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Open Fractures in Children. Principles of Evaluation and Management


David G. Stewart, Jr., Robert M. Kay and David L. Skaggs
J Bone Joint Surg Am. 2005;87:2784-2798. doi:10.2106/JBJS.E.00528

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

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, débridement 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- There is a gradual progression from childhood to adult-
dents (including those in which the child is an occupant of the hood. As children of the same chronologic age often demon-
motor vehicle or is struck by an automobile while riding a bicy- strate widely different physiologic or bone ages, it is not
cle or as a pedestrian) or falls from heights. The reported demo- possible to make comprehensive recommendations based ex-
graphics and injury mechanisms have varied widely from center clusively on age. Our discussion of children refers to skeletally
to center. Most investigators have reported a preponderance immature patients. Patients with closed physes can often be
of boys and a predilection for the forearm and tibia. In a treated according to adult algorithms.
multicenter study of 554 open fractures in children, the sites of
injury were the tibia or fibula (190 fractures; 34%), radius or Initial Evaluation and Management
ulna (178; 32%), hand or metacarpals (fifty-four; 10%), femur The initial treatment of patients with open fractures requires
(thirty-seven; 6.7%), humerus (thirty-six; 6.5%), foot or meta- care of the so-called trauma ABCs (airway, breathing, and cir-
tarsals (twenty-four; 4.3%), elbow (fourteen; 2.5%), ankle (thir- culation) and achieving control of the cervical spine8,9. A
teen; 2.3%), and other sites (eight; 1.4%)1. In another study, of rolled towel or pad is typically placed under the shoulders of
children presenting to one hospital, thirty-two (80%) of forty young children to avoid neck flexion, as the proportionately
open fractures involved the forearm2. In yet another study, 9% large head of a child leads to neck flexion and a risk of neuro-
of fractures in children admitted to a tertiary pediatric trauma logic injury when an adult board is used10.
center were open3, although we suspect that open injuries con- The Pediatric Advanced Life Support (PALS)11 and Ad-
stitute a substantially smaller percentage of pediatric fractures vanced Trauma Life Support (ATLS)12 manuals provide help-
outside of tertiary care centers. ful guidelines for the evaluation and care of children who have
Open fractures in children differ from open fractures in sustained traumatic injuries. Patients with a high-energy in-
adults in many ways. Thicker and more active periosteum pro- jury or multiple injuries should be evaluated by a trauma
vides greater fracture stability and leads to more rapid and re- surgeon13. Intravenous lines are started, fluid resuscitation is
liable fracture-healing in young children compared with that begun, and intravenous antibiotics are given promptly. If in-
in older children and adults4. Young children have a greater travenous access is not readily obtainable, intraosseous infu-
potential for periosteal bone formation5. Healing is usually sion can be performed with a large bone-marrow needle with
faster and more reliable in children than it is in adults with a stylet placed in the proximal part of the tibia, approximately
similar injuries, and children can even have reconstitution of 1 cm distal to the tibial tubercle to avoid physeal injury14. In-
bone in the face of bone loss6. Infection rates in children with vestigators studying a rabbit model noted no physeal distur-
open fractures have been reported to be lower than those in bance following intraosseous infusion15. Intraosseous infusion
adults with such fractures7. has been reported to be safe and effective in children16, al-
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though there have been case reports describing compartment velope is adequate for wound coverage. Type-III fractures
syndrome following prolonged or rapid infusions17,18. If intra- include subtypes A, B, and C. Type IIIA indicates a heavily
osseous infusion is used, care should be taken to avoid pro- contaminated, segmental, or comminuted fracture with ade-
longed or excessively rapid infusions and to change to a standard quate soft-tissue coverage. Type IIIB includes severe soft-tissue
venous access as soon as feasible. damage that often requires coverage procedures and is typi-
Patients who have not had a tetanus immunization cally associated with extensive periosteal stripping, exposed or
within the past five years and those whose immunization sta- comminuted bone, and heavy contamination. An open frac-
tus is unknown are given a dose of tetanus toxoid. Many chil- ture is considered to be type IIIC when there are arterial inju-
dren do not receive their routine immunizations on time19, ries requiring repair, regardless of the fracture configuration,
and underimmunization was demonstrated to be prevalent in energy level of the injury, or degree of associated local soft-tis-
one study of patients seen at an adult emergency department20. sue injury.
The orthopaedic surgeon cannot assume that the child is up to The true extent of soft-tissue injury may be underesti-
date with regard to tetanus immunizations or that tetanus mated on initial examination. The stage at the time of débri-
prophylaxis has been given by other care providers. Human dement and lavage is frequently different from the initial
tetanus immune globulin provides immediate protection, but preoperative classification25, and definitive staging is best done
some authors have concluded that it is indicated only for pa- at the time of surgery. Although intraoperative findings fre-
tients who have never received primary immunization against quently require upgrading of the Gustilo-Anderson classifica-
tetanus21, and its indications for children are unclear. tion, it is important to perform the initial staging as accurately
Neurologic evaluation of all of the major nerves or mus- and promptly as possible, as the initial choice of antibiotics
cle groups is performed in both the injured and the unin- depends on accurate staging.
volved extremities. If the patient is not able to cooperate with
a full neurologic examination because of age, mentation, or Infection
trauma, he or she is observed for spontaneous motion, and Factors Influencing Infection Rate
any apparent deficit is noted. This may require some patience The reported rates of infection in association with type-I, II,
when an injured and frightened child is being examined. and III open fractures in children vary widely. In a series of 554
Small children may not answer questions regarding sensation fractures, the authors reported a 3% overall infection rate, with
but will often react to sensory stimuli. The results of the exam- rates of 2% (five of 302) for type-I fractures, 2% (three of 154)
ination, including a notation of any portions that could not be for type-II fractures, and 8% (eight of ninety-eight) for type-III
adequately performed, are recorded. The parents also should fractures1. Hutchins et al. reported five cases of osteomyelitis in
be notified preoperatively if the patient’s neurologic status association with ten type-III open femoral fractures but no
could not be fully ascertained. The vascular evaluation should infections in association with thirty-four type-I or II open fe-
include assessment of capillary refill as well as the color of the moral fractures in the same study26. The osteomyelitis rate for
skin and digits; palpation of distal pulses; and, when the in- type-III femoral fractures reported by Hutchins et al. is sharply
jury is severe or pulses are questionable, assessment of distal higher than the rates of osteomyelitis or malunion reported for
arteries for Doppler pulses. Compartments should be pal- type-III fractures of the tibia and other bones. This high rate
pated to ensure that they are supple. If compartments are may at least partly reflect the considerably higher energy that is
tense or there is disproportionate pain with passive stretch of necessary to produce a type-III femoral fracture.
the digits, a compartment syndrome should be suspected and In their classic article, Gustilo and Anderson reported
compartment pressures should be measured. that the infection rate associated with type-III open fractures
After wound assessment, a sterile dressing is applied. decreased from 12% to 5% when preoperative antibiotics were
Repeat inspections involving dressing changes are minimized given, wounds were left open, emergency débridement was
to avoid additional contamination or tissue trauma. Gross de- performed, and no internal fixation was used22. These multiple
formities are realigned with gentle traction to reduce the ten- simultaneous interventions make it difficult to determine
sion on soft tissues. Early splinting before the patient is taken which influenced outcome and which represent confounding
to the operating room minimizes ongoing injury to soft tis- variables. Subsequent investigators have attempted to evalu-
sues and decreases pain. ate these factors in more detail.

