Age as a prognostic factor in open tibial fractures in children

Open fractures of the limbs in children and adolescents

Open fracture is rare in children, raising dual issues of sepsis and mechanics. Here, we address certain practical questions regarding childhood open fracture. Should the recognized adult classifications be used in children? Two classifications exist for adults, without pediatric specificities; of these, we recommend Gustilo's, as being more precise in its description of severe grades. Is there any consensus on emergency prophylactic antibiotic therapy in children? The risks seem to be the same, and 24hours' prophylactic antibiotic therapy should be initiated as soon as possible, as in adults. What are the most recent guidelines on time to treatment, type of internal fixation and possible associated procedures in tibial fracture in children? Wound cleansing is indispensable. Treatment under anesthesia can be delayed up to 24hours in the absence of neurovascular complications on condition that antibiotic therapy is implemented immediately. In Gustilo grade I and II, or IIIA, external fixation is not systematic and non-operative treatment or intramedullary nailing is possible. In grades IIIB and IIIC, external fixation is the rule, although conversion is possible if indicated early enough. Do the particular cases of nail bed injury or lawn mower foot injury in children require specific management? Nail bed injury is not to be minimized and should be treated strictly. In case of serious accidents with garden equipment, initial wound care in surgery should be economic, but experienced practitioners should weigh the risk/benefit ratio between conservation and early amputation. LEVEL OF EVIDENCE: IV.

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.

Resect or Retain Bone Fragments in Children and Teenagers with Severe Open Fractures?: A Case Report

CASE

A 14-year-old pedestrian was hit by a car and encountered similar bilateral Gustilo IIIB open tibial fractures. The right tibial fracture involved a large borderline vital butterfly fragment without periosteal contact, which was retained and proceeded to sufficient healing within 12 weeks. The left tibial fracture was treated according to the principles for the treatment of severe open fractures in adults, involving resection of devitalized fragments and bone transport, and healed within 15 months.

CONCLUSIONS

Teenagers do possess larger bone healing potential than adults. Therefore, a rapid bone union can be achieved even with apparently devitalized bone fragments if sufficient soft-tissue closure and stable fracture fixation is established early in the treatment of open limb fractures.

A comparison between the Major Trauma Centre management of complex open lower limb fractures in children and the elderly

INTRODUCTION

Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding.

METHODS

A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score).

RESULTS

33 paediatric patients and 99 elderly patients were identified. Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections. Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation.

DISCUSSION

These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.

Management of pediatric open tibia fractures with supracutaneous locked plates

We evaluated the novel application of supracutaneous locked plates in pediatric open tibia fractures. Pediatric open tibia fractures stabilized with a locked supracutaneous plate from January 2011 to December 2014 were reviewed. Twenty-eight children, mean age 8.9 years, with 29 open tibia fractures were included. Nine of these children who had metaphyseal or metadiaphyseal fractures did not require joint spanning. The mean follow-up duration was 13.5 months. The mean time to uneventful union was 11.46 weeks, with no unacceptable malunion. Supracutaneous locked plates showed early union and no refractures. They could favorably replace tubular external fixators in stabilizing pediatric open tibia fractures.

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.

Traumatic extremity arterial injury in children: epidemiology, diagnostics, treatment and prognostic value of Mangled Extremity Severity Score

Background

Traumatic paediatric arterial injuries are a great challenge due to low incidence and specific characteristics of paediatric anatomy and physiology. The aim of the present study was to investigate their epidemiology, diagnostic and therapeutic options and complications. Furthermore, the prognostic value of the Mangled Extremity Severity Score (MESS) was evaluated.

Methods

In a retrospective clinical study 44 children aged 9.0 ± 3.2 years treated for traumatic extremity arterial lesions in our Level I trauma center between 1971 and 2006 were enrolled. Exclusion criteria were age > 14, venous and iatrogenic vascular injury. Demographic data, mechanism of injury, severity of arterial lesions (by Vollmar and MESS), diagnostic and therapeutic management, complications and outcome were evaluated.

Results

The most commonly injured vessel was the femoral artery (25%) followed by the brachial artery (22.7%). The mechanism of injury was penetrating (31.8%), isolated severe blunt extremity trauma (29.6%), multiple trauma (25%) and humeral supracondylar fractures (13.6%). In 63.6% no specific vascular diagnostic procedure was performed in favour of emergency surgery. Surgical reconstructive strategies were preferred (68.2%). A MESS < 7 was associated with initial (p < 0.05) and definite limb salvage (p < 0.001) of the lower extremity.

Conclusions

Traumatic paediatric vascular injuries are very rare. The most common situations of vascular lesions in childhood were penetrating injuries and fractures of the extremities either as isolated injuries or in multiply injured patients. In paediatric patients, the MESS could serve as a basis for decision making for limb salvage or amputation.

