New fracture patterns distal epiphysis femur in youth: Update of current classification

INTRO

Distal growth core fractures of the femur are the third most common fracture in patients older than 10 years. These fractures result from high-energy trauma and have a high risk of evolving into growth disorders. The classification most used to describe these types of fractures is that described by Salter and Harris. Special clinical cases often occur in clinical practice that are not described in the classifications used. In our study, we analyzed and further focused on new fracture patterns related to pediatric epiphyseal detachments not easily described by the normal classifications currently used in the literature.

MATERIALS AND METHODS

From January 2020 to December 2022, we treated 2 male clinical cases with epiphyseal detachments of the distal femur that could not be classified according to the Salter and Harris classification. age of the patients was 10 and 11 years, respectively; for both patients, the traumatic mechanism was a direct trauma to the right knee at high speed using an electric scooter; Serious clinical and radiographic follow-ups were performed at month 1, month 3, month 6, month 12, and month 24 from the date of surgery.

DISCUSSION

Distal femur fractures represent a challenge for the orthopedics because they have a high incidence of complications. In our experience, there has been an increase in this type of injury caused using recently developed electric vehicles, which can reach considerable speeds. The Salter Harris classification is among the most widely used for fractures involving the growth physis. This classification proved to be rather limiting in the present case, so we decided to classify the fracture as 'Salter Harris III equivalent'.

CONCLUSIONS

The fracture examined is a very rare fracture of the distal femur and is not reflected in the classifications currently in use. The patient presented an excellent clinical and radiographic result after surgery with the presence of a shortening of the affected femur in relation to the contralateral one, which suggests that the growth deficit may continue and increase over time for which reason future studies until skeletal maturity will be necessary to quantify the damage to the growth physis.

Clinical effect analysis of different treatment schemes for children with ulnar and radial double fractures

Objective

The objective of the study is to evaluate the safety and efficacy of three different treatment methods for pediatric ulnar and radial double fractures.

Methods

120 children with ulnar and radial double fractures were included in the study. According to the different treatment plans, children were divided into three groups: manual reduction, splint external fixation, double elastic intramedullary fixation, and double plate fixation. Surgical indicators, radiological results, clinical efficacy, and complications were evaluated and compared among the groups.

Results

The average hospital stay and operation time were significantly longer in the double plate internal fixation group compared to the other two groups. The double elastic intramedullary nailing group showed a higher fracture healing rate at 3 months compared to the other groups. There were no significant differences in clinical efficacy among the three groups. Complications were observed in all groups but did not show significant statistical differences.

Conclusion

Double elastic intramedullary nailing fixation demonstrated favorable outcomes in terms of surgical indicators and fracture healing rates for pediatric ulnar and radial double fractures.

Management of multiple and displaced mandibular fractures in a pediatric patient sans mandibular immobilization, sans open reduction and internal fixation

Maxillofacial fractures in the pediatric population are generally managed by conservative approaches such as soft diet and medication or semi-invasive procedures namely inter-maxillary fixation or circum-mandibular wiring. These approaches are preferred over any invasive treatment to minimize injury to the growing skeleton and tooth germs. Displaced fractures that cause functional problems such as restricted mouth opening, malocclusion or impaired breathing, mandate open reduction and internal fixation. However, surgical management is associated with morbidity related to general anesthesia, risk of injury to vital structures, and potential, skeletal or dental growth disturbances. This case report describes a non-invasive method of managing displaced, multiple fractures of the mandible in a pediatric patient, with the use of low intensity pulsed ultrasound to achieve favorable clinical outcomes and nil complications. Neither immobilization of the mandible with inter-maxillary fixation nor open reduction and internal fixation was used. Low intensity pulsed ultrasound therapy is painless and patient-friendly.

The diagnostic value of sonographic findings in pediatric elbow fractures: A systematic review and meta-analysis

BACKGROUND

Sonography is a beneficial imaging modality for detecting elbow fractures in children, considering the lack of radiation exposure and time efficiency. This systematic review aims to determine the diagnostic value and clinical applicability of sonography and each sonographic finding in detecting pediatric elbow fractures.

