This document describes a study examining the effect of delayed surgery timing on infection rates for open hand injuries. Key findings include: - 232 patients underwent semi-urgent hand surgery, with a median time to surgery of 45.9 hours. - Infection occurred in 3 patients (1.3% rate), with no association found between antibiotic administration and infection. - Treating patients as outpatients via a dedicated hand team reduced costs compared to inpatient admissions, while still allowing for specialized surgical care. - However, the study had limitations as a retrospective review with few positive infection cases to draw strong conclusions. Larger prospective studies would be needed.

2. Hand Injuries
• 20% at emergency department
• Surgery within 6 hours
• Can it wait?

3. • Review by the hand registrar
• Stable hemodynamics
• Definitive follow-up plans given
• Sterile wound dressing performed
• Pain control

4. Treatment Protocol in Operating Theater
Surgical
debridement
Postoperatively,
oral antibiotics
Patients are
discharged on
the same day
Close follow-up
plan in the
outpatient
clinic.
Reviewed in the
clinic within 2 to
5 days.
Simple -
followed up for
6 weeks.
Complex
injuries -
followed up for
3 months and
above

5. P4 System
• Reduce admissions
• Man-hour saving in ED
• Reduced cost of admission
• Wait in comfort at home
• Improved DSOT utilization
• Supervised by consultant
• Dedicated hand team

6. Aim
Does delay in timing to surgery for
open hand injuries result in increased infection?
Population
• Open hand
injuries
Intervention
• Semi urgent
surgery in
dedicated
theatre
Comparator
• Surgery
within 6
hours
Outcome
• Occurrence
of infection
Study design
• Retrospective
cohort study

7. Method
• Inclusion
• involving consecutive open hand injuries with semi-emergent surgery
• Exclusion
• closed hand injuries
• open injuries in the upper extremity not of the fingers and hand
• polytrauma patients who required inpatient observation
• other concomitant injuries requiring inpatient management
• bite injuries (including fight bite and animal bite injuries)
• existing acute or chronic infections
• severe injuries that required immediate replantation or critical revascularization
• heavily contaminated or mutilated injuries
• Ethical approval (DSRB 2018/01315)

8. Types of surgery
soft tissue debridement
tendon repair
surgical fixation
terminalization
skin grafting
bony debridement
local flap
nerve repair
arthrodesis
complex reconstructions*
*Complex reconstruction - cases that require repair of two or more tissue components (tendons, nerves, local/regional flaps, or bony fixation—not including joint
immobilization using K-wire for the purpose of protecting tendon repair).

9. Statistical Analysis
• Ordinal data - median and interquartile range (IQR),
• Categorical data - frequency and percentages
• Crude odds ratio (OR) - for univariate analysis.
• Results are presented as OR and 95% confidence intervals (CI)
• A p-value <0.05 was deemed statistically significant

10. Results
• 232 patients included in our study.
• Median age of cases was 33 years (range = 26–45);
• 91% (211 patients) were males.
• 92% (214 patients) were performed under local anesthesia

13. Characteristics
Total Study
Population
(n)
Total
Infection
Population
(n)
Percentage
(%)
p Value
OR (95% CI)
Population 232 3 1.29 -
Gender
Male 211 2 0.95 0.126
0.11 (0.01 –
2.01)
Female
21 1 4.76
Age
36.9
(SD=14.0)
40.0
(SD=12.2) -
0.751
0.99 (0.91 –
1.07)
Open Fractures
Yes 78 2 2.56 0.208
4.1 (0.46 –
69.89)
No
154 1 0.65
Antibiotic Usage
Intravenous (IV) in ED
Yes 93 1 1.08 0.752
0.721 (0.06 –
5.26)
No
139 2 1.44
Post-operatively
Yes 225 3 1.18 0.991
0.98 (0.01 –
No
7 0 0
Table 1: Summary of demographic data,
open fracture, timing to surgery and
antibiotic usage of the study population

14. SN Diagnosis Operative
Description
Time to
Surgery
(hours)
IV
antibiotic
s in ED
Abx on discharge
from ED
Cultures Outcome
1 Open bony
mallet of finger
Surgical fixation 47.3 Nil Amoxicillin /
Clavulanic Acid
MSSA; E.
Cloacae; Proteus
Vulgaris
Infection
resolved
2 Index fingernail
bed laceration
Soft tissue
debridement
9.2 Nil Clindamycin MSSA; Strep.
Agalactiae
Infection
resolved
3 Open proximal
phalanx fracture
with cut radial
digital nerve
(RDN)
Surgical fixation of
proximal phalanx
fracture and RDN
nerve graft
19.4 Cefazolin Amoxicillin /
Clavulanic Acid
Citrobacter
Koseri
Ray
amputation
Table 2: 3 cases for post-operative deep-seated infection that required surgical debridement with positive post-operative
cultures. Operative details, antibiotics details and outcomes are summarised in this table

15. Study Population Non-Infected Group Infected Group
p-value
OR (95% CI)
Number of patients 232 229 3 -
Mean Age (SD) 36.9 (14.2) 36.8 (14.3) 40.0 (12.2)
0.70
1.01 (0.93 –
1.08)
Time to Surgery (hours),
Mean (SD)
49.9 (32.2) 50.2 (32.2) 25.3 (19.7)
0.17
0.95 (0.87 –
1.01)
Time to Surgery (hours),
Median
45.9 46.0 19.4
Table 3: Timing to surgery for the study population divided into those who sustained
post-operative infection versus those who did not

16. Table 4: Overall treatment cost in a patient requiring debridement and nerve repair performed as an ambulatory case as
compared to inpatient admission.
Nerve Repair (Day case)
Singapore Dollars (S$)
Nerve Repair (Admission)
Singapore Dollars (S$)
Day surgery facility charge 86 86
Consumables 1209.23 1209.23
Surgical procedure 3920.25 3920.25
Microscope use 192.60 192.60
Inpatient stay Nil 500 (2 days)
Hand Occupational Therapist
visits 320 (4 visits) 320 (4 visits)
Hand Doctor visits 408 (4 visits) 408 (4 visits)
Total costs 6136.08 6636.08

17. Summary
• No association between administration of antibiotics (pre- and
postoperatively) and infection rates*
• Age was also not associated with infection rates
• Reduced waiting time for admission
• Treatment cost was also reduced
• Office hours surgery - experienced surgical team
• Preop screening/planning facilitated preparation of implants etc
• * Positive cases too little to conclude, Other confounding factors

18. Limitations
• Retrospective study.
• Low number of positive cases affected the statistical analysis
• This study was not a controlled study
• Comparator was published data*
• * Published rates of open hand injuries are up to 14%. (Our study had an
infection rate of 1.3%)
• Majority of our cases (85.3%) - surgery within 72 hours of presentation