Open fractures of the tibia in the pediatric population: a systematic review

Management of Pediatric Type III Tibial Shaft Fractures: A Cohort Study Utilizing the Trauma Quality Improvement Program Database

BACKGROUND

Pediatric open tibial fractures represent a challenging subset of injuries with limited literature to guide management. For children, the epidemiology, management, and outcomes of tibial-shaft fractures have not been fully described.

METHODS

A retrospective analysis of the Trauma Quality Improvement Program Data Bank from 2017-2020 was used to query demographics, injury patterns, and management strategies in pediatric open tibial fractures. Fractures were compared by age group (0-5, 6-12, 13-17 years) and type (I/II vs type III). A subgroup analysis was performed on patients with type III open fractures.

RESULTS

A total of 3480 open tibial fractures were identified, 3049 were type I/II, and 431 were type III. Motor vehicle accidents (48%) were the most common mechanism of injury (P < 0.001). Subanalysis of 128 type IIIb/c tibial fractures revealed local flap reconstruction (25%) skin graft (25%), and free tissue transfer were the most common management strategies and soft-tissue coverage was achieved after 162 hours (interquartile range = 109-231). Negative pressure wound therapy was utilized in 63% of cases but used in isolation in only 23% of cases. Immediate fixation with intramedullary nailing was more frequently used in the 13-17 age group while plate fixation was more commonly used in younger age groups.

CONCLUSIONS

Soft-tissue management patterns following open tibial shaft fractures mirror those seen in adult cohorts. The median time to achieve soft-tissue coverage exceeds the traditional 72-hour target advocated by Godina. Age-based variation is seen in orthopedic management of these fractures based on growth maintenance concerns.

Traffic Accidents in Children and Adolescents: A Complex Orthopedic and Medico-Legal Approach

Traffic accidents involving children and adolescents present complex challenges from both the medico-legal and orthopedic standpoints. Despite the implementation of road traffic safety laws, pediatric road traffic injuries continue to be a significant contributor to mortality rates, physical harm, and hospitalization on a global scale. For children and young people, automobile accidents are considered to be the primary culprit of mortality in developed nations. Even in highly developed nations, trauma is a significant factor in infant mortality. Each age category, from childhood to young adulthood, has its fracture patterns, as their skeletons are considerably different from those of adults. The consequences of traffic accidents extend beyond the immediate physical trauma. The medico-legal aspects surrounding these incidents add another layer of complexity, as legal repercussions may affect the responsible adult or parent, particularly in cases involving child fatalities. To effectively address traffic accidents in children and adolescents, a comprehensive approach is necessary. This approach should involve not only medical professionals but also legal experts and policymakers. Collaboration between orthopedic specialists, medico-legal professionals, law enforcement agencies, and relevant government bodies can facilitate the development and implementation of strategies aimed at prevention, education, the enforcement of traffic laws, and improved infrastructure. By addressing both the medical and legal aspects, it is possible to enhance road safety for children and adolescents, reducing the incidence of injuries and their associated long-term consequences. In this review, we aimed to summarize traffic accidents in children and adolescents from a complex orthopedic and medico-legal approach.

Comparison of nonoperative versus operative management in pediatric gustilo-anderson type I open tibia fractures

BACKGROUND

Recent studies suggest pediatric Gustilo-Anderson type I fractures, especially of the upper extremity, may be adequately treated without formal operative debridement, though few tibial fractures have been included in these studies. The purpose of this study is to provide initial data suggesting whether Gustilo-Anderson type I tibia fractures may be safely treated nonoperatively.

METHODS

Institutional retrospective review was performed for children with type I tibial fractures managed with and without operative debridement from 1999 through 2020. Incomplete follow-up, polytrauma, and delayed diagnosis of greater than 12 h since the time of injury were criteria for exclusion. Data including age, sex, mechanism of injury, management, time-to-antibiotic administration, and complications were recorded.

RESULTS

Thirty-three patients met inclusion criteria and were followed to union. Average age was 9.9 ± 3.7 years. All patients were evaluated in the emergency department and received intravenous antibiotics within 8 h of presentation. Median time-to-antibiotics was 2 h. All patients received cefazolin except one who received clindamycin at an outside hospital and subsequent cephalexin. Three patients (8.8%) received augmentation with gentamicin. Twenty-one patients (63.6%) underwent operative irrigation and debridement (I&D), and of those, sixteen underwent surgical fixation of their fracture. Twelve (36.4%) patients had bedside I&D with saline under conscious sedation, with one requiring subsequent operative I&D and intramedullary nailing. Three infections (14.3%) occurred in the operative group and none in the nonoperative group. Complications among the nonoperative patients include delayed union (8.3%), angulation (8.3%), and refracture (8.3%). Complications among the operative patients include delayed union (9.5%), angulation (14.3%), and one patient experienced both (4.8%). Other operative group complications include leg-length discrepancy (4.8%), heterotopic ossification (4.8%), and symptomatic hardware (4.8%).