METHODS

Pubmed, Scopus, and WOS databases were searched for related original articles until February 25, 2023, and data related to diagnostic performance were extracted. We used the Bivariate model and hierarchic summary receiver operating characteristic (HSROC) approach to calculate pooled diagnostic values. Cochrane Q test and I-squared were performed to evaluate heterogeneity. We assessed heterogeneity with meta-regression.

RESULTS

Eight studies were included, which involved a total number of 880 patients. According to meta-analysis, sonography demonstrated a pooled sensitivity of 97% (91-99%) and specificity of 90% (80-95%), positive likelihood ratio(LR+) of 9.82 (4.59-20.97), and negative likelihood ratio (LR-) of 0.03 (0.01-0.10). For the sonographic posterior fat pad sign as a sole diagnostic sign, we calculated a Pooled Sensitivity of 80% (70-88%), Specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). Also, lipohemarthrosis demonstrated a pooled sensitivity of 80% (70-88%), specificity of 97% (87-99%), LR+ of 28.8 (6-139.3), and LR- of 0.2 (0.13-0.31). The sensitivity of detecting fractures with cortical line disruption was significantly higher in studies that utilized a comprehensive technique compared to a conventional technique.

CONCLUSIONS

Sonography is a valuable diagnostic tool for the assessment of pediatric elbow injuries, and it can be capable of confirmation or exclusion of the diagnosis.

Minimally Invasive Techniques in the Surgical Management of Traumatic Pediatric Thoracolumbar Fractures

BACKGROUND

Thoracolumbar (TL) fractures are uncommon in children. While surgical treatment is recommended for unstable TL fractures, there is no consensus on appropriate surgical treatment. We present a case series of pediatric patients with traumatic TL fractures treated with minimally invasive techniques. We discuss our early experience and technical challenges with navigation and robotic-assisted fixation.

METHODS

A retrospective review of a prospectively maintained trauma database from February 2018 to February 2023 of all pediatric patients (<18 years old) undergoing percutaneous fixation for unstable TL fractures was performed. Minimally invasive techniques included fluoroscopy and/or navigation-guided or robotic-assisted surgery. Clinical course, radiographic findings, and technical challenges were reviewed.

RESULTS

A cohort of 12 patients (age range, 4-17 years) with 6 (50%) Chance fractures, 2 (16%) pars fractures, 2 (16%) pedicle fracture, 1 (8%) burst fracture, and 1 (8%) other fracture were identified. Nine patients had fractures involving the lumbar spine, and the remaining 3 had thoracic fractures. In all cases, percutaneous pedicle screws were placed above and below the fracture with the use of neuronavigation or robotic-assisted navigation (n = 2). Blood loss was <30 mL for single-level fractures and instrumented fusion. Two patients had hardware-related complications. At follow-up (mean 9.67 months after surgery), patients were doing well clinically, and most imaging showed stable alignment.

CONCLUSIONS

Our early experience shows that short segment instrumentation through a minimally invasive approach is a safe and effective surgical option for young pediatric patients with good clinical outcomes and favorable radiographic postoperative finding.

K Wires or Cannulated Screws for Fixation of Lateral Condyle Fractures in Children: A Systematic Review of Comparative Studies

Introduction

Lateral condyle fractures in children have been typically been treated operatively using Kirschner wires (K wire) or cannulated screws (CCS); however, a definitive choice of implant remains a matter of debate. This systematic review aims to determine if union and functional outcomes of these fractures are better with screw fixation.

Methodology

A search of PubMed, Medline, Cochrane, and Google scholar was performed in March 2021. The results were screened by title and abstract, and relevance and a quality assessment of the data were performed for the articles meeting the inclusion criteria. Articles comparing radiological and functional outcomes of lateral condyle fractures treated with K wires or screws were included for examination. Articles were excluded if they did not compare outcomes of K wires and CCS together, or were in a language other than English, technical notes, case reports, and articles, which describe the use of fixation methods other than K wire or CCS as well as biomechanical studies were also excluded. Risk of bias and quality assessment of included articles were also done.

