ORIGINAL ARTICLE
Assessing the Variability of Antibiotic Management in Patients
With Open Hand Fractures Presenting to the Pediatric
Emergency Department
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Sophia Görgens, MD, Deepa Patel, MD, Kaitlin Keenan, DO,
Joanna Fishbein, MPH, and Francesca Bullaro, MD
Objectives: Open hand fractures may be difficult to recognize and treat.
There is variability in management and administration of antibiotics for
these types of injuries. Unlike open long bone fractures, there is no stan-
dardized protocol for antibiotic administration for open hand fractures in
children. The objective of this study is to assess the variability of antibiotic
management of open hand fractures in children.
Methods: We performed a retrospective chart review at a tertiary hospital
in New York of patients with hand injuries between ages 0 and 18 years
presenting to the emergency department during January 2019 and
December 2020. Patient encounters were reviewed for open fractures of
the hand. Descriptive statistics were included for demographic and
physical characteristics.
Results: There were 80 encounters with open hand fractures, of which the
most common being tuft fractures (77.5%). The mean age was 7.6 years (SD,
4.7 years) with male predominance (58.8%). Crush injuries were the most
common mechanism of injury (78.8%). Bedside repair was performed on
62 encounters (77.5%), of which 45 (72.5%) required nail bed repair, 56
(90.3%) required suturing, and 24 (38.7%) required reduction. Antibiotics
were given to 62 (77.5%) encounters, most commonly oral cefalexin
(45.2%), oral amoxicillin-clavulanic acid (27.4%), and intravenous cefazolin
(14.5%). Median time to antibiotics from emergency department registration
to administration was 150 minutes (interquartile range, 92–216 minutes).
Antibiotic prescriptions were sent for 71 encounters (88.8%). Seventy seven
(96.3%) of the encounters were discharged home.
Conclusions: Pediatric open hand fractures have a variability of type and
timing to antibiotics. Future initiatives should attempt to create standard-
ized guidelines for management of open hand fractures.
Key Words: open hand fractures, antibiotic choice,
antibiotic timing, trauma
(Pediatr Emer Care 2022;38: 502–505)
O pen fractures involve exposure of bone and deep tissue to the
outside environment through a break in the skin, from small
poke-hole or puncture wounds to large lacerations.1,2 As open
fractures are at higher risk for infection, their management neces-
sitates antibiotics.1,2 In the United States, incidences of finger
fractures peak at age 10 to 14 years while incidences of hand frac-
tures peak at age 15 to 19 years.3 This age peak is likely related to
higher sports participation.3 After forearm fractures, hand and
wrist fractures are the most common type of fractures in the pedi-
atric population.3 In all age groups, males predominate fracture in-
cidences, likely due to increased contact sports and risk-taking in
males.3 The most commonly fractured finger is the fifth digit, and
the most commonly fractured bones are the phalanges.4–6 Injuries
From the Northwell Health, New Hyde Park, NY.
Disclosure: The authors declare no conflict of interest.
Reprints: Sophia Görgens, MD, 306 Community Dr, Apt 1N, Manhasset, NY
11030 (e‐mail: sgorgens@northwell.edu; sophia.gorgens@gmail.com).
Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
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in older children happen more often in sports incidences while
younger children tend to experience crush injuries.5–7
Studies have reported that timing to antibiotics more than
any other factor—including time to irrigation and debridement
in the operating room (OR)—decreases infection rates.1 The
Gustilo-Anderson classification system, which organizes open
fractures based on the length of laceration, soft tissue damage,
contamination, periosteal stripping, and vascular damage, is the
most widely accepted system to guide antibiotic choice.2 The
Gustilo-Anderson system, the criterion standard for open frac-
tures per the American College of Surgeons guidelines, is de-
signed with long bones in mind and is not specifically targeted
to open fractures of the hand. 1,2,8,9 Ideally, antibiotics for open
fractures should be given within 1 hour of arrival in the emergency
department (ED).9 In the scientific literature, there is a paucity of
research on antibiotic choice and timing in open hand fractures, with
most data coming from hand surgery cases rather than ED cases.10,11
While many physicians generally follow the Gustilo-Anderson rec-
ommendations for antibiotic choice, other common antibiotics cho-
sen include cafalexin, cefuroxime, penicillin, flucloxacillin, ampicil-
lin, and cephradine.10,11
A challenge with open fractures in hands is that they may be
difficult to recognize—many tufts fractures and any distal phalanx
fracture with a nailbed injury (as seen in Seymour fractures) are
assumed to be an open fracture.12 Most studies involving Sey-
mour fractures indicate reduced infection rates if antibiotics are
given within 24 hours of the injury.13–16 For tuft fractures, the rec-
ommendations are more nebulous, with recommendations for an-
tibiotics geared more toward grossly contaminated injuries due to
low risk of infection otherwise.12,16–18
Although previous studies have examined general pediatric
hand fractures, few have analyzed open fractures in detail. The goal
of this retrospective study is to fill this gap and examine the medical
records of patients younger than 18 years who presented to Cohen
Children's Medical Center with open hand fractures, to describe the
variability of management (mechanism and type of injury, time and
type of antibiotics, consult type, disposition), and to identify areas
of improvement for standardization of care.
METHODS
We performed a retrospective chart review at a tertiary, level
1 pediatric trauma center in New York of patients with hand inju-
ries between ages 0 and 18 years presenting to the ED during
January 2019 and December 2020 as a walk-in or urgent care re-
ferral. Patients older than 18 years and transferred patients were
excluded. Only open fractures of the hand were included while
closed fractures and fractures involving the radius or ulna were ex-
cluded.
First, all electronic medical records pertaining to any type
of hand injuries were pulled by International Classification of
Diseases, Tenth Revision (ICD-10) codes as recorded in the
Pediatric Emergency Care • Volume 38, Number 10, October 2022
 Pediatric Emergency Care • Volume 38, Number 10, October 2022 Antibiotic Management in Open Hand Fractures