CONCLUSION

No infections were observed in a small group of children with type I tibia fractures treated with bedside debridement and antibiotics, and similar non-infectious complication rates were observed relative to operative debridement. This study provides initial data that suggests nonoperative management of type I tibial fractures may be safe and supports the development of larger studies.

Pediatric Open Long-Bone Fracture and Subsequent Deep Infection Risk: The Importance of Early Hospital Care

The purpose of the current study was to identify risk factors for deep infection after an open long-bone fracture in pediatric patients. Systematic billing queries were utilized to identify pediatric patients who presented to a level I trauma center from 1998 to 2019 with open long-bone fractures. There were 303 open long-bone fractures, and 24 (7.9%) of these became infected. Fractures of the tibia/fibula (p = 0.022), higher revised Gustilo-Anderson type (p = 0.017), and a longer duration of time between the injury and hospital presentation (p = 0.008) were all associated with the presence of deep infection. Those who went on to have a deep infection also required more operative debridements (p = 0.022) and a total number of operative procedures (p = 0.026). The only factor that remained significant in multivariable regression was the duration between the injury and hospital presentation (OR 1.01 [95%CI 1.003-1.017]; p = 0.009), where the odds of deep infection increased by 1% for every minute of delayed presentation.

Treatment of Infected Nonunions With Bone Defects Using Autologous Bone Graft and Absorbable Antibiotic-Loaded Calcium Sulfate-Hydroxyapatite Paste

BACKGROUND

Revision surgery in the presence of infection carries high risks. We describe our results using a new technique to treat these challenging problems. We treated infected nonunions with cavitary voids with adjuvant antibiotic loaded calcium sulfate-hydroxyapatite paste composite and autologous bone graft (ABG) layer technique coupled with stable fixation.

METHODS

Thirty consecutive patients who underwent revision foot and ankle surgery for an infected nonunion were prospectively studied. Following multidisciplinary team workup, surgical debridement and biopsies were undertaken. Bone voids were measured and classified according to containment and size. ABG was mixed and layered with an adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste followed by surgical reconstruction including arthrodesis and fixation. Empirical and pathogen-specific antibiotics were instituted until intraoperative sample-specific antibiotics were identified and used. Patients were prospectively followed up for a minimum of 1 year.

RESULTS

The male-female ratio was 16:14, mean age was 51.3 years, and 23.3% smoked at definitive surgery. Void volume was <1 cm³ (n=9), 1-2 cm³ (n = 13), and >2 cm³ (n=8). No patients either were lost to follow-up or had a further infective episode at a mean of 38.3 months; 86.7% united with fusion on imaging. Four patients had radiographic evidence of nonunion; 3 were asymptomatic and 1 required revision surgery (void >2 cm³). Independent ambulation was achieved at an average of 12 weeks, at 1 year mean American Orthopaedic Foot & Ankle Society score was 77.7 (SD 9.59), and the Manchester-Oxford Foot Questionnaire reached an effect size >0.5 in all domains at 1 year following surgery. The union rate was independent of smoking status and vitamin D deficiency (P = .94).

CONCLUSION

Layered autologous bone grafting with adjuvant antibiotic-loaded calcium sulfate-hydroxyapatite paste has been shown to be effective and safe in revision arthrodesis, with low comorbidities in void gaps without infection recurrence.

Outcomes and complications following flexible intramedullary nailing for the treatment of tibial fractures in children: a meta-analysis

INTRODUCTION

Tibial shaft fractures are common occurrence in children and surgical treatment is sometimes required, particularly in unstable or open fractures, and in polytrauma. The aim of this study was to investigate the available evidence on the efficacy and safety of flexible intramedullary nailing (FIN) for both open and closed tibia fractures in children, exploring the main surgical outcomes and rate of complications.

MATERIALS AND METHODS

Pubmed/Medline, Scopus and Cochrane Central databases were searched following the PRISMA guideline. Studies reporting on the outcomes of FIN for paediatric tibia shaft fractures were included. Weighted means were evaluated for surgical outcomes. Meta-analysis of proportion and odd ratios were used to analyse total complication rates and differences between open and closed fractures.