Results

Seven clinical studies were included. 44.4% (n = 4) were retrospective review of records with level III evidence (77.7%, n = 7). Only two included articles had good-quality assessment scores. Union was reported in 85.7% % in K wire group and 99.6% in CCS group. Functional outcomes were not statistically significant between the two groups.

Conclusion

Using screws to fix lateral condyle provides better union; however, there is no difference in the functional outcomes and complication rate between the two. Using screws or buried K wires adds the burden of an additional procedure for removal.

[Clavicle shaft fractures in childhood and adolescence : Consensus report of the Pediatric Traumatology Section of the German Society for Trauma Surgery]

INTRODUCTION

Clavicle shaft fractures are among the most common fractures in childhood and adolescence. In the past they were almost exclusively treated conservatively but in recent years there has been an increase in surgical treatment. Nevertheless, exact recommendations for the choice of diagnostics and for the treatment regimen do not yet exist.

MATERIAL AND METHODS

Therefore, our aim was to develop a consensus within the 7th scientific working meeting of the section for pediatric traumatology in the German Society for Trauma Surgery based on expert opinion.

RESULTS

Single-plane radiographic imaging is considered the gold standard diagnostic tool. Children younger than 10 years are primarily treated conservatively, and the type of immobilization is secondary. In girls older than 12 years and boys older than 14 years, fractures dislocated by more than the shaft width and shortened by > 2 cm should be treated by open reduction and stabilized by osteosynthesis, followed by free-functional follow-up treatment.

CONCLUSION

In addition to X‑rays, diagnostics using ultrasound must be further established. Treatment continues to be primarily conservative, but surgical treatment is also important, especially in adolescents. If the indications are correct, a good outcome can be expected regardless of the choice of treatment.

Effect of non-steroidal anti-inflammatory drugs on fracture healing in children: A systematic review

BACKGROUND

Non-steroidal anti-inflammatory drugs (NSAIDs) are among the most commonly prescribed medications in the United States. Although they are safe and effective means of analgesia for children with broken bones, there is considerable variation in their clinical use due to persistent concerns about their potentially adverse effect on fracture healing.

AIM

To assess whether NSAID exposure is a risk factor for fracture nonunion in children.

METHODS

We systematically reviewed the literature reporting the effect of NSAIDs on bone healing. We included all clinical studies that reported on adverse bone healing complications in children with respect to NSAID exposure. The outcomes of interest were delayed union or nonunion. Study quality was assessed using the Newcastle-Ottawa scale for non-randomized studies. A final table was constructed summarizing the available evidence.

RESULTS

A total of 120 articles were identified and screened, of which 6 articles were included for final review. Nonunion in children is extremely rare; among the studies included, there were 2011 nonunions among 238822 fractures (0.84%). None of the included studies documented an increased risk of nonunion or delayed bone healing in those children who are treated with NSAIDs in the immediate post-injury or peri-operative time period. Additionally, children are likely to take these medications for only a few days after injury or surgery, further decreasing their risk of adverse side-effects.

CONCLUSION

This systematic review suggests that NSAIDS can be safely prescribed to pediatric orthopaedic patients absent other contraindications without concern for increased risk of fracture non-union or delayed bone healing. Additional prospective studies are needed focusing on higher risk fractures and elective orthopaedic procedures such as osteotomies and spinal fusion.

Proximal Humerus Fractures in the Pediatric Population

PURPOSE OF REVIEW

The purpose of this review is to review recent literature focusing on proximal humerus anatomy, epidemiology of these fractures, diagnosis and treatment options, and clinical outcomes.