admitting diagnosis, primary discharge diagnosis, secondary

discharge diagnosis, or final diagnosis. The ICD-10 codes that
likely did not pertain to hand fractures were excluded. This re-
sulted in 1293 diagnoses between 2019 and 2020. These charts
were further narrowed by examining both the radiologist read of
the radiographic images as well as the emergency medicine
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physician's diagnosis. Any nonfracture hand injuries were ex-

cluded as were any closed fractures or fractures not pertaining
to the small bones of the fingers, hand, or wrist. For the remain-
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ing open fracture encounters, any patients with more than one
ICD-10 code were examined and their diagnoses combined to
one encounter. If a patient presented to the ED again at a later
date, that was considered a new encounter. This resulted in a to-
tal of 80 encounters involving open hand fractures (Fig. 1).
These 80 patient encounters were reviewed in more detail, in-
cluding demographic data, timing of encounters, injury and phys-
ical characteristics, and type and timing of treatment. From these
data points, descriptive statistics were computed.

RESULTS FIGURE 2. Pie chart presentation of mechanism of injury.

Of the 80 patients, demographic statistics included a predom-
inant male proportion (58.8%) versus female (41.2%) with a mean
age of 7.6 years (SD, 4.7 years; range, 0.8–17.5 years). The racial
composition was 41.2% White, 31.2% multiracial/other, 17.5%
Black, 7.5% Asian, and 2.5% unknown, whereas ethnic composi-
tion showed 83.8% non-Hispanic versus 15% Hispanic and 1.3%
unknown. Of the group, 32.5% were privately insured and 33.8%
were publicly insured while 28.7% were of unknown insurance
status. Most patients arrived by private means (73.8%) as opposed
to by emergency medical services (26.3%). The Emergency Se-
verity Index—a triage stratification scale (1–5) used to prioritize
ED patients (with 1 being the most emergent)—for most of our
cohort indicated a lower acuity, with Emergency Severity Index
levels of 4 (58.8%) and 3 (21.3%) predominating. Seasonality
showed most injuries occurred during the summer months
(31%), then fall (26%), winter (21%), and spring (21%). Crush in-
juries were the most common mechanism of injury (78.8%), while
sports (7.5%), penetrating (5%), blunt (5%), and other (3.8%)
made up the remaining encounters (Fig. 2). Although the right
and left hands were injured at equal frequency (16.3%), hand
dominance was often not documented (67.5%).
One encounter (1.3%) involved only a metacarpal fracture;
one encounter (1.3%) included both a metacarpal and a phalanx
fracture, and the other 78 encounters (97.5%) involved only pha-
lanx fractures. Of the 80 encounters, 6 (7.5%) had 2 fractured
bones while the remaining 74 (92.5%) had one fractured bone.
From the phalanx, the most commonly injured digit was the third
(35%) and the most commonly injured bone was the distal pha-
lanx (93.8%). On radiograph description, 20 (25%) of fractures
were displaced, 2 (2.5%) were angulated, and none had a rota-
tional component. Tufts fractures (62 encounters, 77.5%) were
the most common type of fractures.
Almost all encounters had skin injuries (79 encounters,
98.8%) or nail injuries (54 encounters, 67.5%). Bedside repair
was performed on 62 encounters (77.5%), of which 45 (72.5%)
required nail bed repair, 56 (90.3%) required suturing, and 24
(38.7%) required reduction. All nail bed repairs and suturing were
performed by the hand surgery consultant. A total of 57 patients
(71%) required a hand consult—56 required suturing and 45 re-
quired nail bed repair. Because of the nature of the hand injuries
that presented, only one (1.3%) required admission for immedi-
ate OR management while the others were all managed
nonoperatively with plans to re-evaluate at a later date.
Antibiotics were given to 62 encounters (77.5%), most com-
monly oral cefalexin (45.2%), oral amoxicillan-clavulanic acid
(27.4%), and intravenous (IV) cefazolin (14.5%; Table 1). Median
time from ED registration to ordering antibiotics was 98 minutes
(56–171 minutes). Median time from ED registration to antibiotic
administration was 150 minutes (interquartile range [IQR],
92–216 minutes). Median time from ordering antibiotics to ad-
ministration was 31 minutes (IQR, 18–56 minutes). Median
length of stay in the ED was 189 minutes (IQR, 130–238 mi-
nutes). Antibiotic prescriptions were sent upon discharge for 71
encounters (88.8%), most frequently oral cefalexin (52.1%), oral
amoxicillin-clavulanic acid (36.6%), or oral clindamycin (7.0%;
Table 2). Of the total encounters, 77 (96.3%) were discharged
home while 3 (3.8%) were admitted for further management al-
though only 1 (1.3%) required immediate OR intervention.
Because the need for antibiotics in tuft fractures has been dis-
puted, we additionally took a subset of the data—all open fractures
excluding tuft fractures—and examined time to antibiotics within
this group. Of the 80 total encounters, 18 (22.5%) were not tuft
fractures, meaning that they were either fractures involving the
base or shaft of the distal phalanx or involving a hand bone other
than the distal phalanx. Three encounters did not receive antibi-
otics in the ED, and 2 of those 3 did not receive an antibiotic pre-
scription. For the 15 encounters that received antibiotics in the ED,
the median time from ED registration to ordering antibiotics was