Classification Antibiotics
The modified Gustilo-Anderson system continues to be Prompt administration of antibiotics is clearly an important
widely used for the classification of open fractures in both way to minimize the risk of infection associated with open
children and adults22,23, although its reproducibility has been fractures7,22,27. In a retrospective review of 1104 open fractures
questioned24. A type-I open injury is a low-energy puncture in children and adults, Wilkins and Patzakis reported an infec-
wound that measures <1 cm, with little contamination, frac- tion rate of 4.7% in patients in whom antibiotics had been ad-
ture comminution, or soft-tissue injury. With type-II injuries, ministered within three hours after the injury compared with
the skin wound is 1 to 10 cm in size, there is no extensive com- 7.4% in patients who had received antibiotics more than three
minution or severe periosteal stripping, and the soft-tissue en- hours after the injury27.
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Patzakis and Wilkins performed a randomized prospec-


tive study of adults and children who had a total of 1104 open
fracture wounds, seventy-seven of which became infected, and
found that early administration of antibiotics with activities
against both gram-positive and gram-negative organisms was
the most important factor in reducing the infection rate7. The
infection rate was 2% for patients who had been given a ceph-
alosporin, 10% for those who had been given penicillin and
streptomycin, and 14% for those who had not been given
antibiotics. The factors that influenced the infection rate in-
cluded a failure to administer antibiotics, resistance of wound-
contaminant organisms to the antibiotics, increased time from
the injury to the administration of antibiotics, extent of soft-
tissue damage, and open tibial fracture. Factors found to have
no effect on the infection rate included the time from injury to
débridement, type of wound closure, and duration of anti-
biotic treatment (three compared with five to ten days).
The appropriate duration of antibiotics following débri-
dement of open fractures remains controversial. In a double-
blind prospective trial of adult patients with an open fracture
who received intravenous cefamandole, Dellinger et al. dem-
onstrated no difference in infection rates between those
treated for one day and those treated for five days28. In most
studies of open fractures in children, the authors have re-
ported the practice of administering intravenous antibiotics
for at least forty-eight hours, although this has not been con-
clusively demonstrated to be superior to twenty-four hours of
administration. Fig. 1-A
Radiograph of a ten-year-old boy who sustained a type-III open frac-
Choice of Antibiotics ture of the tibia and fibula with severe soft-tissue loss medially
Cefazolin (100 mg/kg/day, divided into doses given every eight when he was dragged along the road. The shear injury to the me-
hours, up to a maximum dose of 2 g every eight hours) is typi- dial malleolus and physis was initially not appreciated by the treat-
cally administered to all patients with an open fracture. Pa- ing physicians. (Figs. 1-A, 1-B, and 1-C reprinted, with permission,
tients with a severe type-II or III injury typically are given from: Skaggs DL, Flynn JM. Staying out of trouble in pediatric or-
gentamicin (5 to 7.5 mg/kg/day divided into doses given every
thopaedics. Philadelphia: Lippincott Williams and Wilkins; 2005.)
eight hours) in addition to cefazolin. Penicillin (150,000 units/
kg/day divided into doses given every six hours, up to a maxi-
mum dose of 24 million units/day) is added to cover Clostrid- extensively for children with cystic fibrosis, but routine use for
ium species and anaerobes in patients with farm or vascular children cannot be recommended at this time.
injuries. Clindamycin (15 to 40 mg/kg/day divided into doses The increasing incidence of community-acquired methi-
given every six to eight hours, up to a maximum dose of 2.7 g/ cillin-resistant Staphylococcus aureus infections has led some
day) is commonly used instead of cefazolin for patients with to wonder whether recommendations for initial antibiotics
allergies to cephalosporins or penicillin. Patzakis et al. re- should be altered. We are aware of no studies demonstrating
ported that the infection rates following oral administration a benefit to the use of clindamycin, vancomycin, or other
of ciprofloxacin were similar to the rates following intrave- agents instead of cefazolin for prophylaxis for patients with an
nous administration of cefamandole and gentamicin in adult open fracture, and these alternatives do not have the same record
patients with a type-I or II open fracture, but the ciprofloxacin of proven efficacy for preventing infection of open fractures.
yielded inferior results in patients with a type-III fracture29. There is also concern about fostering additional bacterial re-
However, ciprofloxacin has not been approved for use in pa- sistance by the indiscriminate use of second-tier antibiotics
tients under the age of eighteen years because animal data that are best administered to treat established infections, as
have suggested that ciprofloxacin has adverse effects on bone- increasing resistance of community-acquired methicillin-
healing30 and a possible relationship with chondropathy. Some resistant Staphylococcus aureus isolates to clindamycin in chil-
data suggest a 2% to 3% prevalence of articular side effects in dren has been demonstrated34. Clindamycin, vancomycin, or
children receiving ciprofloxacin compared with a 0.1% preva- other substitutes for cefazolin cannot be routinely recom-
lence in adults31, although other studies have not demon- mended for first-line prophylaxis, except for patients with al-
strated an increased risk in children32,33. Ciprofloxacin is used lergies to cephalosporins.
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Fig. 1-B Fig. 1-C


