Open Fractures and Complex Hand Injuries in Ankara, Turkey

Open fractures and complex hand injuries are serious traumas in which bone integrity is disrupted and soft tissue, nerves, vessels, and tendon structures are affected simultaneously. In such injuries, the risk of infection is high and a multidisciplinary surgical approach is required.

In open fractures, bone ends emerge outside the skin and come into contact with the external environment. This situation increases the risk of bacterial contamination. As an initial intervention, wound cleaning, antibiotic therapy, and temporary stabilization should be provided. Surgical fixation constitutes the second stage.

In complex hand injuries, crushing, amputation, or high-energy occupational accidents are generally involved. In such situations, bone, tendon, vessel, and nerve repairs are planned simultaneously using microsurgical techniques. Anatomical repair of each tissue layer determines functional recovery.

After such surgeries, starting physical therapy early is critically important to preserve hand function. The rehabilitation process should be planned individually and functional recovery should be ensured under long-term follow-up.

What Are Open Fractures and Complex Hand Injuries?

An open fracture is a type of fracture in which the bone comes into contact with the external environment by disrupting the integrity of the skin. Complex hand injuries are serious traumas in which bones, tendons, nerves, vessels, and soft tissues are damaged together. These conditions usually occur as a result of high-energy accidents and carry the risk of infection, loss of function, and permanent disability. Early surgical intervention, appropriate antibiotic treatment, and a multidisciplinary approach increase treatment success.

Why are hand injuries so complex and vitally important?

When you place your hand on the table and look at it, beneath that elegant structure you see lies an incredible crowd and order. Nowhere else in the body are so many critical structures packed into such a narrow space. Imagine that we examine a cross-section of one of your fingers; bones separated by millimetric distances, tendons that allow you to bend your finger, vessels that nourish that area, and nerves that allow you to feel stand shoulder to shoulder.

This crowded arrangement is the fundamental factor that increases the severity of injuries. While a deep cut on your calf may only affect muscle tissue, a cut of similar depth on your hand can simultaneously sever the tendon, nerve, and vessel. This situation almost eliminates the concept of a “simple cut” in hand surgery. For us, a hand injury is not just the disruption of tissue integrity. It is the risk of losing function, meaning movement and sensation.

The functional importance of the hand is directly connected to social and economic life. An individual who cannot use their hand does not only experience a physical disability; they may also lose their independence, become unable to perform their job, and face serious psychological difficulties. For this reason, our approach to complex injuries of the hand is always based on the principle of “maximum preservation and maximum repair.” Our goal is not only to close the wound but to ensure that the hand can hold life again.

What are the most common causes of hand injuries and who are the risk groups?

The picture we see in our clinical practice shows that hand injuries unfortunately affect people in the most productive period of life. The young and middle-aged male population is the group most frequently exposed to these injuries due to occupational accidents and trauma. This situation turns the issue from a medical problem into a social and economic matter.

How the injury occurs, meaning the mechanism, is the first clue that determines our treatment plan. There is a wide spectrum from household accidents to industrial injuries. Knowing the mechanism of injury allows us to predict how much the tissue has been crushed, contaminated, and its healing potential.

Common causes of injury include:

• Glass cuts
• Knife injuries
• Circular saw accidents
• Press machine compressions
• Traffic accidents
• Firearm injuries
• Crush injuries caused by falls

For example, a glass cut caused by a broken glass in the kitchen is generally a “clean” injury. The tissue is cut smoothly and its repair is relatively easier. However, getting the hand caught in an industrial machine or firearm injuries create a much more chaotic picture. In these cases, the tissue is not only cut; it is crushed, fragmented, heated, and sometimes torn off. These high-energy traumas disrupt tissue nutrition and dramatically increase the risk of infection.

What does an open fracture mean and why is it so dangerous?

As a medical term, an “open fracture” refers to a situation far more serious than it sounds. Under normal conditions, our bones are located in a sterile environment isolated from the outside world by muscle and skin layers. In an open fracture, the broken bone ends pierce the skin and emerge outside, or the skin is opened by an external trauma and the bone becomes visible.

The greatest danger of this condition is infection. Bone marrow and deep tissues come into contact with air, dust, clothing fragments, or bacteria on the object that caused the injury. The moment the skin barrier disappears, our body becomes like a defenseless fortress. Bacteria can rapidly descend into deeper tissues and settle in the bone. Bone infection (osteomyelitis) is a very serious complication whose treatment may take months or even years and may sometimes lead to the loss of the limb.

When evaluating open fractures, we use a classification system called “Gustilo-Anderson.” This system allows us to perform a risk analysis according to the size of the wound and the degree of contamination. Sometimes a tiny bone tip emerges from inside to outside, which carries a lower risk (Type 1). Sometimes, however, after a high-energy accident, there may not even be skin left to cover the bone, vessels may be torn, and very severe tissue damage occurs (Type 3). Regardless of the classification, every open fracture requires emergency intervention because every passing hour is an opportunity for bacteria to multiply.

What first aid steps should be applied at the time of injury and until reaching the hospital?

During an accident, especially when there is a serious injury, bleeding, and deformity in the hand, it is very natural to panic. However, maintaining calmness and applying correct first aid prevents further damage to tissues during the time until reaching the hospital.