RECENT FINDINGS

Non- or minimally displaced proximal humerus fractures treated nonoperatively do not lead to short- or long-term complication and do not cross over to operative treatment. There is a higher rate of operative management with older age, increased injury severity score, treatment at an adult hospital, and private insurance. Operative management is preferred with closed or open reduction and percutaneous pinning, but elastic nailing and plate fixation are other options with good postoperative outcomes. Pediatric proximal humerus fractures occur after fall onto the affected shoulder or arm. Diagnosis is usually made with radiographs. Understanding the proximal humerus anatomy is critical to the proper management of these injuries to aid reduction and predict remodeling potential. There is considerable debate around the management of proximal humerus fractures in the pediatric population. Treatment is based on patient age, fracture displacement, and remodeling capacity. Nonoperative management is successful in younger patients or less displaced fractures, and operative management is usually considered in older patients with more displaced fractures.

Open reduction of radial neck fractures in children: injury severity predicts the radiographic and clinical outcomes

BACKGROUND

Radial neck fractures are the third most common elbow fracture in children. Open reduction may be required if closed or mini-open techniques are not successful in reducing the fracture. Previous reports on open reduction have noted poor outcomes and complications with this treatment approach. However, it is unknown whether it is the open procedure itself or the severity of the initial injury that leads to the poor results. The purpose of this study was to evaluate the correlation between intraoperative findings at the time of open reduction of radial neck fractures and the clinical and radiographic outcomes.

METHODS

Data from patients who underwent open reduction for an acute radial neck fracture between January 2009 and December 2018 were abstracted and reviewed. Patients undergoing open treatment for a nonunion or malunion and those with inadequate follow-up were excluded. Demographic data, injury characteristics, treatment strategies, intraoperative findings, and clinical and radiographic outcomes were assessed.

RESULTS

Twenty-two patients met the inclusion criteria. Of these patients, 14 were girls. The mean age was 9.7 ± 3 years, and the mean follow-up period was 15.8 months. Fifteen patients had a Judet grade IV displacement. Fair or poor outcomes were observed in 12 patients (55%). Ten reoperations were recorded during the study period. Age, weight, and associated injuries were not predictive of poor outcomes. Intraoperative findings of soft-tissue stripping and radial head comminution were the only significant predictors of fair or poor clinical outcomes (P < .001) and subsequent radiographic changes including fragmentation and collapse of the radial head and arthritic changes (P < .001). The quality of reduction and the choice of hardware were not significantly associated with either clinical or radiographic outcomes.

CONCLUSION

Our findings support the notion that the outcomes of open reduction of radial neck fractures are most closely correlated with the injury severity, with the intraoperative findings of complete soft-tissue stripping or comminution of the radial head fragment being significant predictors of poor clinical and radiographic outcomes. The choice of hardware and the quality of reduction achieved at the time of surgery have less significance than injury severity.

The effects of home confinement on pediatric fractures during the COVID 19 outbreak

OBJECTIVE

To control the transmission of coronavirus disease 2019 (COVID-19), the Chinese government encouraged people to stay at home. This study aimed to evaluate the effects of home confinement on the occurrence of fractures among children.

STUDY DESIGN

We retrospectively reviewed children admitted to Children's Hospital of Chongqing Medical University, for traumatic injury from January 24 to March 10, 2020, and the same time period in 2017, 2018 and 2019. At the same time, children with fracture were screened out and the date for the past 4 years was compared in terms of etiology, location of fracture, sex and age to evaluate the effects of home confinement on the epidemiology of pediatric fractures during the COVID-19 outbreak.

RESULTS

There were 6066 fractures in5,346 patients in 2017-2019, and 1034 fractures in 862 patients in 2020; the number of patients in all years reached a peak at the age of 2 to 4 years. The patients were slightly younger in 2020 than in 2017-2019 (t = 9.953, 95% CI: 0.846-1.262), and the proportion of boys in 2017-2019 is higher than in 2020 (X² = 6.944, P = 0.008). Home confinement and traffic restriction resulted in a reduction in traffic accidents-associated fractures among children (X² = 16.399, P < 0.001).