Fig. 1-B Thirteen months later, medial growth arrest of the physis is demonstrated by the angulation of the growth plate. It can also be seen
that the medial malleolus is not of normal size. Fig. 1-C Twenty-two months later, 26° of varus is present.

Local antibiotic therapy is safe, and high local antibiotic hours or more after the injury (p = 0.43)1. When the fractures
concentrations but low systemic levels are achieved35. Ami- were separated into groups according to whether they were
noglycoside-impregnated polymethylmethacrylate beads ap- Gustilo-Anderson type I, II, or III, there was no significant dif-
pear to further reduce the risk of infection in type-III open ference in the infection rate between the fractures that had
tibial fractures in adults36. These beads have also been success- been treated within six hours after the injury and those that
fully used in children, although additional studies may be in- had been treated at least seven hours after the injury in any
dicated to evaluate their efficacy in populations consisting group. The authors concluded that irrigation and débride-
only of children. There are no standardized recommendations ment of open fractures in children can be performed within
regarding whether antibiotic-impregnated beads should be the first twenty-four hours after injury without increasing the
used prophylactically during the first débridement of injuries risk of infection as long as intravenous antibiotics are started
at high risk for infection, such as type-III open femoral frac- on presentation to the emergency department. A prior retro-
tures, or only at a later débridement, when an established in- spective single-institution study of 104 children also demon-
fection is evident. Our practice generally is to use antibiotic strated no increase in the risk of infection for surgery as the
beads only in severe established infections. surgical delay increased from six to twenty-four hours37. In a
similar study of 103 adults with an open tibial fracture,
Timing of Surgery Khatod et al. reported no relationship between infection rate
Traditional teaching is that open fractures must be operated and surgical delay 38.
on within six to eight hours after the injury. However, a litera- We are aware of only one retrospective study of children
ture review calls this recommendation into question. In a ret- that demonstrated an increased risk of infection when opera-
rospective multicenter study of 554 open fractures in children tive treatment was performed more than six hours after injury
presenting to a pediatric trauma center, an infection devel- rather than less than six hours after injury 39, and the authors of
oped in association with 3% (twelve) of 344 fractures that had that study did not report the time at which antibiotics were
been treated with irrigation and débridement within six hours initially administered. The study, by Kreder and Armstrong,
after the injury compared with 2% (four) of 210 treated seven involved open tibial fractures in children, and an infection de-
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Irrigation and Débridement


The initial irrigation and débridement of open fractures in
young children should be different from that of similar
wounds in adults, largely because of the better healing poten-
tial in children. After the wound is extended and irrigated and
areas of gross contamination are removed, the tourniquet (if
used) is deflated to identify tissue viability. Muscle that bleeds
or contracts when pinched by a forceps should be retained. In
contrast to our practice with adults, we recommend retaining
tissue of questionable viability in young children at the time of
the initial débridement if a second débridement is planned, as
we have been surprised many times by the healing in young
children. Both bone ends should be visualized and cleaned, as
debris may be found here even in type-I injuries.
Periosteum in young children can reconstitute bone
even when there is bone loss. Devitalized bone stripped of all
soft-tissue attachments usually should be removed in an adult,
whereas this bone may be left in place and will usually incor-
porate in young children. The incised area can be gently reap-
proximated with simple nylon or Prolene (polypropylene)
sutures, while the traumatic wound can be closed over a drain
or left open40. Low-grade open fractures can usually be treated
adequately with a single procedure, whereas type-III and severe
type-II injuries typically should undergo débridement every
forty-eight to seventy-two hours until the soft tissues have stabi-

Fig. 2-A
Open distal fractures of the tibia and fibula sustained in a motor-ve-
hicle accident by a five-year-old boy.

veloped in two of eight cases in which the time between the in-
jury and surgery was more than six hours compared with five
(12%) of forty-two cases in which the operation was per-
formed within six hours39. We interpret these results with cau-
tion, as the numbers were so small that if one less patient had
been infected in the late-treatment group, the infection rates
would have been identical.
The current literature seems to indicate that delaying
operative treatment of open fractures does not increase the
rate of infection if antibiotics are administered early. How-
ever, such studies have not addressed the risk to the soft-
tissue envelope when operative intervention is delayed. This
topic remains controversial, and some surgeons strongly be-
lieve that all open fractures should undergo emergent irriga-
tion and débridement within six hours in spite of the lack of
evidence supporting this approach in the medical literature.
Our practice is to operatively débride all open fractures
within the first twenty-four hours and to operate emergently
when a fracture is associated with neurovascular compro-
mise, severe soft-tissue injury, or another urgent operative
indication. At times, when a patient with a type-I or II open
fracture without neurovascular compromise, soft tissue at
risk, or a risk of compartment syndrome comes in after 10 Fig. 2-B
p.m., we will wait until the next morning to provide opera- In contrast to the more rigid fixation that is standard in adults, sim-
tive treatment. ple Kirschner-wire fixation was used.
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Fig. 2-C Fig. 2-D


