open fractures in children. principles of evaluation and management

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2005;87:2784-2798. doi:10.2106/JBJS.E.00528J Bone Joint Surg Am.David G. Stewart, Jr., Robert M. Kay and David L. Skaggs Open Fractures in Children. Principles of Evaluation and Management

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COPYRIGHT 2005 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED

2784

Current Concepts Review

Open Fractures in Children

Principles of Evaluation and Management

BY DAVID G. STEWART JR., MD, ROBERT M. KAY, MD, AND DAVID L. SKAGGS, MD

Open fractures in children often have a better prognosis than similar injuries in adults, and treatment may be dif-

ferent from that for adults.

Emergent administration of appropriate antibiotics is essential to decrease the risk of infection.

Stabilization of unstable fractures is usually beneficial, although children may require less rigidity than adults.

If viability of soft tissue is in doubt, dbridement should be deferred until a later operation, as the superior heal-

ing potential of young children may produce unexpected recovery.

Associated injuries are common with open fractures in children, and serial examinations over time often uncover

these injuries.

Most open fractures in children result from motor-vehicle acci-dents (including those in which the child is an occupant of themotor vehicle or is struck by an automobile while riding a bicy-cle or as a pedestrian) or falls from heights. The reported demo-graphics and injury mechanisms have varied widely from center

to center. Most investigators have reported a preponderanceof boys and a predilection for the forearm and tibia. In amulticenter study of 554 open fractures in children, the sites ofinjury were the tibia or fibula (190 fractures; 34%), radius orulna (178; 32%), hand or metacarpals (fifty-four; 10%), femur(thirty-seven; 6.7%), humerus (thirty-six; 6.5%), foot or meta-tarsals (twenty-four; 4.3%), elbow (fourteen; 2.5%), ankle (thir-teen; 2.3%), and other sites (eight; 1.4%)1. In another study, ofchildren presenting to one hospital, thirty-two (80%) of fortyopen fractures involved the forearm2. In yet another study, 9%of fractures in children admitted to a tertiary pediatric traumacenter were open3, although we suspect that open injuries con-stitute a substantially smaller percentage of pediatric fractures

outside of tertiary care centers.Open fractures in children differ from open fractures inadults in many ways. Thicker and more active periosteum pro-vides greater fracture stability and leads to more rapid and re-liable fracture-healing in young children compared with thatin older children and adults4. Young children have a greaterpotential for periosteal bone formation5. Healing is usuallyfaster and more reliable in children than it is in adults withsimilar injuries, and children can even have reconstitution ofbone in the face of bone loss6. Infection rates in children withopen fractures have been reported to be lower than those inadults with such fractures7.

There is a gradual progression from childhood to adult-hood. As children of the same chronologic age often demon-strate widely different physiologic or bone ages, it is notpossible to make comprehensive recommendations based ex-clusively on age. Our discussion of children refers to skeletally

immature patients. Patients with closed physes can often betreated according to adult algorithms.

Initial Evaluation and Management

The initial treatment of patients with open fractures requirescare of the so-called trauma ABCs (airway, breathing, and cir-culation) and achieving control of the cervical spine8,9. Arolled towel or pad is typically placed under the shoulders ofyoung children to avoid neck flexion, as the proportionatelylarge head of a child leads to neck flexion and a risk of neuro-logic injury when an adult board is used10.

The Pediatric Advanced Life Support (PALS)11 and Ad-vanced Trauma Life Support (ATLS)12 manuals provide help-

ful guidelines for the evaluation and care of children who havesustained traumatic injuries. Patients with a high-energy injury or multiple injuries should be evaluated by a traumasurgeon13. Intravenous lines are started, fluid resuscitation isbegun, and intravenous antibiotics are given promptly. If in-travenous access is not readily obtainable, intraosseous infu-sion can be performed with a large bone-marrow needle witha stylet placed in the proximal part of the tibia, approximately1 cm distal to the tibial tubercle to avoid physeal injury14. In-vestigators studying a rabbit model noted no physeal distur-bance following intraosseous infusion15. Intraosseous infusionhas been reported to be safe and effective in children16, al-


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OP EN FR A C T U R E S IN CHILDREN

though there have been case reports describing compartmentsyndrome following prolonged or rapid infusions17,18. If intra-osseous infusion is used, care should be taken to avoid pro-longed or excessively rapid infusions and to change to a standard

venous access as soon as feasible.Patients who have not had a tetanus immunizationwithin the past five years and those whose immunization sta-tus is unknown are given a dose of tetanus toxoid. Many chil-dren do not receive their routine immunizations on time19,and underimmunization was demonstrated to be prevalent inone study of patients seen at an adult emergency department20.The orthopaedic surgeon cannot assume that the child is up todate with regard to tetanus immunizations or that tetanusprophylaxis has been given by other care providers. Humantetanus immune globulin provides immediate protection, butsome authors have concluded that it is indicated only for pa-tients who have never received primary immunization againsttetanus21, and its indications for children are unclear.

Neurologic evaluation of all of the major nerves or mus-cle groups is performed in both the injured and the unin-volved extremities. If the patient is not able to cooperate witha full neurologic examination because of age, mentation, ortrauma, he or she is observed for spontaneous motion, andany apparent deficit is noted. This may require some patiencewhen an injured and frightened child is being examined.Small children may not answer questions regarding sensationbut will often react to sensory stimuli. The results of the exam-ination, including a notation of any portions that could not beadequately performed, are recorded. The parents also shouldbe notified preoperatively if the patients neurologic statuscould not be fully ascertained. The vascular evaluation should

include assessment of capillary refill as well as the color of theskin and digits; palpation of distal pulses; and, when the in-jury is severe or pulses are questionable, assessment of distalarteries for Doppler pulses. Compartments should be pal-pated to ensure that they are supple. If compartments aretense or there is disproportionate pain with passive stretch ofthe digits, a compartment syndrome should be suspected andcompartment pressures should be measured.

