Skip to main content

Optimizing Management of Open Fractures in Children

Indian Journal of Orthopaedics volume 52, pages 470–480 (2018)Cite this article

Abstract

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

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

43,34 €

Price includes VAT (Finland)
Tax calculation will be finalised during checkout.

References

  1. Flynn MJ, Skaggs Dl, Waters PM. Rockwood and Wilkins’ Fractures in Children. Philadelphia: Lippincott Williams & Wilkins; 2015.

  2. Cheng JC, Shen WY. Limb fracture pattern in different pediatric age groups: A study of 3,350 children. J Orthop Trauma 1993;7:15–22.

    PubMed  Article  CAS  Google Scholar 

  3. Buckley SL, Gotschall C, Robertson W Jr., Sturm P, Tosi L, Thomas M, et al. The relationships of skeletal injuries with trauma score, injury severity score, length of hospital stay, hospital charges, and mortality in children admitted to a regional pediatric trauma center. J Pediatr Orthop 1994;14:449–53.

    Article  CAS  PubMed  Google Scholar 

  4. Rennie L, Court-Brown CM, Mok JY, Beattie TF. The epidemiology of fractures in children. Injury 2007;38:913–22.

    PubMed  PubMed Central  Article  Google Scholar 

  5. Tandon T, Shaik M, Modi N. Paediatric trauma epidemiology in an urban scenario in India. J Orthop Surg (Hong Kong) 2007;15:41–5.

    Article  CAS  Google Scholar 

  6. Schalamon J, v Bismarck S, Schober PH, Höllwarth ME. Multiple trauma in pediatric patients. Pediatr Surg Int 2003;19:417–23.

    PubMed  Article  Google Scholar 

  7. Mencio GA, Swiontkowski MF. Green’s Skeletal Trauma in Children. Philadelphia: Elsevier Saunders; 2015.

  8. Stewart DG Jr., Kay RM, Skaggs DL. Open fractures in children. Principles of evaluation and management. J Bone Joint Surg Am 2005;87:2784–98.

    PubMed  Article  Google Scholar 

  9. Valentine J, Blocker S, Chang JH. Gunshot injuries in children. J Trauma 1984;24:952–6.

    PubMed  Article  CAS  Google Scholar 

  10. Skaggs DL, Friend L, Alman B, Chambers HG, Schmitz M, Leake B, et al. The effect of surgical delay on acute infection following 554 open fractures in children. J Bone Joint Surg Am 2005;87:8–12.

    PubMed  Article  Google Scholar 

  11. Iobst CA, Spurdle C, Baitner AC, King WF, Tidwell M, Swirsky S, et al. A protocol for the management of pediatric type I open fractures. J Child Orthop 2014;8:71–6.

    PubMed  PubMed Central  Article  Google Scholar 

  12. Chameides L, Hazinski MF. Pediatric Advanced Life Support. Dallas: American Heart Association; 1997.

  13. American College of Surgeons, Committee on Trauma. Advanced Trauma Life Support Manual. Chicago: American College of Surgeons; 1997.

  14. Johansen K, Daines M, Howey T, Helfet D, Hansen ST Jr., Objective criteria accurately predict amputation following lower extremity trauma. J Trauma 1990;30:568–72.

    PubMed  Article  CAS  Google Scholar 

  15. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg Am 1976;58:453–8.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  16. Rüedi T, Border JR, Allgöwer M. Classification of soft tissue injuries. In: Müller ME, Allgöwer M, Schneider R, Willenegger H, editors. Manual of Internal Fixation. Techniques Recommended by the AO-ASIF Group. Vol 3. New York: Springer-Verlag; 1991. p. 151–8.

  17. Rajasekaran S, Naresh Babu J, Dheenadhayalan J, Shetty AP, Sundararajan SR, Kumar M, et al. A score for predicting salvage and outcome in Gustillo type-IIIA and type-IIIB open tibial fractures. J Bone Joint Surg Br 2006;88:1351–60.

    PubMed  Article  CAS  Google Scholar 

  18. McNamara MG, Heckman JD, Corley FG. Severe open fractures of the lower extremity: A retrospective evaluation of the mangled extremity severity score (MESS) J Orthop Trauma 1994;8:81–7.

  19. Russell WL, Sailors DM, Whittle TB, Fisher DF Jr., Burns RP. Limb salvage versus traumatic amputation. A decision based on a seven-part predictive index. Ann Surg 1991;213:473–80.

    PubMed  CAS  Google Scholar 

  20. Byrd HS, Spicer TE, Cierney G 3rd. Management of open tibial fractures. Plast Reconstr Surg 1985;76:719–30.

    PubMed  Article  CAS  Google Scholar 

  21. Krettek C, Seekamp A, Köntopp H, Tscherne H. Hannover fracture scale ‘98 – Re-evaluation and new perspectives of an established extremity salvage score. Injury 2001;32:317–28.