Figs. 2-C and 2-D Healing was uneventful, and good union is demonstrated on these radiographs made
four months following the injury.

lized, the remaining tissue appears viable, and the wound is tion or antibiotic irrigation for removing bacteria from wounds
considered clean on the basis of visual inspection. For severe with bone injury or soft-tissue damage44-46. Caution must be
type-III injuries, a multidisciplinary approach including plastic exerted when irrigation is used through a small wound as in-
surgery and, at times, a vacuum-assisted closure is beneficial. creased fluid under pressure may contribute to compartment
If little additional dissection is needed, a compartment syndrome.
release should be done for most high-energy open fractures in
which extensive soft-tissue injury can be expected, such as an Débridement Compared with
open tibial fracture sustained in a motor-vehicle accident. Lavage for Type-I Open Fractures
Pain associated with a compartment syndrome may be diffi- Two recent studies have suggested that operative débridement
cult to discern from the pain associated with an open fracture may not be necessary for all type-I open fractures. Yang and
in a child, so we recommend an aggressive prophylactic ap- Eisler reported no infections in a series of ninety-one patients,
proach. Compartments should be palpated intraoperatively to including thirteen children, in whom a type-I open fracture
ensure that they are supple. Pallor, paresthesias, and absent had been treated nonoperatively47. In the only study of which
pulses are late signs of compartment syndrome. we are aware that evaluated nonoperative treatment of open
While animal studies have demonstrated that high-pres- fractures in an entirely pediatric population, a deep infection
sure lavage with saline solution is more effective than low- was found in one (3%) of forty children48.
pressure lavage for removing bacteria from contaminated We view nonoperative management of open fractures as
wounds, especially when the irrigation is performed more potentially dangerous. Because the numbers in the above
than four hours after the injury41, high-pressure irrigation has studies were so small, there was a realistic potential for a type-
been found in vivo to have a deleterious effect on the early II error (a false-negative finding) as a result of inadequate
stages of bone-healing42. In an animal model, low-pressure la- sample size. There have been rare anecdotes of children having
vage with liquid soap was reported to be more effective than gas gangrene or even dying after having been sent home with-
low-pressure irrigation with saline solution or a detergent so- out operative treatment for an open fracture. At an absolute
lution for removing adherent bacteria from bone, and it pre- minimum, patients with a type-I open fracture should receive
served osteoblasts and osteoclasts better than povidone iodine, in-hospital intravenous antibiotics and observation for forty-
bacitracin wash, chlorhexidine solution, or detergent alone43. eight hours following irrigation of the fracture. Whether ir-
Soap or detergent irrigation is more effective than saline solu- rigation of a presumably clean type-I open fracture in an
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emergency room is sufficient is open to debate, but some sur- may inhibit wound-healing. Use of vacuum-assisted closure in
geons have described finding pieces of gravel or other contam- the treatment of lawnmower injuries in children led to a trend
inants during the operative débridement of even tiny, nearly for fewer revision amputations and better post-treatment
pinpoint wounds that appeared to be clinically benign. In the function with no treatment-related complications or adverse
absence of definitive studies proving the contrary, we believe reactions57. We use vacuum-assisted closure during the first
that surgical irrigation and débridement are indicated for all débridement for many open fractures with large or severe
open fractures. soft-tissue defects that expose bone or tendon, such as ankle
injuries resulting from road-dragging. We have been im-
Wound Cultures pressed with the results of this treatment in our practice.
Routine cultures before or after débridement are not indicated Because 0.5 to 2 cm of overgrowth is generally expected
for patients with an open fracture. Cultures should be per- following a femoral58 or tibial40 fracture in a young child, it has
formed only after an infection has developed. In one study, an been stated that initial shortening of not greater than 2 cm can
infection subsequently developed in twenty-four (20%) of 119 be accepted, although we recommend <1 cm of shortening as
wounds for which cultures had been positive prior to débride- the upper limit, barring unusual circumstances. In young chil-
ment and nine (28%) of thirty-two for which cultures had dren with large soft-tissue defects, soft-tissue tension can be
been positive after débridement49. More importantly, only reduced and the defect size can be decreased by stabilizing
23% of the subsequent infections were caused by organisms long bones in a slightly shortened position with an external
identified by the cultures performed before débridement and fixator or, in some cases, with flexible intramedullary rods.
42% (eight of nineteen) were caused by organisms identified The soft-tissue damage associated with an open frac-
by cultures performed after débridement. Other authors have ture does not necessarily decompress compartments suffi-
also noted little correlation between positive pre-débridement ciently to prevent a compartment syndrome. In adults,
and post-débridement cultures and later infection50. Thus rou- compartment syndrome is more commonly associated with
tine cultures for patients who have no infection are more open fractures than with closed fractures59. We are not aware
likely than not to identify an organism that is not responsible of similar studies of children, but our clinical experience has
for a subsequent infection and may lead to the administration been that children with an open fracture are at high risk for
of incorrect antibiotics. compartment syndrome as a result of the high-energy mecha-
nism, and appropriate clinical suspicion is warranted.
Soft-Tissue Care
In a study of eighty-three children with an open tibial fracture, Treatment Techniques
Cullen et al. reported that a type-I or II open fracture in a child According to Anatomic Area
may be closed over a drain in the absence of gross contamina- Stabilization of open fractures is essential, although, depend-
tion or extensive soft-tissue damage40. Our practice is to close ing on the fracture site, rigid fixation is not always as impor-
the surgically created extension of the wound primarily and to tant in children as it is in certain settings in adults. As a
either leave the traumatic wound open or close it over a drain. general principle, the more extensive the soft-tissue damage,
Early local or free-flap coverage may be indicated for large the greater the need for stable fixation to account for delayed
open wounds with exposed bone51. Closed fractures associated fracture-healing and allow earlier mobility to prevent stiffness.
with severe soft-tissue injuries may also behave like open frac- A corollary is that older children whose biological capacity for
tures. Bumper injuries, high-energy or comminuted fractures, healing approaches that of adults may need more rigid fixa-
and fractures in patients with polytrauma can be challenging, as tion than do young children. Fracture stabilization facilitates
tenuous soft tissues may die under a cast. Delayed soft-tissue rehabilitation, decreases pain, and protects soft tissues. Bone-
coverage of bone has been reported to increase the risk of com- grafting is rarely necessary in young children, except those
plications, including infection and soft-tissue problems52. with substantial bone loss. Surviving periosteum has a re-
Open physeal fractures present special difficulties and markable ability to regenerate bone in young children, even
have been excluded from many series of open fractures in chil- when there is considerable bone loss.
dren. Bae et al. reported on two open physeal fractures with Percutaneous Kirschner-wire fixation generally provides
severe soft-tissue loss that were successfully treated with vas- adequate stability for fractures of the distal part of the radius60
cularized flap coverage53. New techniques, such as use of com- and ulna, supracondylar fractures61, fractures of the distal part
bined pedicle flaps, have been described54. Severe degloving of the tibia, and other sites in young children (Figs. 2-A
injuries about a joint may result in unrecognized physeal in- through 2-D). Clinical experience and animal studies have
jury and growth arrest (Figs. 1-A, 1-B, and 1-C). demonstrated that crossing the physis with smooth Kirschner
Vacuum-assisted closure55,56 has been found to be safe wires of the size that is commonly used should not cause a
and effective for closure of open fractures in children, and it growth disturbance62.
may obviate the need for free tissue transfers in some cases. It Flexible intramedullary implants are frequently used for
is thought that the vacuum-assisted closure system may im- diaphyseal fractures of the forearm. Flexible intramedullary
prove the local wound environment and promote granulation nails also provide good stability for most open diaphyseal and
by removing debris and soluble inflammatory mediators that metadiaphyseal fractures of the femur and tibia that are not
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severely comminuted (Figs. 3-A through 3-E). Compared with Femoral Fractures
external fixation, flexible intramedullary nails allow better Open femoral fractures are rare but severe injuries. Hutchins
soft-tissue access, provide better cosmetic results, and require et al. reported that thirty-two (4%) of 712 femoral fractures
less patient and family care. Other anatomy-specific consider- treated at a large urban pediatric trauma center from 1985 to
ations are discussed below. 1996 were open26. Of forty-three children with a total of forty-
four open femoral fractures (twenty-five type I, nine type II,
Humeral Fractures and ten type III) treated at two centers, thirteen were treated
Although supracondylar fractures of the humerus are com- with a spica cast; twelve, with external fixation; fourteen, with
mon in children, there have been few reports specifically ad- locked intramedullary nailing; three, with open reduction and
dressing open humeral fractures in children. Haasbeek and internal fixation; and two, with pins and a plaster cast. Com-
Cole reported on a series of fifteen patients with an open su- plications in the patients with a type-I fracture included two
pracondylar, T-type, or diaphyseal humeral fracture63. Seven cases of malalignment requiring manipulation following
patients presented with associated nerve injuries, and two pa- treatment with a spica cast, one case of osteonecrosis of the
tients had arterial injury. Two children were lost to follow-up. femoral head following rigid intramedullary nailing, and one
The long-term result was good or excellent for eleven children case of unacceptable shortening requiring conversion from a
and fair for two. Our experience has been that the infection spica cast to external fixation. One patient with a type-II frac-
rate associated with open supracondylar fractures is low as a ture required an osteotomy and intramedullary nailing fol-
result of abundant blood supply about the elbow. We have
found treatment consisting of irrigation and débridement,
fracture reduction, and lateral-entry pinning to be adequate
for the vast majority of open supracondylar fractures.

