ORIF of Forearm fractures have similar soft tissue outcomes when closed primarily or in delayed fashion

Andrew S. Bi et al conducted a study to investigate the effect of delayed closures, whether delayed primary closure (DPC) or split-thickness skin grafting (STSG), of operatively treated forearm fractures on short-term soft tissue outcomes. The authors found that - diaphyseal forearm fractures that undergo ORIF have equivalent short-term soft tissue outcomes when closed primarily at index surgery or when closed in a delayed fashion.

The article has been published in Indian Journal of Orthopaedics.

In this retrospective cohort comparative study of two academic-level one trauma centers adult patients with diaphyseal forearm fractures who underwent open reduction and internal fixation (ORIF) were either closed primarily at index surgery, or underwent delayed closure, either with DPC or with a STSG. Primary outcome measures were soft-tissue outcomes as measured by wound healing (delayed healing, dehiscence, or skin breakdown) and fracture-related infection (FRI) at time of final follow-up.

All forearm fractures were taken to the operating room within 24 h of presentation. If open injuries, they were taken for an irrigation and debridement and concomitant ORIF using compression plating, lag screw fixation with neutralization plating, or bridge plating depending on the fracture pattern.

A formal fasciotomy was performed for any cases with a pre-operative diagnosis of compartment syndrome; otherwise, the forearm fascia was not released beyond the surgical approach. At the end of the procedure, primary closure was always attempted using a 2–0 or 3–0 non-absorbable monofilament suture for the skin.

When unable to be closed, the incision was closed as much as possible using tensioned non-absorbable monofilament sutures; then the remaining open wound was covered with a vesselloop shoelace technique and NPWT dressing. These patients were taken back to the operating room within a few days for a repeat irrigation, debridement, and attempted DPC. A STSG was performed if the wound was unable to close within 7 days. Following STSG, a standardized protocol was followed, including NPWT for five days, followed by daily dressing changes using an antimicrobial ointment, non-adhesive dressing, and a compressive wrap.

The observations of the study were:

• Eighty-one patients with 81 diaphyseal forearm fractures underwent ORIF with a mean follow-up of 14.3 months.

• Forty-one fractures (50.6%) were open injuries.

• Thirteen patients (16.0%) were unable to be closed primarily and underwent an average of 2.46±0.7 surgeries including final coverage, with an average of 4.31±2.8 days to final coverage.

• Four patients (30.8%) underwent DPC and 9 (69.2%) underwent STSG.

• Five (6.6%) patients in the delayed closure group had pre-operative compartment syndrome and underwent formal two-incision fasciotomies.

• There were no significant differences between delayed versus primary closure in wound healing complication rates, FRI, or radiographic union.

The authors concluded that - presence of an open fracture is the main risk factor associated with the inability to attain primary closure following diaphyseal forearm fracture. Results suggest that requiring delayed closure using DPC or STSG does not affect rates of soft tissue outcomes as measured by wound healing or FRI when compared to primary closure at index surgery for diaphyseal forearm fractures.