RESULTS

Twenty-eight studies (835 patients) were included; the mean age was 11.0 ± 3.0 years. The mean follow-up was 22.5 ± 13.5 months; the mean time to full weight-bearing was 7.5 ± 3.7 weeks. The total complication rate was 28.1% (minor = 20.7%, major = 6.3%); this was greater in open fractures (13.6% vs 5.1%, p = 0.007). The rate of union was 97.5%, with a mean time to union of 11.9 ± 7.2 weeks. Malunion was found in 8.5% cases, delayed union in 3.8%, non-union in 1.4%, symptomatic hardware in 5.1%, leg-length discrepancy in 5.0%, superficial infections in 2.3%, deep infections in 1.0%, compartment syndromes in 1.4%, and refracture in 0.2%. Almost all patients returned to unrestricted physical activity.

CONCLUSIONS

FIN offers excellent outcomes for the treatment of paediatric tibia shaft fractures. Patients presenting with an open fracture have a higher but acceptable complication rate. Comparative studies are needed to clarify if other treatments have superior outcomes.

Orthoplastic management of open tibial fractures in children : a consecutive five-year series from a paediatric major trauma centre

AIMS

Open tibial fractures are limb-threatening injuries. While limb loss is rare in children, deep infection and nonunion rates of up to 15% and 8% are reported, respectively. We manage these injuries in a similar manner to those in adults, with a combined orthoplastic approach, often involving the use of vascularised free flaps. We report the orthopaedic and plastic surgical outcomes of a consecutive series of patients over a five-year period, which includes the largest cohort of free flaps for trauma in children to date.

METHODS

Data were extracted from medical records and databases for patients with an open tibial fracture aged < 16 years who presented between 1 May 2014 and 30 April 2019. Patients who were transferred from elsewhere were excluded, yielding 44 open fractures in 43 patients, with a minimum follow-up of one year. Management was reviewed from the time of injury to discharge. Primary outcome measures were the rate of deep infection, time to union, and the Modified Enneking score.

RESULTS

The mean age of the patients was 9.9 years (2.8 to 15.8), and 28 were male (64%). A total of 30 fractures (68%) involved a motor vehicle collision, and 34 (77%) were classified as Gustilo Anderson (GA) grade 3B. There were 17 (50%) GA grade 3B fractures, which were treated with a definitive hexapod fixator, and 33 fractures (75%) were treated with a free flap, of which 30 (91%) were scapular/parascapular or anterolateral thigh (ALT) flaps. All fractures united at a median of 12.3 weeks (interquartile range (IQR) 9.6 to 18.1), with increasing age being significantly associated with a longer time to union (p = 0.005). There were no deep infections, one superficial wound infection, and the use of 20 fixators (20%) was associated with a pin site infection. The median Enneking score was 90% (IQR 87.5% to 95%). Three patients had a bony complication requiring further surgery. There were no flap failures, and eight patients underwent further plastic surgery.

CONCLUSION

The timely and comprehensive orthoplastic care of open tibial fractures in this series of patiemts aged < 16 years resulted in 100% union and 0% deep infection, with excellent patient-reported functional outcomes. Cite this article: Bone Joint J 2021;103-B(6):1160-1167.

The evidence base for 2017 BOAST-4 guidance on open fracture management: Are we due an update?

INTRODUCTION

Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017.

METHODS

Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018-01/02/2021. Results have been summarized and discussed.

DISCUSSION

Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus.

CONCLUSION

The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed.

Paediatric open tibial fractures. Do children require a modified approach to that advised by the British Orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons in the UK?

This study reviews the outcomes of paediatric open tibial fractures treated at a level 1 trauma centre using the British Orthopaedic Association/British Association of Plastic Reconstructive and Aesthetic Surgeons standards and compares the results to management in adults. This was a retrospective study of 60 consecutive cases over a 9-year period. The variables recorded include grade of injury, contamination and pattern of fracture. Other data recorded include time at which antibiotics were given, time to index surgery, type of skeletal fixation and time to definitive cover. Outcomes sought were infection rate, time to union, problems with union and any additional unplanned surgery. The mean time to administration of antibiotics was 3.4 h after injury with a range of 0.35-17 h. The mean time to debridement was 13.4 h (range 1-32 h, SD 7.7). The mean time to union was 4.3 months (range 1.3-15 months). There were five cases of deep infection (8.3%) and three cases of superficial infection (5%). There were no significant differences between timings of antibiotic administration, hours to debridement or days to definitive closure between those cases which became infected and those which did not. This retrospective review of a consecutive series of paediatric open tibial fractures shows a close parallel of outcomes to that from adult centres in the UK using the same standards of care. This strengthens the recommendation that, until the availability of data to suggest otherwise, open tibial fractures in children should follow the same recommendations as suggested for adults. The greater healing potential in children, seen in multiple examples of closed long bone fractures, appears to be attenuated in the higher grades of the open tibial fracture.