    PubMed  Article  CAS  Google Scholar 

  22. Patzakis MJ, Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 1989;243:36–40.

    Google Scholar 

  23. Jaeger M, Maier D, Kern WV, Südkamp NP. Antibiotics in trauma and orthopedic surgery – A primer of evidence-based recommendations. Injury 2006;37 Suppl 2:S74–80.

  24. Nanchahal J, Nayagam S, Khan U, Moran C, Barrett S, Sanderson F, et al. Standards for the Management of Open Fractures of the Lower Limb. London: Royal Society of Medicine Press: 2009.

  25. Zalavras CG, Marcus RE, Levin LS, Patzakis MJ. Management of open fractures and subsequent complications. J Bone Joint Surg Am 2007;89:884–95.

    PubMed  PubMed Central  Article  Google Scholar 

  26. Kreder HJ, Armstrong P. A review of open tibia fractures in children. J Pediatr Orthop 1995;15:482–8.

    PubMed  Article  CAS  Google Scholar 

  27. Jordan DJ, Malahias M, Khan W, Hindocha S. The ortho-plastic approach to soft tissue management in trauma. Open Orthop J 2014;8:399–408.

    PubMed  PubMed Central  Article  Google Scholar 

  28. Anglen JO. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg 2001;9:219–26.

    PubMed  Article  CAS  Google Scholar 

  29. Owens BD, White DW, Wenke JC. Comparison of irrigation solutions and devices in a contaminated musculoskeletal wound survival model. J Bone Joint Surg Am 2009;91:92–8.

    PubMed  Article  Google Scholar 

  30. Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg Br 2007;89:580–5.

    PubMed  Article  CAS  Google Scholar 

  31. Bazzi AA, Brooks JT, Jain A, Ain MC, Tis JE, Sponseller PD, et al. Is nonoperative treatment of pediatric type I open fractures safe and effective? J Child Orthop 2014;8:467–71.

  32. Cullen MC, Roy DR, Crawford AH, Assenmacher J, Levy MS, Wen D, et al. Open fracture of the tibia in children. J Bone Joint Surg Am 1996;78:1039-47.

  33. Gopal S, Majumder S, Batchelor AG, Knight SL, De Boer R Smith RM, et al. Fix and flap: The radical orthopaedic and plastic treatment of severe open fractures of the tibia. J Bone Joint Surg Br 2000;82:959–66.

    PubMed  PubMed Central  Article  CAS  Google Scholar 

  34. Tuttle MS, Smith WR, Williams AE, Agudelo JF, Hartshorn CJ, Moore EE, et al. Safety and efficacy of damage control external fixation versus early definitive stabilization for femoral shaft fractures in the multiple-injured patient. J Trauma 2009;67:602–5.

    PubMed  Article  Google Scholar 

  35. Parikh SN, Jain VV, Youngquist J. Intrafocal pinning for distal radius metaphyseal fractures in children. Orthopedics 2013;36:783–8.

    PubMed  Article  Google Scholar 

  36. Mostafa MF, El-Adl G, Enan A. Percutaneous Kirschner-wire fixation for displaced distal forearm fractures in children. Acta Orthop Belg 2009;75:459-66.

  37. Skaggs DL, Hale JM, Bassett J, Kaminsky C, Kay RM, Tolo VT, et al. Operative treatment of supracondylar fractures of the humerus in children. The consequences of pin placement. J Bone Joint Surg Am 2001;83-A: 735–40.

  38. Hajdu S, Schwendenwein E, Kaltenecker G, László I, Lang S, Vécsei V, et al. The effect of drilling and screw fixation of the growth plate – An experimental study in rabbits. J Orthop Res 2011;29:1834–9.

    PubMed  Article  Google Scholar 

  39. Kruppa C, Bunge P, Schildhauer TA, Dudda M. Low complication rate of elastic stable intramedullary nailing (ESIN) of pediatric forearm fractures: A retrospective study of 202 cases. Medicine (Baltimore) 2017;96:e6669.

  40. Barry M, Paterson JM. A flexible intramedullary nails for fractures in children. J Bone Joint Surg Br 2004;86:947–53.

    PubMed  Article  CAS  Google Scholar 

  41. Aslani H, Tabrizi A, Sadighi A, Mirblok AR. Treatment of open pediatric tibial fractures by external fixation versus flexible intramedullary nailing: A comparative study. Arch Trauma Res 2013;2:108–12.