Forearm Fractures
Recent research suggests that fracture stabilization can mini-
mize the risk of malunion or nonunion. Luhmann et al. re-
ported on a series of sixty-five children with an open forearm
fracture, including fifty-two with a type-I fracture, twelve with
a type-II fracture, and one with a type-III fracture64. None of
thirty-eight fractures treated primarily with operative in-
tramedullary stabilization, Kirschner wires, or plates and
screws required subsequent realignment, whereas five of
twenty-seven fractures treated without stabilization required
additional realignment. This study supports our belief that
when a child is already undergoing anesthesia for irrigation
and débridement, fracture fixation adds little risk and proba-
bly provides substantial benefit by maintaining fracture re-
duction. Greenbaum et al. provided further support for this
belief in their study of sixty-two children with an open fore-
arm fracture65. A trend for internal fixation to minimize angu-
lar deformity and reduce the need for realignment procedures
was noted regardless of the fixation method (transcutaneous
or intramedullary pin fixation or plates and screws), although
this finding was not significant. Pins may be left protruding
through the skin and then pulled out in the physician’s office
in four to six weeks, when early fracture callus is seen on ra-
diographs. Alternatively, pins may be buried under the skin
and removed at a later date.
Haasbeek and Cole noted that, in a series of forty-six
children with an open forearm fracture, a compartment syn- Fig. 3-A