Non-operative versus operative management of open fractures in the paediatric population: A systematic review and meta-analysis of the adverse outcomes

Open fractures are at greater risk of infection and delayed bone healing. Guidelines to reduce these risks exist for adult open fracture management but not for paediatric open fractures, where there is considerable practice variability. This systematic review evaluates the quality of the evidence and clinical outcomes for paediatric open fractures treated non-operatively versus operatively. A PROSPERO-registered, PRISMA-compliant systematic review and meta-analysis. Databases searched were MEDLINE, Embase and Web of Science (WoS) up to March 2019. Clinical studies reporting adverse outcomes of both non-operative and operative management of paediatric open fractures were included. Data extracted included demographics, treatment methods and outcomes. The primary outcome was infection (osteomyelitis and/or wound infection). Secondary outcomes were abnormalities of bone healing (delayed union, malunion and nonunion) and re-fracture. The ROBINS-I tool was used to assess risk of bias. Seventeen studies reporting 1093 open fractures were included. Non-operatively managed injuries had a lower risk of osteomyelitis (RR 0.33 [95%CI 0.12-0.86]), wound infection (RR 0.47 [95%CI 0.22-0.97]) and nonunion (RR 0.27 [95%CI 0.09-0.80]). Gustilo-Anderson (GA) III injuries had the highest incidence of osteomyelitis (10.7%) with no difference in outcome between operative and non-operative groups (RR 0.67 [95%CI 0.22-2.03]). Tibial GA III fractures were associated with a lower risk of osteomyelitis than femoral fractures: adverse effects were seen in the operative group. All studies were retrospective, observational and at high risk of bias. The quality of the evidence relating to paediatric open fractures is low, and findings are limited by significant methodological flaws in the literature. GA I and II fractures were commonly managed non-operatively and associated with a lower infection rate. Operative intervention was more frequent in GA III fractures, where the risk of infection was highest. Operative management of GA III fractures was not associated with a lower infection risk compared to non-operative management. Robust prospective multi-centre studies are needed to explore further the most effective management of paediatric open fractures and to inform guideline development.

Negative pressure wound therapy in reconstructing extensive leg and foot soft tissue loss in a child: a case study

Open fractures of the leg with large loss of tissue require extensive reconstructive methods that can injure the donor area. The use of negative pressure wound therapy (NPWT) may minimise the impact of these reconstructive methods because of its capacity to create granulation tissue that will form a wound bed for the skin graft, thus reducing the volume of soft tissue defect and saving the donor region. This case study describes the effectiveness of NPWT in the treatment and reconstruction of an open fracture of the leg, with massive loss of soft tissue, associated with elastic intramedullary nailing in a 10-year-old female patient, who was a victim of a car accident. Clinical examination revealed a Gustilo-Anderson IIIB open fracture of the left leg, with the avulsion of the fifth toe, disarticulation of the fifth metatarsal bone, extensively damaged skin and subcutaneous tissue in the medium and distal third of the left leg and left foot. The bone was exposed in the distal part of the leg, external malleolus and left calcaneus. Profuse lavage, reduction of the tibial fracture and elastic intramedullary nailing, amputation of the fifth left toe, necrectomy and debridement of devitalised tissue were performed. NPWT was started, with the dressing changed every five days. After 55 days of using NPWT, granulation tissue covered the soft tissue defect and created a wound bed for the skin graft. NPWT helped the management of this open wound, achieving a wound bed for the skin graft, avoiding the use of complex reconstructive methods.

Evidence-based update on the surgical treatment of pediatric tibial shaft fractures

PURPOSE OF REVIEW

To describe surgical treatment options for pediatric tibial shaft fractures which are the third most common pediatric long bone fracture. Management of these injuries is dictated by fracture location, fracture pattern, associated injuries, skeletal maturity, and other patient-specific factors. Although most pediatric tibial shaft fractures can be treated nonoperatively, this review provides an update on surgical treatment options when operative intervention is indicated.