The first and most important rule is to stop the bleeding. Since the hands and fingers are areas with very intense blood supply, frightening amounts of bleeding may occur even with the smallest cut. What should be done is to apply direct and continuous pressure on the wound with a clean cloth. Applying a tourniquet, meaning tightening the arm from above with a belt or rope, is generally not recommended unless there is a complete amputation. Because although a tourniquet stops the bleeding, it may increase damage by cutting off the blood supply to healthy tissues as well.

The main first aid principles that should be considered are:

• Applying pressure on the wound with a clean cloth
• Keeping the hand above heart level
• Immediately removing jewelry such as rings and watches
• If a fracture is suspected, immobilizing the hand with a rigid cardboard
• Not applying tobacco, ash, or ointment to the wound
• If there is an amputated part, wrapping it with a moist cloth and placing it in ice water
• Not giving the patient food or drink

Especially since the patient is highly likely to undergo surgery, “remaining fasting” is vital for anesthesia safety. Not drinking even water prevents the risk of stomach contents entering the lungs during surgery.

What antibiotic treatments and precautions are taken against the risk of infection?

In open fractures and contaminated hand injuries, the use of antibiotics is not a precaution given with the thought “an infection may occur,” but rather like sending reinforcements to a war that has already begun. Because bacteria have already entered the tissue at the moment of injury. For this reason, antibiotic therapy is started as soon as the patient enters the hospital, even in the emergency department.

The antibiotic to be selected in treatment varies depending on where and how the injury occurred. Every environment has its own bacterial flora, and we surgeons choose our weapon by predicting these “invisible enemies.”

Risk factors that vary according to the source of infection include:

• Soil and agricultural land
• Fresh water sources
• Sea water
• Sewage waste
• Animal bites
• Human bites

For example, in an injury that comes into contact with soil in an agricultural area, the risk of tetanus and gas gangrene is very high; in this case, penicillin group drugs are added to treatment. In sea accidents, special antibiotics effective against bacteria living in salt water are selected. In addition, the patient’s tetanus vaccination history must be questioned. If they have not been vaccinated in the last 5–10 years, protection is provided by administering a vaccine and, if necessary, tetanus immunoglobulin (ready-made antibody).

Why is surgical cleaning and debridement the most critical stage of treatment?

When we enter the operating room, the first thing we do is not to join broken bones or suture vessels. The first and most important stage is the surgical cleaning of the wound that we call “debridement.” Debridement does not simply mean washing the wound; it is the surgical removal of all tissues that have lost their vitality, are crushed, contaminated, and will no longer benefit the body.

Why do we do this so aggressively? Because a piece of dead tissue without blood circulation is a perfect culture medium for bacteria. Antibiotics spread throughout the body through the bloodstream; if a tissue has no blood supply, the medication we give cannot reach that area. Therefore, as long as dead tissue remains there, the risk of infection never ends.

The procedures we perform during debridement include:

• Washing with abundant saline solution
• Removal of foreign bodies
• Excision of dead skin edges
• Cleaning of crushed muscle tissues
• Removal of free bone fragments

Sometimes the wound is so contaminated that a single cleaning is not enough. With the method we call “second-look,” we take the patient back to surgery after 24–48 hours and check the condition of the wound again. No repair (bone, nerve, or tendon repair) performed without obtaining clean, viable, and bleeding tissue can be successful. No building is constructed on an unstable foundation.

How are broken bones surgically stabilized and which materials are used?

The bones that form the skeleton of the hand are the lever arms that carry the load pulled by tendons and enable movement. A broken bone means the collapse of the system. Therefore, fixing (stabilizing) the bones in the correct position and firmly is a prerequisite for healing.

Different fixation methods are used according to the type and location of the fracture and the condition of the wound. Sometimes we place the fracture back in position under X-ray (fluoroscopy) control without opening the skin and insert wires from outside. Sometimes we open it and perform a more rigid fixation with plates and screws.

Commonly used bone fixation methods include:

• Kirschner wires (K-wires)
• Plate and screw systems
• Interfragmentary screws
• External fixators
• Intramedullary nails

K-wires are thin metal rods like skewers and are the most frequently used method. Plates and screws are made of titanium, are very thin, and tightly hold the bone fragments together. The greatest advantage of plate application is that the patient can start moving the finger immediately after surgery.

If the wound is very contaminated or there is bone loss, we use external fixation systems that we call “external fixators.” In this system, screws hold onto the bone but the stabilizing metal rods remain outside the body. This both holds the bone and allows dressing of the contaminated wound.

How do microsurgical techniques make a difference in vascular and nerve repairs?

Perhaps the most fascinating part of hand surgery is microsurgery. It is the process of suturing vessels and nerves that are difficult to see with the naked eye under a microscope with threads much thinner than a strand of hair after being magnified many times. Microsurgery is the technology that allows a severed finger to be reattached or a cut nerve to regain life.

In vascular injuries we race against time. If the artery of a finger or hand is cut, the tissue cannot be nourished and the process of necrosis (death) begins. Bringing these vessels end-to-end and suturing them under the microscope to restore blood flow is of vital importance.

Nerve repairs, however, require patience. Nerves are the electrical cables of the body and when they are cut, both the sensation and motor power of the hand are lost. Even if we repair the nerve sheaths, the nerve fibers must regrow internally. This growth occurs at an average speed of 1 mm per day. Therefore, after a cut at the wrist level, it may take months for sensation to reach the fingertip.

Structures repaired with microsurgery include:

• Digital arteries
• Radial and ulnar arteries
• Median nerve
• Ulnar nerve
• Radial nerve
• Veins