drome developed in five, five presented with nerve injury, and An open tibial fracture sustained by a ten-year-old boy who also
one had an arterial injury63. Ten of the forty-six children had a sustained multiple other injuries. Following irrigation and débri-
delayed union, malunion, nonunion, or refracture. These dement, the fracture was treated with a flexible intramedullary
complications were more common in association with type-II rod that was placed proximally to avoid the tibial physis and tibial
and III open injuries. Of thirty-eight patients available for fol- tubercle. (Figs. 3-A through 3-E reprinted, with permission, from:
low-up, thirty-three had a good or excellent outcome, four Skaggs DL, Flynn JM. Staying out of trouble in pediatric ortho-
had a fair outcome, and one had a poor outcome. paedics. Philadelphia: Lippincott Williams and Wilkins; 2005.)
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Fig. 3-B Fig. 3-C


Figs. 3-B and 3-C Radiographs made at four weeks after treatment show substantial callus. The flexible rod was removed in the
physician’s office, and weight-bearing in the cast was encouraged.

lowing a malunion after initial treatment with a spica cast. However, because of a high refracture rate, substantial scar-
Osteomyelitis developed at the sites of five of the ten type-III ring, and delayed unions, the present trend is for external fixa-
fractures, and two type-III fractures treated with an external tion to be employed primarily for fractures that are not
fixator went on to malunion requiring corrective osteotomy26. amenable to flexible nailing because of their location, their
The authors concluded that type-I and II fractures can typi- configuration, or soft-tissue considerations.
cally be treated with irrigation and débridement followed by Few other authors have exclusively examined open femo-
age-appropriate fixation methods, whereas the optimal fixa- ral fractures in children, but most major series of femoral frac-
tion for type-III fractures remains unresolved. Another series, tures in children have included both open and closed injuries.
of eleven open femoral fractures, demonstrated faster healing Flexible intramedullary nailing has become a preferred treat-
of lower-grade injuries and in younger children66. ment for diaphyseal femoral fractures in children70, especially
Open femoral shaft fractures in children younger than those between the ages of six and twelve years. Numerous stud-
the age of six years may be treated with irrigation and débride- ies have demonstrated excellent results, with no nonunions or
ment and a spica cast, although soft-tissue management is of- malunions, in children treated with flexible intramedullary
ten a problem when a spica cast is used. Fixation with a femoral nailing71-74. Those studies have shown dramatically ear-
traditional compression plate is an option for comminuted lier walking, shorter hospital stays, decreased healing times, and
open diaphyseal fractures of the femur in children67, although earlier return to school compared with those results following
it is rarely the treatment of choice. Early results in small series treatment with either external fixation72 or a spica cast74 in age-
in which a submuscular bridge plate was used for open and matched patient groups.
comminuted femoral fractures in children68,69 appear encour-
aging, as these procedures require less initial soft-tissue dissec- Open Tibial Fractures
tion than does traditional plate fixation. External fixation was Successful treatment of open tibial fractures in children has
widely used for open femoral fractures in children in the past. been achieved with a variety of means, including external fixa-
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Fig. 3-D Fig. 3-E


Figs. 3-D and 3-E There was excellent healing at three months.

tion, internal fixation, cast immobilization, and hybrid tech- for acute pediatric trauma in the United States81.
niques75. External fixation has been the traditional choice for Intramedullary fixation with flexible titanium nails is
open fractures with severe comminution or segmental bone becoming the treatment of choice for many fractures of the
loss and in medically unstable patients76. External fixation has tibial diaphysis in children82,83. Kubiak et al. presented a retro-
been used, with good results, for high-grade (type-II and III) spective report on a series of children with a tibial fracture84.
tibial fractures, including those with a segmental or butterfly Sixteen fractures (including five that were open) were treated
pattern6. High rates of pin-track infection, unsightly scars, soft- with flexible intramedullary nailing, and fifteen (including
tissue tethering, delayed union, and refracture make external eight that were open) were managed with external fixation.
fixators less attractive for stable fractures. In one study, rigid The authors found that flexible nailing resulted in faster
external fixation was associated with a 21% refracture rate at union (mean, seven weeks) than did external fixation (mean,
the time of frame removal77. Another study demonstrated a eighteen weeks) and yielded significantly better outcomes in
1.4% refracture rate in patients treated with a unilateral, terms of global function, pain, happiness, and sports activity
more flexible fixator78. The refracture rate is low if healing is (p < 0.01).
noted on three cortices at the time of fixator removal79. The Cullen et al. reported on a series of eighty-three children
effect of dynamization on the refracture rate is controversial80. who had an open tibial fracture40. Forty fractures were fixed
We find external fixators to be particularly helpful for main- percutaneously with Steinmann pins and supplemental cast
taining a plantigrade foot while providing osseous stabiliza- immobilization, thirty-two were treated with a cast only, nine
tion and soft-tissue access in patients with a degloving injury were treated with external fixation, and one each was treated
about the foot and ankle (Fig. 4). Thin wire hybrid fixators with internal fixation and intramedullary nailing. Of the forty
are less useful for children than for adults because of the open fractures treated with percutaneous pinning and a cast, 23%
growth plates near articular surfaces. The Ilizarov bone trans- (nine) had delayed union and 10% (four) had malunion of
port technique may be useful for the late reconstruction of >10°; no malunions were reported in the patients treated with
injuries with large osseous defects, but it is used infrequently the other methods. These data suggest that, while percutane-
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Fig. 4
A child was hit by an automobile as a pedestrian and was dragged, which caused open distal tibial
and fibular fractures in addition to severe soft-tissue loss exposing bone and joints. An external fix-
ator across the ankle helped to maintain the stability of the tibial fracture, prevent ankle equinus,
and immobilize the area of soft-tissue injury to maximize the chance of a future skin graft being
successful. A wound vacuum-assisted closure was used to prepare the area of exposed bone and
joints prior to skin-grafting. (Reprinted, with permission, from: Skaggs DL, Flynn JM. Staying out of
trouble in pediatric orthopaedics. Philadelphia: Lippincott Williams and Wilkins; 2005.)