RECENT FINDINGS

Advances in surgical implants and techniques affords a wide range of options for the surgical treatment of pediatric tibial shaft fractures. Flexible intramedullary nailing is gaining wide adoption for acute surgical treatment. Recent studies support cross-sectional imaging for further evaluation and scrutiny of fracture patterns suspicious for intraphyseal or intra-articular extension. Grade I open tibial shaft fractures may be safely treated with irrigation and debridement in the emergency department; however, no high-level comparative studies have been performed to make any definitive conclusions regarding the effectiveness of this treatment strategy.

SUMMARY

Tibial shaft fractures are common injuries in pediatric patients. Management is dictated by fracture location, fracture pattern, associated injuries, patient age, and other patient-specific factors. Surgical intervention is indicated for fractures that are open, irreducible, have failed nonoperative management, are associated with compartment syndrome, or in the multiply injured patient. Surgical treatment options include flexible intramedullary nailing, plate osteosynthesis, external fixation, and rigid intramedullary nailing. Recent literature has shown increased rates of flexible intramedullary nailing. All operative and nonoperative management options can result in complications including compartment syndrome, infection, delayed union, nonunion, malunion, limb length discrepancy, and symptomatic hardware. Most pediatric patients go on to uneventful union with excellent final outcomes and return to full activities.

Management of Orthopaedic Injuries in Multiply Injured Child

Multiply injured child is a unique challenge to the medical communities worldwide. It is a leading cause of preventable mortality and morbidity in children. Common skeletal injuries include closed or open fractures of tibia and femur and pelvic injuries. Initial management focuses on saving life and then saving limb as per pediatric advanced life support and advanced trauma life support. Orthopedic management of open fracture includes splinting the limb, administration of prophylactic antibiotic, and surgical debridement of the wound when safe. However, gross contamination, compartment syndrome, and vascular injuries demand urgent attention.

Optimizing Management of Open Fractures in Children

Open fractures in children differ from adults owing to their better healing potential. Management strategies for open fracture in children are changing with improvement in our understanding of soft-tissue reconstruction and fracture fixation. A literature review was performed for articles covering management of open fractures in children. The cornerstones of management include prevention of infection, debridement, and skeletal stabilization with soft-tissue coverage. The injury should be categorized according to the established trauma classification systems. Timely administration of appropriate antibiotics is important for preventing infections. Soft-tissue management includes copious irrigation and debridement of the wound. Fractures can be stabilized by a variety of nonoperative and operative means, taking into consideration the special needs of the growing skeleton and the role of a thick and active periosteum in the healing of fractures. The soft-tissue coverage required depends on the grade of injury.

The management of open tibial fractures in children

Aims

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union.

Patients and Methods

A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association.

Results

There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries.

Conclusion

Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53.

Efficacy of a Cellular Bone Allograft for Foot and Ankle Arthrodesis and Revision Nonunion Procedures

BACKGROUND

Bone graft substitutes are often required in patients at risk for nonunion, and therefore, an allograft that most closely mimics an autograft is highly sought after. This study explored the utility and efficacy of a cellular bone allograft used for foot and ankle arthrodesis and revision nonunion procedures in a patient population at risk for nonunion.

METHODS

An institutional review board-approved retrospective review of consecutive patients who underwent arthrodesis and revision nonunion procedures with a cellular bone allograft was performed at a single academic institution. No external sources of funding were provided for this study. Inclusion criteria included patients who were more than 1 year after surgery or less than 1 year after surgery if they had undergone a second operative procedure for nonunion or if they had computed tomography-documented union. Forty operative procedures in 36 patients with a mean follow-up of 13 months (range, 6-25 months) were included for data analysis. All patients had at least one of the following risk factors associated with nonunion: current smoker, diabetes, avascular necrosis (AVN) of the involved bone, active same-site operative infection, history of nonunion, previous same-site surgery, or gap of 5 mm or greater after joint preparation. The primary outcome was radiographic union.

RESULTS

The union rate in this high-risk population was 83% (33/40). Univariate analysis demonstrated that the use of a cellular bone allograft helped mitigate the presence of risk factors known to cause nonunion. There was no significant difference in fusion rates among groups with current smoking, AVN of the involved bone, active same-site operative infections, history of nonunion, rheumatoid arthritis on medication, previous same-site operative procedures or infections, or a gap of 5 mm or greater after joint preparation. However, in this population, diabetic and female patients remained at a high risk of recurrent nonunion ( P = .0015), despite the use of a cellular bone allograft. Chi-square analysis of patients with increasing numbers of risk factors directly correlated with an increased risk of nonunion ( P = .025). Four wound complications were reported in this cohort that required irrigation and debridement (10%).