Fraturas da diáfise da tíbia em crianças

As fraturas da diáfise da tíbia nas crianças e adolescentes são lesões relativamente comuns e geralmente têm boa evolução com os métodos clássicos de tratamento conservador. Sua elevada frequência se deve ao alto grau de exposição da criança nas suas atividades físicas e também pela anatomia e topografia da tíbia, expondo-a ao trauma direto ou indireto. Algumas particularidades devem ser consideradas e respeitadas na sua abordagem, que compreendem aspectos atinentes à faixa etária, local de acometimento (se proximal ou distal), tipo de fratura e de terapêutica instituída. A vantagem anatômica do periósteo mais espesso e a relativa flexibilidade na acomodação de impactos angulares podem proporcionar na criança de menor idade, maior estabilidade e consequente tendência ao melhor prognóstico. Nas crianças maiores e nos adolescentes o grau de exposição a traumas de maior energia, a maior gravidade e complexidade das lesões têm tornado mais comum a estabilização cirúrgica. Complicações encontradas nessas fraturas nos adultos como infecção, retarde de consolidação e pseudartrose são muito menos frequentes nas crianças, mas o risco de instalação de síndromes compartimentais é uma eventualidade que requer atenção, principalmente nas condutas incruentas com imobilizações gessadas.

The ortho-plastic management of Gustilo grade IIIB fractures of the tibia in children: a systematic review of the literature

BACKGROUND

The challenges of managing Gustilo IIIB tibial fractures in children are unique. A multi-disciplinary, evidence based approach is needed. We aimed to evaluate the evidence for the ortho-plastic management of Gustilo grade IIIB open tibial shaft fractures in children based on a review of all published data in order to rationalise the orthopaedic and plastic surgical approach to these complex injuries.

METHOD

A systematic review of the literature was performed. Gustilo grade IIIB tibial shaft fractures in pre-adolescent and adolescent children were identified and evaluated with regard to both the skeletal and soft tissue management, and the outcome.

RESULTS

Of 54 children with grade IIIB tibial fractures, a mean union time of 31 weeks included 33 weeks for 42 adolescents and 23 weeks for 12 pre-adolescents. Faster union time in pre-adolescents tended towards significance. Delayed union occurred in 22%, nonunion in 13%, mostly in adolescents. Two of 45 covered by vascularised flaps and 3 of 9 treated without flaps developed deep infection (p=0.028). There was no correlation between method of skeletal fixation and union time.

CONCLUSION

Gustilo IIIB tibial shaft fractures in pre-adolescents tended towards faster healing with fewer complications, irrespective of the method of skeletal fixation. In adolescents, healing times were similar to adults. Soft tissue closure without flaps was associated with deep infection in one-third of patients, requiring debridement and flap cover. Adequate debridement and flap cover is suggested in all cases, irrespective of age.

Nonoperative management of pediatric grade 1 open fractures with less than a 24-hour admission

BACKGROUND

The purpose of this study was to evaluate the results of nonoperative management of pediatric grade 1 open fractures treated either in the emergency room only or with a less than 24-hour admission.

METHODS

A retrospective chart review was done on all patients with this type of injury who were treated by nonoperative modalities in the emergency room and who were admitted for no more than 24 hours for administration of intravenously administered antibiotics. Our population included 25 patients who were followed up until healing was confirmed clinically and radiographically.

RESULTS

One patient with persistent serosanguineous drainage from the wound site and fever was admitted for 48 hours of intravenously administered antibiotics for presumed infection. That patient went on to heal both clinically and radiographically without further complication. Therefore, our infection rate was 4.0%.

CONCLUSIONS

This study demonstrates the safe nonoperative treatment of grade 1 open fractures in our pediatric population. This management eliminates any possible anesthetic risk as well as significantly decreases the cost of caring for these patients in the health care system.

Open tibial fractures in the paediatric population: a systematic review of the literature

INTRODUCTION

Open tibial fractures have been studied extensively in adults, and detailed treatment strategies have been developed: wound irrigation and debridement, fracture stabilization and delayed primary wound closure or early flap coverage are basic principles of management. No clear guidelines regarding the management of open tibial fractures in children exist.

SOURCES OF DATA

We searched Medline, Embase, Cochrane, CINAHL and Google Scholar databases using the keywords: 'open', 'tibia', 'fracture', 'children', 'paediatric', 'pediatric', 'external fixation', 'nailing'. Fourteen clinical studies were included. Quality of the studies was assessed using the Coleman Methodology Score.

AREAS OF AGREEMENT

Age above 10 years and grade III (severe) open fractures are associated with complications and outcomes similar to those in adults.

AREAS OF CONTROVERSY

It is unclear whether open fractures of the tibia in children should be managed according to the principles followed in adults. Many authors support primary skin closure and non-operative management for grade I open fractures. There is no clear effect of fracture fixation method on time to union.

GROWING POINTS

The quality of the studies was relatively poor. Patients' age affects outcome; adolescents should probably be managed as adults.

AREAS TIMELY FOR DEVELOPING RESEARCH

Carefully designed prospective cohort studies including a large number of children would be of value. Adequate follow-up is necessary to assess the long-term effects in the growing skeleton. The efficacy of flexible intramedullary nailing for open fractures needs further evaluation. Outcome studies based on general health measures are needed.