CONCLUSION

Home confinement lead to the significant reduction in the number of pediatric fractures, especially in male children, but the number of patients under 4 years old was still considerable, and the proportion of younger patients even increased. Therefore, the perspective of children should not be relaxed during home isolation.

Early Pediatric Fractures in a Universally Insured Population within the United States

Background

Musculoskeletal injury, including fracture, is one of the most common causes of morbidity in pediatric patients. The purpose of this epidemiologic study is to determine the prevalence and risk factors for fracture in a large cohort of pediatric patients under the age of 5.

Results

Of the 233,869 patients included in the study, 13,698 fractures were identified in 10,889 patients. The highest annual incidence was in the 4 year old age group with a rate of 24.2 fractures per 1000 children. The annual incidence within all age groups was 11.7 fractures per 1000 children. The two most common fractures were forearm and humerus fractures. Fracture incidence was increased in male children, patients who live outside the US, and in Caucasian patients. An increase in rate of fracture was also identified in children of officers when compared with children of enlisted service members. There were 35 abuse related fractures in our cohort, with 19 of them occurring in children less than 1 year old. Only three children in our cohort had Osteogenesis Imperfecta.

Conclusion

Fractures are common injuries in young children with an incidence over the first 5 years of life of 5.86%. Multiple risk factors were also identified including age, race, geographic location and socioeconomic status. The results of this study are an important contribution to epidemiologic and public health literature and serve to characterize the incidence of and risk factors for sustaining an early childhood fracture.

Outcomes of Pediatric Pelvic Fractures: A Level I Trauma Center's 20-Year Experience

BACKGROUND

Pediatric pelvic fractures are rare. The contribution of pelvic fracture pattern, risk factors for associated injuries, and mortality are poorly defined in this population.

METHODS

Patients aged 0-17 with pelvic fractures at a level I trauma center over a 20-y period were reviewed. Fracture patterns were classified according to the Young-Burgess classification when applicable. Fractures were analyzed for location, pubic symphysis or sacroiliac widening, and contrast extravasation.

RESULTS

There were 163 pelvic fractures in 8758 admissions (incidence 2%). The most common associated injures were extremity fractures (60%, n = 98), abdominal solid organ (55%, n = 89), and chest (48%, n = 78), with the majority (61%, n = 99) sustaining injuries to multiple organs. Unstable fractures were associated with injures to the thorax (70% versus 40%), heart (15% versus 2%), and spleen (40% versus 18%), all P < 0.05. Nonpelvic operative interventions were required in 45% (n = 73) and were more common in unstable fractures (36% versus 19%), contrast extravasation (63% versus 26%), sacroiliac widening (36% versus 20%), and sacral fractures (39% versus 13%), all P < 0.05. Mortality was 13% and higher in males versus females (18% versus 5%), contrast extravasation (50% versus 3%), or sacroiliac/pubic symphysis widening (13% versus 2%) (all P < 0.05). Male gender (OR 6.03), brain injury (OR 6.18), spine injury (OR 5.06), and cardiac injury (OR 35.0) were independently associated with mortality (all P < 0.05).

CONCLUSIONS

Pediatric pelvic fractures are rare but critical injuries associated with significant morbidity and need for interventions. Increasing fracture severity corresponds to injuries to other body systems and increased mortality.

Functional and radiological results of percutaneous K-wire aided Métaizeau technique in the treatment of displaced radial neck fractures in children

OBJECTIVES

The aim of the present study was to determine the radiological and functional results and the efficiency of paediatric radial neck fracture fixation following reduction with the Métaizeau technique together with percutaneous K-wire applied under fluoroscopy to ensure minimum soft tissue damage.