FIGURE 1. Methods—of the 68,043 total ED visits during 2019–2020, 1393 hand injuries were identified. Of these, 337 encounters involved
hand fractures. Eighty were deemed open fractures and were then further analyzed.

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Copyright © 2022 Wolters Kluwer Health, Inc. All rights reserved.

 Görgens et al
TABLE 1. Percentage of Patient Encounters That Received Each
Type of Antibiotic in the ED, Among Those Who Received
Antibiotics
Type of Antibiotics Given in the Percentage of Patient
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ED Encounters (N = 62)
Oral cefalexin 45.2% (28/62)
Oral amoxicillan-clavulanic acid 27.4% (17/62)
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Intravenous cefazolin 14.5% (9/62)
Oral amoxicillin 3.2% (2/62)
Oral clindamycin 3.2% (2/62)
Intravenous ampicillin-sulbactam 3.2% (2/62)
Intravenous gentamycin 1.6% (1/62)
Oral trimethoprim/ 1.6% (1/62)
sulfamethoxazole
113 minutes (IQR, 87–229 minutes). Median time to antibiotics
from ED registration to administration was 180 minutes (IQR,
118–257 minutes). Median time from ordering antibiotics to ad-
ministration was 34 minutes (IQR, 17–64).
DISCUSSION
As there is a paucity of data about the usage and variability of
antibiotics in pediatric patients with open hand fractures, we con-
ducted a retrospective analysis of ED visits to gather more descrip-
tive information.
Prior literature has also shown that younger children experi-
ence more crush injuries (eg, from doors or windows slamming on
their fingers) than older children. In our study, the mean age was
7.6 years (SD, 4.7 years), which correlates with the fact that crush
injuries were the most common mechanism of injury observed
(78.8%) and that 75 of the 80 encounters (93.7%) included a distal
phalanx fracture.
Repairs were performed by the emergency physician except
for in cases where a hand surgeon was consulted. At our institu-
tion, hand surgeon consultants are exclusively plastic surgeons,
but other institutions may also have orthopedic surgeons as hand
specialists. Whether or not a hand surgeon was consulted usually
pertained to the complexity of the repair, with hand surgeons per-
forming all nail bed repairs and suturing while simple reductions
or splinting was managed by emergency physicians.
Our study found that there was a wide variability in timing to
antibiotics. The median time to antibiotics from ED registration to
administration was 150 minutes (IQR, 92–216 minutes) while the
time from ordering antibiotics to administration was considerably
shorter (31 minutes; IQR, 18–56 minutes). Many variables can af-
fect overall time to antibiotics, including patient presentation,
nursing or pharmacy administrative issues, physician decision mak-
ing, patient volume in the ED, and consultative services. Factors
TABLE 2. Percentage of Patient Encounters That Received Each Type of Antibiotic as a Prescription at Discharge, Among Those Who
Were Prescribed Antibiotics
Type of Antibiotics Prescribed at Discharge
Oral cefalexin
Oral amoxicillan-clavulanic acid
Oral clindamycin
Oral trimethoprim/sulfamethoxazole
Oral amoxicillin
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Pediatric Emergency Care • Volume 38, Number 10, October 2022
that could influence physician timing in particular include failure
to recognize open hand fractures immediately, failure to perceive
the need for antibiotics in open hand fractures, lack of clear guide-
lines on type and timing of antibiotics for open hand fractures, and
high physician workload in the ED. Although for open long bone
fractures, the golden rule of 1 hour to antibiotics is important and
more routinely adhered to, there is no similar literature supporting
either urgency or laxity in time to administration of antibiotics in
hand fractures, which may be contributing to delays in treatment
and may lead emergency physicians to rely on recommendations
from the hand surgery consultants. However, a clear cause cannot
be concluded from our retrospective study, and further investigation
would be needed to elucidate why there was often a delay in time to
antibiotics.
In addition, we did a statistical analysis on a subgroup of the