ous pinning of open tibial fractures in children is possible, significant correlation between patient age and time to union
there may be a high risk of malunion. In our practice, we pre- (p < 0.001). All fractures united and the fixators were removed
fer to use flexible intramedullary nails for this injury. at an average of seven weeks, with no pin-track infections. The
Many reports suggest that open tibial fractures have a authors concluded that, when an open tibial fracture is not as-
more benign course in children under the age of eleven or sociated with segmental bone deficiency or soft-tissue loss re-
twelve years, and especially in those under the age of six quiring major reconstruction, osseous healing can be expected
years85-87. Blasier and Barnes reported complication rates of within six months.
27% in children younger than twelve years and 69% in older The long-term outcome of open tibial fractures in chil-
children88. Court-Brown et al. noted that even thirteen to six- dren may not be as benign as has been presumed. Reported
teen-year-old patients may have better healing than adults89. complications have included compartment syndrome in 2%
Buckley et al. identified a relationship between the time to to 4% of patients, delayed union in 11% to 22%, and infec-
fracture union and the severity of the soft-tissue injury, frac- tion in up to 10%87-89. Nonunion has been rare in most series
ture configuration, segmental bone loss, and infection in of open tibial fractures, although it was reported in seven of
children75. In a series of children with a total of ninety open ninety children in one study88. Limb-length discrepancy is
tibial fractures (thirty-eight type I, thirty-five type II, and another known complication. Overgrowth of at least 1 cm
seventeen type III), Grimard et al. found ten delayed unions was reported following five of eighty-three open tibial frac-
and seven nonunions87. Patient age and fracture type were tures in one series40. In a series of ninety-two children with
associated with the time to union—that is, the risk of de- open tibial fractures of all types, sixty-five of which were
layed union or nonunion was significantly higher in children treated with a cast, twenty-six of which were treated with ex-
older than the age of twelve years than in those younger than ternal fixation, and one of which was treated with internal
the age of six years (p = 0.02). fixation, Hope and Cole reported a limb-length discrepancy
Robertson et al. reported on a series of open tibial frac- of at least 0.5 cm in sixty patients between 1.5 and 9.7 years
tures. Sixteen were treated with a cast alone; ten, with external postoperatively90. Of seventy-four patients seen at the time of
fixation and a supplemental short leg cast; two, with in- final follow-up, half reported pain at the fracture site and
tramedullary nailing; two, with open reduction and internal seventeen each had restriction of sports activity, joint stiff-
fixation; and one, with amputation66. The authors reported a ness, or cosmetic defects.
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Open Pelvic Fractures juries), Letts et al. identified thirteen missed injuries and fifty-
A study of fifteen open pelvic fractures in children treated at seven complications, most commonly due to fractures94. One
one institution over a twelve-year period demonstrated that, study suggested that treatment at a pediatric trauma center
after a minimum of two years of follow-up, ten were vertically may result in lower mortality, although such centers are not
unstable91. Fourteen of the fifteen fractures had been caused by available in all areas95.
an automobile-pedestrian accident, and thirteen of the four- Polytrauma is a relative indication for the operative
teen had been caused by a run-over mechanism. Three of the treatment of displaced fracture. Treatment of a patient with
fifteen patients died, and sepsis and infection from bowel and polytrauma with a spica cast limits access to the abdomen for
genitourinary sources were the most common complications. serial examination, and children with a head injury who are
The authors recommended fracture fixation, débridement, treated with casts are at increased risk for unrecognized skin
and intravenous antibiotics for all patients, and they recom- breakdown. Early stabilization of open fractures is recom-
mended diverting colostomies and cystostomies as indicated. mended. However, although there is a relationship between
External fixation can provide provisional stability while allow- delayed stabilization of a long-bone fracture, especially one of
ing abdominal access in patients with multiple injuries (Figs. the femur, and an increased risk of acute respiratory distress
5-A and 5-B). syndrome, fat emboli, and deep venous thrombosis in adult
patients with polytrauma, there does not appear to be a simi-
Special Cases lar degree of association in children. Reporting on a series of
Polytrauma seventy-eight children who had sustained polytrauma, Loder
Associated injuries are common in children with open frac- noted that early fracture stabilization decreased stays in the
tures, especially those of the femur and tibia. Hutchins et al. hospital and the intensive care unit, ventilator time, and over-
reported that thirty-three of forty-three children with an open all complications96. In a separate study, Loder et al. found that
femoral fracture had associated injuries (most commonly children with polytrauma in whom a fracture was treated
other fractures)26, and Robertson et al. reported that nine of more than seventy-two hours following the injury had a trend
eleven children with an open femoral fracture and eighteen of for an increased rate of immobilization-related complications,
thirty-two with an open tibial fracture had other major although the increase did not reach significance97.
injuries66. Cullen et al. reported that 58% of open tibial frac-
tures in children treated in their center over a ten-year period Traumatic Amputations
were associated with other major injuries40. Traumatic amputation is the most severe form of open injury.
Motor-vehicle accidents and falls from heights are the At one Midwestern center, lawnmower injuries were reported
most common mechanisms of multiple injuries inchildren. to be responsible for 29% (sixty-nine) of 256 amputations in
Up to 76% of patients with polytrauma have extremity frac- 235 children; farm machinery, for 24% (fifty-seven); motor-
tures92, and approximately 9% to 10% of these fractures are vehicle accidents, for 16% (thirty-eight); train accidents, for
open3,92. Patients with pelvic or vertebral fractures were found to 9% (twenty); and other mechanisms, for the remaining 22%
have an average of five other associated injuries93. In a study of (fifty-one)98. Seasonal variation in the types of injuries has
149 children who had sustained polytrauma (a total of 494 in- been noted, with farming injuries being more common in the