METHODS

The study included 20 patients with Judet Type 3, Type 4a and Type 4b fractures operated on with the Métaizeau technique aided by percutaneous K-wire between 2007 and 2014. The mean age of the patients was 9.75 years (range, 4-13 years). Mean preoperative angulation was measured as 52.4° (range, 35°-85°). The average postoperative follow-up time was 34.65 months (range, 13-84) months. Postoperative radiological evaluations were made according to the Ursei classification and functional assessment with the Tibone - Stoltz classification system.

RESULTS

Radiologically, the difference between preoperative and postoperative radius head angulation was found statistically significant (p0.001). In the clinical assessment of injured and uninjured arms, there was no statistically significant difference between flexion-extension (p = 0.330) and supination-pronation range of motion (p = 0.330) and carrying angles (p = 0.094). According to the radiological Ursei evaluation, 17 (85%) patients were in perfect condition and 3 (15%) were good. In the classification of Tibone - Stoltz, 16 (80%) patients were evaluated as perfect, 3 (15%) as good and 1 (5%) as fair.

CONCLUSION

From the results of this study and related literature, the use of the Métaizeau technique in displaced radial neck fractures requiring surgical treatment in children can be recommended since it creates minimum damage to the soft tissue, is easy to apply and the results are satisfactory.

LEVEL OF EVIDENCE

Level IV, therapeutic study.

Advantages and disadvantages of the prone position in the surgical treatment of supracondylar humerus fractures in children. A literature review

INTRODUCTION

Supracondylar humerus fractures are the most common elbow injuries in children. The widely adopted approach for Gartland III extension type consists of closed reduction and percutaneous pinning; the pin configuration can be lateral or crossed in relationship with the habit of the surgeons. Iatrogenic injury of the ulnar nerve is the most common risk during the insertion of the medial pin. The aim of this study was to analyze advantages and disadvantages of percutaneous pinning with the patient in prone position.

MATERIALS AND METHODS

A literature review of the period 2005-2017 was carried out; four medical search engine (Pubmed, Cochrane Library, ISI Web of Science and Scopus) were consulted using the review's filter and the key words "Ulnar nerve AND supracondylar humerus fractures". The total number of patients were analyzed for: ulnar nerve injuries, anesthesiologic management, time of surgery.

RESULTS

Twenty-nine papers were read, 23 regarding cross pinning in supine position and 6 in prone position. On one hand, 1529 children were treated with closed reduction and cross pinning in supine position; 69 of these patients (4.5%) suffered from iatrogenic ulnar nerve injury. On the other hand, 579 patients underwent the same treatment in prone position; no ulnar nerve lesions were reported in this group. Only one article compared both groups of children in supine and prone position regarding time of anesthesia which is slightly higher in the prone group. There were no differences between supine and prone positions regarding x-ray exposition, time of surgery, closed reduction manoeuvers, pin positioning, x-ray results, clinical and functional results.

DISCUSSION AND CONCLUSIONS

The ulnar nerve in children is hypermobile in the cubital tunnel and tends to dislocate anteriorly over the medial epicondyle, especially when the elbow is in hyperflexion. This may be the reason of the increased risk of nerve injury during the insertion of the medial pin in supine position and, instead, an advantage of the prone position. The insertion of both pins from the lateral side could reduce this complication. Larger studies need to be carried out regarding the reported higher duration of anesthesia in prone position.

Pediatric pelvic ring injuries: How benign are they?

INTRODUCTION

With an incidence of less than 0.2% of all pediatric fractures, pelvic ring injuries are rare. Historically they were conservatively treated, but because malunion and long-term morbidity are associated with unstable injuries, a trend towards operative treatment can be observed. The purpose was to determine clinical and radiographic outcomes following these complex pediatric pelvic ring injuries.

PATIENTS AND METHODS

This Level IV retrospective analysis was completed at a private orthopaedic practice in association with a Level One teaching trauma center. There were 33 children with pelvic ring injuries with a mean age of 12.6 years (4-16) and an average follow up of 28.6 months (range 6-101). Injuries were 2 A2, 3 B1, 16 B2, 10 B3, and 2 C2 according to OTA/AO classification. Group 1 had 16 unstable, operatively treated injuries and Group 2 had 17 stable, non-operatively treated injuries. Radiographic deformity, leg length discrepancy, low back, and SI joint pain were evaluated.