open fracture encounters that excluded all tuft fractures. The
thought behind this was that there may be less perceived urgency
on administering antibiotics to patients with tuft fractures because
the literature is equivocal about the necessity of antibiotics in tuft
fractures. There were 18 nontuft fractures among the 80 total open
fractures, but the median time to antibiotics was not shorter for
these nontuft fractures—it was in fact longer. This may have been
due to the relatively small sample size (n = 18), but from these re-
sults, it does seem that nontuft fractures were not treated with an-
tibiotics any more urgently than tufts fractures.
Antibiotic choice for treatment of open hand fractures in this
population similarly demonstrated variability in our study. Al-
though these 80 encounters were all open fractures and may have
benefited from antibiotics, antibiotics were given to 62 encounters
(77.5%). Physician medical decision making was not clearly doc-
umented within the electronic medical record for the remaining 18
encounters that did not receive antibiotics. The most common
types of antibiotics given in the ED were oral cefalexin (45.2%),
oral amoxicillin-clavulanic acid (27.4%), and IV cefazolin
(14.5%). It is unclear why the third most common antibiotic
choice was an IV medication as opposed to oral—it may be that
IV access was simply already established in these patients or that
these injuries appeared clinically more concerning for potential in-
fection. The choices did not seem to be affected by medication al-
lergies, as very few patients had documented allergies. In terms of
microbial coverage, all chosen antibiotics have adequate coverage
for open fractures, leading us to believe that variability may re-
sult from emergency physician or consultants' preference. As
Gustilo-Anderson classification was not documented in the
charts and as this classification system is historically difficult
to apply to open hand fractures, it seems unlikely that providers
were following these guidelines.
While 62 encounters (77.5%) were given antibiotics in the
ED, 71 (88.8%) were prescribed antibiotics at discharge. It is unclear
why there is a discrepancy in these numbers or why antibiotic admin-
istration and prescriptions were not always contiguous. Similarly, the
choice of antibiotics prescribed at discharge—most frequently oral
cefalexin (52.1%), oral amoxicillin-clavulanic acid (36.6%), or oral
Percentage of Patient Encounters (N = 71)
52.1% (37/71)
36.6% (26/71)
7.0% (5/71)
2.8% (2/71)
1.4% (1/71)
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 Pediatric Emergency Care • Volume 38, Number 10, October 2022
clindamycin (7.0%)—did not follow a recognizable pattern or guide-
line and may simply have been due to provider preference.
This study is not without its limitations. None of the patients
had documented Gustilo-Anderson classifications, so severity of
injury was not quantified. Outpatient records for the patients were
not included in this study, and therefore, patient adherence to an-
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tibiotics is unknown. More importantly, patient follow-up and
long-term outcomes after the injury are unknown. Therefore, no
conclusions can be made about the effect, if any, of antibiotic var-
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iability on patient outcomes.
This study was a retrospective chart review to assess the current
practices in the care of open fractures of the hand in pediatric patients
presenting to the ED. The next steps include the development of a
standardized approach to the type and timing of antibiotics for open
fractures of the hand. In addition, future studies looking at
long-term outcomes for patients treated with various types of antibi-
otics to identify if one is superior in reducing infection to another and
understanding the approach of discharge antibiotic management
timing to find the shortest, most effective time course are needed.
CONCLUSIONS
Pediatric open hand fractures have a variability of type and
timing to antibiotics. Future initiatives should attempt to create
standardized guidelines for management of open hand fractures.
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