Fig. 5-A Fig. 5-B


Figs. 5-A and 5-B An open pelvic fracture in the setting of high-energy polytrauma. Note that the external fixator on the pelvis allows adequate room
for abdominal swelling and access for operative procedures.
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spring and fall and lawnmower injuries seen more frequently fractures, and six underwent closed reduction and cast im-
in the summer months. There are also differences in the mobilization. Five children required readmission to the hos-
mechanisms of injury seen at different ages, with most burns pital, and three required a third admission. At the time of a
occurring in younger children and boating injuries occurring three-year follow-up, the children demonstrated a high level
primarily in adolescents. of athletic ability, but twelve stated that the injury affected
Because of the increased wound-healing ability in chil- their plans and goals for the future.
dren, every effort should be made to preserve all extremities of
children, even those with severe type-III open fractures. There Long-Term Problems
is a poor correlation between the Mangled Extremity Severity Some patients with open fractures experience psychological
Score (MESS) and the need for amputation in a child99. When problems and chronic pain. In a long-term follow-up study
amputation is required, the physis should be preserved with as of eighteen children with an open tibial fracture, Levy et al.
much length as possible. Even a stump that initially appears determined that missed school time averaged 4.1 months
very short after a traumatic amputation in a growing child and six children had to repeat a year of school107. Seven pa-
may achieve substantial length by skeletal maturity if the phy- tients had a limp, five had chronic pain in spite of osseous
sis is preserved. union, and four had nightmares involving the accident. Early
Children have remarkable regenerative potential that al- psychosocial intervention for severely traumatized children may
lows replantation of some amputated parts that would not be be helpful to assist the patient and family in coping with the re-
salvageable in adults. Replantation following hand and upper- covery process.
extremity amputations require careful postoperative coopera-
tion of the patient and family and intensive rehabilitation100. Overview
However, replanted structures in children tend to have slightly Open fractures in children present special challenges. The im-
lower survival rates than those in adults because of lower se- mediate administration of appropriate antibiotics on presenta-
lectivity by the surgeon, less favorable mechanisms of injury tion is crucial to minimize the risk of infection. Formal
(including crush and avulsion mechanisms), and the in- operative débridement of all open fractures is a time-honored
creased technical challenges associated with small anatomic principle, although whether operative treatment within six
structures101. Reimplantations also require highly specialized hours rather than twenty-four hours influences the infection
care that may not be available at all centers. rate is controversial. Thorough débridement and irrigation of
McClure and Shaughnessy reported that, in a series of the wound with careful soft-tissue management are recom-
twelve children with a farm-related amputation of an upper or mended. Open fractures in children have better healing poten-
lower limb, an infection developed in all six who had under- tial than those in adults. For this reason, tissue of questionable
gone replantation and in none of those who had not102. Only viability should not be débrided at the first operative interven-
two of the six replanted parts survived, with the remainder tion. Unstable fractures require some form of fixation, although
failing because of infection or vascular compromise. the fixation does not always need to be rigid, and fixation tech-
niques should respect the physis of growing children.
Lawnmower Injuries
Power lawnmowers inflict substantial numbers of prevent-
able fractures and amputations in children103. In a series of
David G. Stewart Jr., MD
children seen with lawnmower injuries at one center, eight of
Children’s Bone and Spine Surgery, 10001 South Eastern Avenue,
sixteen patients had sustained a traumatic amputation, fif- Suite 407, Henderson, NV 89052
teen of twenty nonamputation fractures involved the foot,
and an average of 2.9 operative procedures were required104. Robert M. Kay, MD
Five patients required free-flap transfers for soft-tissue cov- David L. Skaggs, MD
erage. Dormans et al. reported that, in their series of sixteen Children’s Hospital Los Angeles, 4650 Sunset Boulevard, MS 69,
children with lawnmower injuries, all patients with a shred- Los Angeles, CA 90027. E-mail address for D.L. Skaggs:
dskaggs@chla.usc.edu
ding-type injury had a poor result following limb salvage or
ultimately required amputation105. In a study of twenty-four The authors did not receive grants or outside funding in support
children with lower-extremity injuries caused by a riding of their research or preparation of this manuscript. They did not
lawnmower, Farley et al. reported fractures in eight patients, receive payments or other benefits or a commitment or agreement
amputations in ten, and fractures combined with amputa- to provide such benefits from a commercial entity. No commercial
tions in six106. The patients were an average of 4.7 years old at entity paid or directed, or agreed to pay or direct, any benefits to
the time of injury, and they underwent an average of three any research fund, foundation, educational institution, or other char-
itable or nonprofit organization with which the authors are affiliated
irrigation and débridement procedures over a two-week hos- or associated.
pitalization period following the injury. Sixteen children re-
quired completion of an amputation, and eleven underwent
split-thickness skin-grafting of open wounds. Five patients
were treated with open reduction and internal fixation of doi:10.2106/JBJS.E.00528
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