Elastic stable intramedullary nailing of tibial shaft fractures in children

Most pediatric tibia shaft fractures are amenable to nonoperative treatment with satisfying results, yet surgical stabilization is necessary in certain cases. The purpose of our study was to determine the effectiveness and the complications associated with elastic stable intramedullary nailing in severe pediatric tibial fractures. We retrospectively reviewed 24 tibia shaft fractures in 24 patients that were treated operatively by elastic stable intramedullary nailing between 1997 and 2005 at our institution. Extensive review of all charts and radiographic data was completed at Cincinnati Children's Hospital Medical Center. There were 8 closed and 16 open fractures. The average union time for all tibia fractures was 20.4 weeks. The average union time for closed and open fractures was 21.5 and 20.2 weeks, respectively. Complications include 2 (8%) neurovascular, 2 (8%) infections, 2 (8%) malunions, and 1 (4%) leg-length discrepancy. Although complications do exist, elastic stable intramedullary nailing of pediatric tibia shaft fractures using Nancy nails is an effective treatment option.

Complications after titanium elastic nailing of pediatric tibial fractures

A retrospective review of 60 diaphyseal tibia fractures (31 closed and 29 open fractures) treated with flexible intramedullary fixation was conducted. All charts and radiographs were reviewed. Children ranged in age from 5.1 to 17 years. Fifty patients with 51 fractures were followed up until union and comprised the study group. The mean follow-up period for these 50 patients was 79 weeks. Forty-five fractures achieved bony union within 18 weeks (mean, 8 weeks). Five patients (11%) had delayed healing (3 had delayed unions that ultimately healed with casting or observation, and 2 had nonunions that required secondary procedures to achieve union [1 patient underwent a fibular osteotomy, and 1 underwent exchange nailing with a reamed tibial nail]). These 5 fractures ultimately healed, with a mean time to union of 41 weeks. Patients with delayed healing tended to be older (mean age, 14.1 years) versus the study population as a whole (mean age, 11.7 years). In addition to delayed union, other complications were observed in the study population. One patient healed with malunion (13-degree valgus), requiring corrective osteotomy. One patient with a grade II open fracture was diagnosed with osteomyelitis at the fracture site after attaining bony union. Two patients developed nail migration through the skin, requiring modification or nail removal. The fixation of pediatric diaphyseal tibia fractures with titanium elastic nails is effective but has a substantial rate of delayed healing, particularly in older patients.

Subatmospheric pressure dressings in the temporary treatment of soft tissue injuries associated with type III open tibial shaft fractures in children

PURPOSE

This study was designed to evaluate the use of subatmospheric pressure dressings on high-energy open tibial shaft fractures in children. We hypothesized that the use of a negative-pressure dressing in these fractures would result in a decreased incidence of infection and decreased need for pedicled muscle flaps and free tissue transfer.

METHODS

A retrospective case series of 15 consecutive pediatric patients with 16 type III open tibial shaft fractures (8 type IIIA, 7 type IIIB, and 1 type IIIC). The patients' age ranged from 2 to 17 years. All patients underwent a standard protocol of serial irrigation and debridement of the open wound with bony stabilization. Temporary coverage of the open wound was obtained with the use of a subatmospheric pressure dressing until definitive wound coverage or closure.

RESULTS

Infection occurred in 5 of 16 fractures, 2 requiring antibiotics alone (1 type IIIA and 1 type IIIB) and 3 requiring surgical intervention (2 type IIIB and 1 type IIIC). Seven of 16 (3 type IIIA, 3 type IIIB, and 1 type IIIC) fractures required repeat surgical intervention to facilitate bony healing. Only 3 patients required free tissue transfers or rotational muscle flaps for coverage, a 50% decrease compared with the initial classification.

CONCLUSIONS

Compared with other described methods, the use of subatmospheric pressure dressings in the temporary treatment of soft tissue wounds associated with high-energy open tibial shaft may reduce the need for major soft tissue coverage procedures. Its effect on infection and fracture healing rates requires further study.

SIGNIFICANCE

A reduction in the need for major soft tissue coverage procedures with the use of negative-pressure dressings in this setting should result in decreased morbidity for these patients and in decreased social and financial costs.

Nonoperative management of pediatric type I open fractures

The purpose of this study was to examine the results of pediatric patients with type I open fractures managed nonoperatively. A retrospective chart review of all type I open fractures managed nonoperatively from 1998 to 2003 was performed. Forty patients were followed until healing of the fracture clinically and radiologically. One deep infection occurred in this series, producing an overall infection rate of 2.5%. This compares favorably with the literature's infection rate of 1.9% in pediatric type I open fractures treated operatively. There was a 0% infection rate in the 32 upper-extremity type I open fractures and a 0% infection rate in the 23 patients under age 12. These results suggest that nonoperative management of pediatric type I open fractures is safe and effective, especially in children under age 12 with upper-extremity fractures.

Bony tissue repair

Bone is among the most frequently injured of tissues, and bony injuries are among the conditions most commonly treated by hand therapists. An understanding of the biology of bony tissue repair, as well as the techniques available for its promotion, is therefore of the utmost importance to practitioners of hand therapy. This article addresses the biology of bony tissue repair, techniques currently available for the treatment of bony injuries, and management of specific bony injuries of the hand.