVIDENCE: Level IV.

Purpose: There is limited published evidence regarding the optimal management of type I open fractures of the distal radius. The purpose of this study was to compare short-term complication rates among open fractures of the distal radius, with attention to the timing of management of type I fractures. Our hypothesis was that there would not be a temporal association between treatment and infection for type I open distal radius fractures (DRFs). Methods: A retrospective review of all open DRFs at a single level-1 trauma center over a 10-year period was performed. Patients were grouped based on Gustilo Anderson open fracture classification. The primary outcome measures were superficial and deep infection rates in all patients with a minimum of 6-month follow-up. A subgroup analysis was performed for Gustilo Anderson type I injuries with a 3-month follow-up based on time to surgery. Results: Seventy-one patients with open DRFs were included for analysis with an average follow-up of 16.7 months. There was a higher rate of deep infection (30%) and average number of revision surgeries (3.0) in the type III cohort compared with both type II (4% and 0.6) and type I (0% and 0.39) cohorts. A subgroup analysis of 63 type I fractures with a minimum of 3-month follow-up revealed zero infections, with no difference in other complications or number of revision surgeries among patients definitively managed within 24 hours, 24-72 hours, and greater than 72 hours. Two patients were managed nonoperatively, without complication. Conclusions: Type I open DRFs differ from higher grade DRFs with regard to demographics and injury characteristics, along with infection, complication, and reoperation rates. With no infections in the type I DRF cohort and no difference in complication rates based on time to debridement, our data suggest that it is safe to manage type I open DRFs similarly to closed injuries regarding surgical timing. Type of study/level of evidence: Therapeutic III.

The authors aimed to characterize surgical and functional outcomes of open fractures of the distal radius in patients younger than 65 years. At their level I trauma center, the authors conducted a retrospective review of 92 patients (age range, 16-64 years) who had 94 open fractures of the distal radius (average follow-up, 30 months; range, 3-95 months). Sixty-four fractures received definitive treatment at the time of initial débridement; 30 received definitive fixation and soft tissue coverage after staged débridement. Primary surgical outcome was development of deep surgical site infection requiring repeat surgical débridement; secondary surgical outcome was surgical complications requiring reoperation. Functional outcome was assessed by wrist range of motion. Overall infection rate was 15% (14 of 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 ( $P=.13$ ). Twenty-one (33%) of 64 fractures in the immediate definitive fixation group required reoperation compared with 15 (50%) of 30 in the staged treatment group ( $P=.11$ ). Deep surgical site infections and surgical complications associated with open fractures of the distal radius are driven by soft tissue injury. [_Orthopedics_. 2019; 42(4):219-225.]