    PubMed  PubMed Central  Article  Google Scholar 

  42. Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE. Complications and outcomes of open pediatric forearm fractures. J Pediatr Orthop 2004;24:1–6.

    PubMed  Article  Google Scholar 

  43. Caird MS, Mueller KA, Puryear A, Farley FA. Compression plating of pediatric femoral shaft fractures. J Pediatr Orthop 2003;23:448–52.

    PubMed  Google Scholar 

  44. Garg S, Dobbs MB, Schoenecker PL, Luhmann SJ, Gordon JE. Surgical treatment of traumatic pediatric humeral diaphyseal fractures with titanium elastic nails. J Child Orthop 2009;3:121–7.

    PubMed  PubMed Central  Article  Google Scholar 

  45. Allison P, Dahan-Oliel N, Jando VT, Yang SS, Hamdy RC. Open fractures of the femur in children: Analysis of various treatment methods. J Child Orthop 2011;5:101–8.

    PubMed  PubMed Central  Article  Google Scholar 

  46. Canavese F, Marengo L, Andreacchio A, Mansour M, Paonessa M, Rousset M, et al. Complications of elastic stable intramedullary nailing of femoral shaft fractures in children weighing fifty kilograms (one hundred and ten pounds) and more. Int Orthop 2016;40:2627–34.

    PubMed  Article  Google Scholar 

  47. Aslani H, Tabrizi A, Sadighi A, Mirbolook AR. Treatment of pediatric open femoral fractures with external fixator versus flexible intramedullary nails. Arch Bone Jt Surg 2013;1:64–7.

    PubMed  PubMed Central  Google Scholar 

  48. Abdelgawad AA, Sieg RN, Laughlin MD, Shunia J, Kanlic EM. Submuscular bridge plating for complex pediatric femur fractures is reliable. Clin Orthop Relat Res 2013;471:2797–807.

    PubMed  PubMed Central  Article  Google Scholar 

  49. Baldwin KD, Babatunde OM, Russell Huffman G, Hosalkar HS. Open fractures of the tibia in the pediatric population: A systematic review. J Child Orthop 2009;3:199–208.

    PubMed  PubMed Central  Article  Google Scholar 

  50. Hull JB, Bell MJ. Modern trends for external fixation of fractures in children: A critical review. J Pediatr Orthop B 1997;6:103–9.

    PubMed  Article  CAS  Google Scholar 

  51. Srivastava AK, Mehlman CT, Wall EJ, Do TT. Elastic stable intramedullary nailing of tibial shaft fractures in children. J Pediatr Orthop 2008;28:152–8.

    PubMed  PubMed Central  Article  Google Scholar 

  52. Radhakrishna VN, Madhuri V. Management of pediatric open tibia fractures with supracutaneous locked plates. J Pediatr Orthop B 2018;27:13–6.

    PubMed  Article  Google Scholar 

  53. Blasier RD, Barnes CL. Age as a prognostic factor in open tibial fractures in children. Clin Orthop Relat Res 1996;331:261–4.

    Article  Google Scholar 

  54. Kumar A, Singh JK, Singh C. Prevention of chaff cutter injuries in rural India. Int J Inj Contr Saf Promot 2013;20:59–67.

    PubMed  Article  Google Scholar 

  55. Kumar A, Singh JK, Mohan, D, Varghese M. Farm hand tools injuries: A case study from Northern India. Saf Sci 2008;46:54–65.

    Article  Google Scholar 

  56. Huda F, Wasim S. Nonfatal agriculture injuries in children – A retrospective study. Indian J Child Health 2016;3:305–7.

    Google Scholar 

  57. Agarwal A, Pruthi M. Bicycle-spoke injuries of the foot in children. J Orthop Surg (Hong Kong) 2010;18:338–41.

    Article  Google Scholar 

Download references

Author information

Affiliations

  1. Central Institute of Orthopaedics, Safdarjung Hospital, India

    Vikas Gupta

  2. Department of Orthopaedics, All India Institute of Medical Sciences, New Delhi, India

    Kumar Shashikant

  3. Department of Paediatric Orthopaedics, KUMC GURO Hospital, Seoul, Korea

    Akshat Sharma

Authors
  1. Akshat Sharma
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Vikas Gupta
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Kumar Shashikant
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Akshat Sharma.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Sharma, A., Gupta, V. & Shashikant, K. Optimizing Management of Open Fractures in Children. IJOO 52, 470–480 (2018). https://doi.org/10.4103/ortho.IJOrtho_319_17

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.4103/ortho.IJOrtho_319_17

Keywords

  • Antibiotics
  • children
  • debridement
  • open fracture

MeSH terms

  • Pediatrics
  • open fractures
  • debridement
  • antibiotics