RESULTS

For Group 1, 10 of 15 patients (67%) had a permanent ischial height difference >5mm compared to Group 2, in which 5 of 12 (42%) had an ischial height difference of >5mm. Group 1 had more pelvic asymmetry (12.3mm vs. 6.6mm) and ring width difference (6.9mm vs. 3.9mm) on final X-rays as compared to Group 2. Children with 5-10mm posterior sacral displacement had significantly more pain than children with 0-4mm displacement (p=0.034). Thirteen children (39%) had residual low back/SI joint pain; the rate was significantly higher in the Group 1 (3/17 vs. 10/16, p=0.008). In three (9%) children with 2 B2 and 1 B3 injury, leg length discrepancy between 5mm to 15mm occurred.

DISCUSSION AND CONCLUSION

In pediatric patients with pelvic ring injuries, radiographic deformity persisted and did not remodel. Pelvic ring deformity occurred more commonly with complex unstable ring injuries. The complex displaced injuries have higher rates of operative intervention, residual deformity, and low back and SI joint pain.

Casting: Pearls and pitfalls learned while caring for children’s fractures

Casting is a routine procedure used for fracture care in the pediatric population. The purpose of this review is to provide pearls and pitfalls that our institution has learned from previous literature. When applying the cast, we recommend using cotton padding for the liner and fiberglass or plaster depending on how much swelling is expected. A well-molded cast must be applied in order to prevent further fracture displacement. Cast valving is a valuable technique that allows a decrease in pressure which prevents discomfort and complications like compartment syndrome. Preventing thermal injuries, skin complications, and a wet cast are other important considerations when caring for casts. Appropriate use of a cast saw, avoiding pressure spots, and properly covering the cast are ways to respectively prevent those complications. Lastly, patient education remains one of the most valuable tools in ensuring proper cast maintenance.

Pediatric Open Fractures

Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge because of the risk of healing complications and infection, leading to significant morbidity even in the pediatric population. Therefore, the management of pediatric open fractures requires special consideration. This article comprehensively reviews the initial evaluation, classification, treatment, outcomes, and controversies of open fractures in children.

Pediatric fractures: temporal trends and cost implications of treatment under general anesthesia

PURPOSE

Pediatric fractures are common and are often managed by manipulation under general anesthesia (MUA). This study's aim was to assess the changing pattern of pediatric fractures over 6 years and use this data to perform a workload forecast and estimate cost implications of treatment under general anesthesia.

METHODS

The Emergency Department (ED), operating theater and ward admissions data of children aged 1-11 years presenting with fractures was analyzed. We calculated caseload trends, delay to operation, various parameters of service provision, and the current cost of treating each fracture. We then performed predictive cost analysis for the next 3 years to estimate potential savings by manipulating fractures in ED under ketamine sedation.

RESULTS

The case load has increased >350% in 6 years (total fractures increasing at 23% and MUAs increasing at 17% per year, respectively). The summer months and evenings have been consistently busier. 72% of fractures were managed by pure reduction alone (MUA), 22% by reduction + K-wires, and various other procedures were performed in 1%. The median delays from ED presentation to admission, definitive procedure and discharge were 4, 21 and 33 h, respectively. Each MUA took 52 min and cost the hospital £723. Assuming that the current trends continue, the expenditures would be £101 K, £114 K, and £128 K for 2010, 2011 and 2012, respectively.

DISCUSSION

Fracture manipulation in children under general anesthesia often requires an overnight hospital stay, which is not only uncomfortable for the child and inconvenient for the parents but it also increases the burden on the limited National Health Service (NHS) resources. There is a 23% annual increase in fractures and children have to wait for 21 h before the definitive procedure. Using ketamine to manipulate children's fractures in the ED could offer potential service and cost improvements.