CONCLUSION

These data demonstrated a union rate of 83% in patients with risk factors known to cause nonunion. The benefits of the use of a cellular bone allograft allowed for the avoidance of morbidity associated with autograft harvesting while still improving the local biology to facilitate fusion in a difficult patient population to attain a successful fusion mass.

LEVEL OF EVIDENCE

Level IV, retrospective case series.

Efficacy of a Cellular Allogeneic Bone Graft in Foot and Ankle Arthrodesis Procedures

A cellular allogeneic bone graft can be used in patients at high risk for nonunion after arthrodesis surgery. This study explores the utility and efficacy of MAP3 in foot and ankle arthrodesis procedures. Map3 is a cellular allogeneic bone graft that contains osteogenic, osteoconductive, osteoinductive, and angiogenic properties. A total of 23 mostly high-risk patients were included in this study. The overall fusion rate was 83%. Univariate analysis demonstrated diabetic patients remain at risk of recurrent nonunion (P<.001) despite supplementation with MAP3. These data demonstrate successful fusion in high-risk patients when MAP3 is used.

Flexible Intramedullary Nailing of Unstable and/or Open Tibia Shaft Fractures in the Pediatric Population

Tibial shaft fractures are common injuries in the pediatric population, and can be treated conservatively the vast majority of the time. Yet, it is important to recognize that open and/or unstable tibial shaft fractures represent a different entity. Rigid intramedullary devices are generally contraindicated because of the skeletal immaturity of these patients, and external fixation is associated with a high complication rate. As a result, flexible nailing is being utilized with increasing frequency. It is essential for the clinician to understand the pearls and pitfalls associated with the utilization of these flexible nails; particularly in regards to their immediate use in the context of open fractures and the risk of compartment syndrome postoperatively after fixation.

Elastic nailing of tibia shaft fractures in young children up to 10 years of age

INTRODUCTION

Although tibia shaft fractures in children usually have satisfactory results after closed reduction and casting, there are several surgical indications, including associated fractures and soft tissue injuries such as open fractures. Titanium elastic nails (TENs) are often used for pediatric tibia fractures, and have the advantage of preserving the open physis. However, complications such as delayed union or nonunion are not uncommon in older children or open fractures. In the present study, we evaluated children up to 10 years of age with closed or open tibial shaft fractures treated with elastic nailing technique.

METHODS

A total of 16 tibia shaft fractures treated by elastic nailing from 2001 to 2013 were reviewed. The mean patient age at operation was 7 years (range: 5-10 years). Thirteen of 16 cases were open fractures (grade I: 4, grade II: 6, grade IIIA: 3 cases); the other cases had associated fractures that necessitated operative treatments. Closed, antegrade intramedullary nailing was used to insert two nails through the proximal tibial metaphysis. All patients were followed up for at least one year after the injury. Outcomes were evaluated using modified Flynn's criteria, including union, alignment, leg length discrepancies, and complications.

RESULTS

All fractures achieved union a mean of 16.1 weeks after surgery (range: 11-26 weeks). No patient reported knee pain or experienced any loss of knee or ankle motion. There was a case of superficial infection in a patient with grade III open fracture. Three patients reported soft tissue discomfort due to prominent TEN tips at the proximal insertion site, which required cutting the tip before union or removing the nail after union. At the last follow-up, there were no angular or rotational deformities over 10° in either the sagittal or coronal planes. With the exception of one case with an overgrowth of 15 mm, no patient showed shortening or overgrowth exceeding 10mm. Among final outcomes, 15 were excellent and 1 was satisfactory.

SUMMARY

Even with open fractures or soft tissue injuries, elastic nailing can achieve satisfactory results in young children, with minimal complications of delayed bone healing, or infection.