After wound assessment, a sterile dressing is applied.Repeat inspections involving dressing changes are minimizedto avoid additional contamination or tissue trauma. Gross de-formities are realigned with gentle traction to reduce the ten-sion on soft tissues. Early splinting before the patient is taken

to the operating room minimizes ongoing injury to soft tis-sues and decreases pain.

Classification

The modified Gustilo-Anderson system continues to bewidely used for the classification of open fractures in bothchildren and adults22,23, although its reproducibility has beenquestioned24. A type-I open injury is a low-energy puncturewound that measures


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OP EN FR A C T U R E S IN CHILDREN

spring and fall and lawnmower injuries seen more frequentlyin the summer months. There are also differences in themechanisms of injury seen at different ages, with most burnsoccurring in younger children and boating injuries occurring

primarily in adolescents.Because of the increased wound-healing ability in chil-dren, every effort should be made to preserve all extremities ofchildren, even those with severe type-III open fractures. Thereis a poor correlation between the Mangled Extremity SeverityScore (MESS) and the need for amputation in a child99. Whenamputation is required, the physis should be preserved with asmuch length as possible. Even a stump that initially appearsvery short after a traumatic amputation in a growing childmay achieve substantial length by skeletal maturity if the phy-sis is preserved.

Children have remarkable regenerative potential that al-lows replantation of some amputated parts that would not besalvageable in adults. Replantation following hand and upper-

extremity amputations require careful postoperative coopera-tion of the patient and family and intensive rehabilitation100.However, replanted structures in children tend to have slightlylower survival rates than those in adults because of lower se-lectivity by the surgeon, less favorable mechanisms of injury(including crush and avulsion mechanisms), and the in-creased technical challenges associated with small anatomicstructures101. Reimplantations also require highly specializedcare that may not be available at all centers.

McClure and Shaughnessy reported that, in a series oftwelve children with a farm-related amputation of an upper orlower limb, an infection developed in all six who had under-gone replantation and in none of those who had not102. Only

two of the six replanted parts survived, with the remainderfailing because of infection or vascular compromise.

Lawnmower InjuriesPower lawnmowers inflict substantial numbers of prevent-able fractures and amputations in children103. In a series ofchildren seen with lawnmower injuries at one center, eight ofsixteen patients had sustained a traumatic amputation, fif-teen of twenty nonamputation fractures involved the foot,and an average of 2.9 operative procedures were required104.Five patients required free-flap transfers for soft-tissue cov-erage. Dormans et al. reported that, in their series of sixteenchildren with lawnmower injuries, all patients with a shred-

ding-type injury had a poor result following limb salvage orultimately required amputation105. In a study of twenty-fourchildren with lower-extremity injuries caused by a ridinglawnmower, Farley et al. reported fractures in eight patients,amputations in ten, and fractures combined with amputa-tions in six106. The patients were an average of 4.7 years old atthe time of injury, and they underwent an average of threeirrigation and dbridement procedures over a two-week hos-pitalization period following the injury. Sixteen children re-quired completion of an amputation, and eleven underwentsplit-thickness skin-grafting of open wounds. Five patientswere treated with open reduction and internal fixation of

fractures, and six underwent closed reduction and cast im-mobilization. Five children required readmission to the hos-pital, and three required a third admission. At the time of athree-year follow-up, the children demonstrated a high level

of athletic ability, but twelve stated that the injury affectedtheir plans and goals for the future.

Long-Term Problems

Some patients with open fractures experience psychologicalproblems and chronic pain. In a long-term follow-up studyof eighteen children with an open tibial fracture, Levy et al.determined that missed school time averaged 4.1 monthsand six children had to repeat a year of school107. Seven pa-tients had a limp, five had chronic pain in spite of osseousunion, and four had nightmares involving the accident. Earlypsychosocial intervention for severely traumatized children maybe helpful to assist the patient and family in coping with the re-covery process.

Overview

Open fractures in children present special challenges. The im-mediate administration of appropriate antibiotics on presenta-tion is crucial to minimize the risk of infection. Formaloperative dbridement of all open fractures is a time-honoredprinciple, although whether operative treatment within sixhours rather than twenty-four hours influences the infectionrate is controversial. Thorough dbridement and irrigation ofthe wound with careful soft-tissue management are recom-mended. Open fractures in children have better healing poten-tial than those in adults. For this reason, tissue of questionableviability should not be dbrided at the first operative interven-

tion. Unstable fractures require some form of fixation, althoughthe fixation does not always need to be rigid, and fixation tech-niques should respect the physis of growing children.

David G. Stewart Jr., MDChildrens Bone and Spine Surgery, 10001 South Eastern Avenue,Suite 407, Henderson, NV 89052

Robert M. Kay, MDDavid L. Skaggs, MDChildrens Hospital Los Angeles, 4650 Sunset Boulevard, MS 69,Los Angeles, CA 90027. E-mail address for D.L. Skaggs:[email protected]

The authors did not receive grants or outside funding in supportof their research or preparation of this manuscript. They did notreceive payments or other benefits or a commitment or agreementto provide such benefits from a commercial entity. No commercialentity paid or directed, or agreed to pay or direct, any benefits toany research fund, foundation, educational institution, or other char-itable or nonprofit organization with which the authors are affiliatedor associated.

doi:10.2106/JBJS.E.00528


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open fractures in children. principles of evaluation and management

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