Acute Management of Open Fractures: An Evidence-Based Review

Open fractures are complex injuries associated with high morbidity and mortality. Despite advances made in fracture care and infection prevention, open fractures remain a therapeutic challenge with varying levels of evidence to support some of the most commonly used practices. Additionally, a significant number of studies on this topic have focused on open tibial fractures. A systematic approach to evaluation and management should begin as soon as immediate life-threatening conditions have been stabilized. The Gustilo classification is arguably the most widely used method for characterizing open fractures. A first-generation cephalosporin should be administered as soon as possible. The optimal duration of antibiotics has not been well defined, but they should be continued for 24 hours. There is inconclusive evidence to support either extending the duration or broadening the antibiotic prophylaxis for type Gustilo type III wounds. Urgent surgical irrigation and debridement remains the mainstay of infection eradication, although questions persist regarding the optimal irrigation solution, volume, and delivery pressure. Wound sampling has a poor predictive value in determining subsequent infections. Early wound closure is recommended to minimize the risk of infection and cannot be substituted by negative-pressure wound therapy. Antibiotic-impregnated devices can be important adjuncts to systemic antibiotics in highly contaminated or comminuted injuries. Multiple fixation techniques are available, each having advantages and disadvantages. It is extremely important to maintain a high index of suspicion for compartment syndrome, especially in the setting of high-energy trauma.

Do minimally displaced, closed tibial fractures in children need monitoring for compartment syndrome?

INTRODUCTION

Acute compartment syndrome (ACS) may be seen following tibial fractures in adults. Although the risk of this complication is thought to be lower in children (especially in those under the age of 12 years) it is routine practice in many units to admit all children with this injury for observation. The aim of this study was to ascertain whether all children under the age of 12 presenting with fractures of the tibia merited admission and to provide recommendations on how to manage these patients based on our experience with this injury.

PATIENTS AND METHODS

We retrospectively studied the clinical and radiographic progress of consecutive patients presenting to our institution with tibial fractures over a 5-year period.

RESULTS

A total of 159 tibial fractures were seen in the study period. The mean age of patients treated was 5.8 years. 81% of the injuries occurred in the diaphyseal region and 60% involved the tibia only. A total of 9% of injuries were open and overall 66% of fractures were managed non-operatively. No cases of ACS were seen.

DISCUSSION

Based on our experience we provide a treatment algorithm detailing how children in the under 12 age group presenting with tibial fractures may be managed. Patients with minimally displaced fractures involving the tibia only, whose pain is adequately controlled and who can safely mobilise with suitable parental supervision may be safely discharged from the emergency department in a back slab with early follow up. Although no children under the age of 12 in the present study developed ACS following a fracture of the tibia, certain features such as a history of a high energy injury, displaced fractures or co-existing fibular fractures should raise suspicion that this complication may ensue. In these cases admission and observation may be warranted.

Percutaneous plating of distal tibial fractures in children and adolescents

Fractures of the tibia and fibula are among the most common injuries involving the lower extremities in children and adolescents. Although most can be treated nonoperatively, with satisfactory long-term results, some fractures require surgical stabilization. The increasing experience in adults with minimally invasive plate osteosynthesis for the treatment of complex fractures of the lower extremity has supported the treatment of selected distal tibia fractures in older children and adolescents. This article details the surgical technique for plating of the distal tibia using the percutaneous approach and assesses the results and complications in a pediatric series. We retrospectively reviewed 11 consecutive patients with open physes who had undergone percutaneous plating of a distal tibial fracture between January 2008 and January 2012. All patients were monitored clinically and radiographically until fracture union. Complications related to treatment, such as malunion, delayed union, nonunion, infection, and the need for subsequent surgical treatment, were recorded. Eleven patients (11 tibial fractures) were treated with minimally invasive plate osteosynthesis. The average follow-up period was 22 months (range, 12-48 months). Fractures healed with an average time to union of 9.4 weeks (range, 8-16 weeks). There were no cases of delayed union or nonunion. No clinically evident neurovascular complications were observed. One patient had a superficial infection, treated successfully by oral antibiotics. There were no cases of rotational deformity or leg-length discrepancy at the final follow-up. Because of its biologic advantages and stable fixation that allows early mobilization, percutaneous plating seems a reasonable treatment option for selected distal tibial fractures in children and adolescents.

LEVEL OF EVIDENCE

Level IV therapeutic study - Case series.

Immediate intramedullary flexible nailing of open pediatric tibial shaft fractures

BACKGROUND

Flexible nailing has become the preferred implant for pediatric patients with tibial shaft fractures that require operative fixation. Immediate definitive fracture fixation with flexible nails in patients with high-energy, open fractures has not been examined. The purpose of our study was to determine if immediate flexible nailing of open pediatric tibial shaft fractures is safe and efficacious from a bone healing, wound, and infectious standpoint.

METHODS

A retrospective review of 26 tibial shaft fractures consecutively treated with flexible nailing at our institution from 2003 to 2010 was performed. Age, mechanism of injury, associated injuries, presence of compartment syndrome, antibiotic administration, systemic insults, time to union, as well as bone healing (nonunion, delayed union, malunion, leg length discrepancy, growth arrest), wound, and infectious complications were collected. Comparisons were made between patients with open fractures and those with closed fractures.

RESULTS

We identified 14 patients with open fractures and a control group of 12 patients with closed injuries who underwent flexible nailing. Patients with open fractures were more likely to have polytraumatic injuries (71.0% vs. 25.0%, P = 0.04). There was no difference (P = 1.0) in the rates of compartment syndrome (open = 14.0%, closed = 17.0%) between the 2 groups. Systemic complications (pulmonary compromise and increased intracranial pressure) were noted in 2 patients who underwent immediate nailing of their open fractures; both of whom had closed head injuries. There was no difference (P = 1.0) in the rates of wound/infectious complications between the open (7.0%) and closed (4.0%) fractures groups, with no cases of wound breakdown or osteomyelitis. There was an increased rate (P = 0.02) of bone healing complications in the open fracture group (21.0% vs. 4.0%); all in patients with Gustilo type 2 or 3 injuries. All patients achieved radiographic union at final follow-up.

CONCLUSIONS

Immediate flexible nailing of open pediatric tibial shaft fractures can be safely performed with minimal risk of wound or infectious complications. Clinicians should understand that prolonged bone healing (particularly in Gustilo type 2 or 3 injuries) should be expected in patients who undergo immediate flexible nailing of their open fractures. Open tibial shaft fractures are high-energy injuries, and should be seen as surrogate markers of polytrauma in the pediatric population. The risk of compartment syndrome is high regardless of whether a patient has a closed or open tibia fracture, and caution should be used in performing flexible nailing in patients who may have closed head injury due to a risk of systemic complications.

LEVEL OF EVIDENCE

Level III, therapeutic study, retrospective cohort.

Evidence-based review: management of open pediatric fractures

Open fractures in the pediatric population are rare. As such, recommendations for care based on high-level studies are scarce. Furthermore, most level I and II recommendations come from studies involving open fractures in adults. Although it is generally accepted that open pediatric fractures have better outcomes than open fractures in adults, the lack of quality studies provide ample opportunities to answer questions regarding care of these injuries. This review explores the available literature and gives corresponding recommendations based on the level of evidence.

Traumatic diaphyseal bone defects in children

Traumatic bone defects (BD) are rare in children. There are no pediatric series in the literature on this topic. The aim of this first pediatric series was to determine the epidemiological characteristics and evaluate the results of different treatments in this entity.

MATERIAL AND METHODS

This retrospective multicenter study evaluated diaphyseal bone defects in cases in which bone reconstruction was performed. BD was either initial and associated with trauma or secondary, resulting from infected non-union.

RESULTS

The series included 27 patients (17 boys and 10 girls), mean age 11.4 years old (3-16) (20 traffic accidents). At the outset of all patients' history was an open fracture (one stage 1, seven stage 2, 11 stage 3A and seven stage 3B, 1 NR). BD involved 13 tibias, 9 femurs, three humerus, one radius and one ulna. Bone defects were initial in 20 cases and secondary in seven cases. They were less than 2 cm in two cases, between 2 and 5 cm in 9 cases, between 5 and 10 cm in 10 cases and more than 10 cm in six cases. Treatment of BD was immediate in one case and delayed in 26 cases. Techniques used included: induced membrane in 10 cases, bone transport in seven cases, bone autograft in eight cases, vascularized fibular transfer in one case, no bone reconstruction in one case. Union was obtained in 27 patients. Union was obtained within a mean 12.3 months BD (3-62). Fifteen patients presented with sequellae.

DISCUSSION

Traumatic bone defects have a better prognosis in children than in adults. The thicker, more active and richly vascularized periosteum in children is an important prognostic factor. Treatment of BD requires good initial bone stabilization. Reconstruction depends on the integrity of the periosteum. In case of an intact periosteum, bone reconstruction does not seem necessary in young children. If one part of the periosteum is intact, a simple autograft seems sufficient even with extensive bone defects. In the absence of the periosteum or especially in case of infection, the induced membrane technique seems preferable, with bone transport or a vascularized bone transfer.

LEVEL OF EVIDENCE

IV: retrospective study.