Acknowledgment
The author would like to acknowledge Fred F. Behrens, MD (deceased), for his contributions to earlier versions of this chapter.
Characteristics
It is generally accepted that open fractures among children have better clinical outcomes than similar injuries in adults, but high-level comparative studies are lacking. Although skeletal maturity and preexisting conditions (such as osteogenesis imperfecta) influence the injury patterns of open fractures, it is primarily the kinetic energy E k = mv 2 /2 that determines the severity and specific features of a particular injury. Thus closed pediatric fractures are largely caused by low-energy domestic activities and play, whereas violent traffic and other accidents are responsible for more than 80% of open fractures in those older than 2 years. Even in adolescents, athletic activities account for less than 5% of open fractures. Although some open fractures occur through the physes, the majority are located in the diaphyses.
Open fractures in children younger than school age are rare because of their small body mass, the large amount of protective subcutaneous fat, and their limited exposure to high-risk activities. Furthermore, massive violence in this younger age group leads to loss of life rather than limb injury.
Classification
Most classifications of open musculoskeletal injuries account for the size, severity, and extent of the soft tissue lesion but neglect such modifying factors as wound contamination, fracture pattern, and associated injuries. The open fracture classification that is currently most popular for both children and adults was developed by Gustilo and Anderson in 1976 and divides open fractures into three types according to the severity of the soft tissue injury. It was further refined in 1984 to allow for better differentiation of the most severe injuries ( Table 6-1 ). The Gustilo classification is widely used and does help guide treatment and predict clinical outcomes such as risk of wound infections. However, the reliability and reproducibility of this classification system has been an area of some debate.
| TYPE | DESCRIPTION |
|---|---|
| I | Skin opening of 1 cm or less, quite clean; most likely from inside to outside; minimal muscle contusion; simple transverse or short oblique fractures |
| II | Laceration more than 1 cm long, with extensive soft tissue damage, flaps, or avulsion; minimal to moderate crushing component; simple transverse or short oblique fractures with minimal comminution |
| III | Extensive soft tissue damage, including muscles, skin, and neurovascular structures; often a high-velocity injury with a severe crushing component |
| IIIA | Usually results from high-energy trauma; however, soft tissue coverage of the fractured bone still adequate, despite extensive soft tissue laceration or flaps |
| IIIB | More extensive soft tissue injury (than type IIIA) with periosteal stripping and bone exposure; usually associated with massive contamination |
| IIIC | Any open fracture associated with arterial injury requiring repair, independent of the fracture type |
In type I open fractures, the wound is less than 1 cm long. It is often a clean puncture wound in which a spike of bone has pierced the skin. These fractures are accompanied by minimal soft tissue damage and no sign of crushing injury. The fracture pattern is typically transverse, or short oblique, with little comminution, if any ( Fig. 6-1 ).
In type II open fractures, the laceration is greater than 1 cm in length but no extensive soft tissue damage is present. These fractures are associated with a slight or moderate crushing injury, moderate comminution at the fracture site, and moderate contamination.
Type III injuries are characterized by extensive damage to skin, muscle, bone, and, possibly, neurovascular structures. A high degree of contamination may be present. Type III injuries are divided into three subgroups. In type IIIA, soft tissue coverage of the fractured bone is adequate, despite the extensive injury. This subtype includes segmental and severely comminuted fractures from high-energy trauma, regardless of the size of the wound. A type IIIB injury has extensive soft tissue disruption or loss, with periosteal stripping and exposure of bone. Massive contamination and comminution of the fractures are common. A local or free flap is generally needed to obtain satisfactory wound coverage. Type IIIC includes any open fractures associated with an arterial injury that needs repair, regardless of the extent of soft tissue damage. The incidence of wound infection, delayed union, nonunion, amputation, and residual disability is directly related to the type of soft tissue injury. The more severe the injury, the greater the risk of complications. Based on a systematic review of the literature related to open tibial fractures in children and adolescents, age older than 10 years and type III open fractures were associated with complications and outcomes similar to those reported in adults.
Open fractures inflicted by lawn mowers ( Fig. 6-2 ) and farm injuries deserve particular attention because both generate highly contaminated open injuries, mainly through the impact of debris or through the direct force of the cutting blades, which rotate at 3000 rpm and generate about 2100 foot-pounds of kinetic injury. Lawn mower injuries, which often cause compartment syndromes, most commonly afflict children younger than 14 years. Tornado and lawn mower injuries are often complicated by posttraumatic infections with mixed flora, mostly gram-negative bacilli.
The Mangled Extremity
With advances in prehospital resuscitation and the development of free flaps and microvascular reconstruction, many limbs with extensive open fractures that involve vascular compromise or partial amputation can now be salvaged. However, despite the great potential for healing that is typical in children, some of the more severe open fractures are better managed with primary amputation ( Figs. 6-2 and 6-3 ) than with extensive reconstructive procedures that leave the patient with a dubious cosmetic result and only marginal function. To provide some guidance when deciding between limb salvage and amputation, a number of investigators have developed severity indices. In 1990, Johansen and associates developed the Mangled Extremity Severity Score (MESS), a rating scale for lower extremity trauma based on skeletal and soft tissue damage, limb ischemia, shock, and age of the patient ( Table 6-2 ). In a series of type III open lower extremity fractures, the MESS accurately predicted successful limb salvage in 93% and amputation in 63% of children. In a recent review of pediatric open fractures of the lower extremity, a MESS of 6.5 or greater was a good predictor of the need for amputation. However, there is no substitute for evaluation by experienced surgeons with widespread consultation from multiple individuals.
| VARIABLE | POINTS |
|---|---|
| Skeletal/Soft Tissue Injury | |
| Low energy (stab, simple fracture, “civilian” gunshot wound) | 1 |
| Medium energy (open or multiple fractures, dislocation) | 2 |
| High energy (close-range shotgun or “military” gunshot wound, crush injury) | 3 |
| Very high energy (same as high energy plus gross contamination, soft tissue avulsion) | 4 |
| Limb Ischemia | |
| Pulse reduced or absent but perfusion normal | 1 ∗ |
| Pulseless; paresthesias, diminished capillary refill | 2 ∗ |
| Cool, paralyzed, insensate, numb | 3 ∗ |
| Shock | |
| Systolic blood pressure always >90 mm Hg | 0 |
| Hypotensive transiently | 1 |
| Persistent hypotension | 2 |
| Age (Years) | |
| <30 | 0 |
| 30–50 | 1 |
| >50 | 2 |
Closed Fractures with Severe Soft Tissue Injuries
It has become increasingly clear that some closed fractures caused by violent force may result in extensive destruction of the soft tissue sleeve surrounding the leg and pelvis without resulting in an open lesion. These closed fractures with severe soft tissue injury are characterized by skin contusions, deep abrasions, burns, or frank separation of the cutis from the subcuticular tissue. Even in children, these lesions can result in partial or full tissue loss and secondary infection of the fracture site. To avoid catastrophes, surgeons must treat these lesions as open fractures, which facilitates repeated injury evaluation and decreases complications. Tscherne and Gotzen provided a classification that describes four grades of these treacherous injuries that may prove useful in choosing among different treatment options ( Table 6-3 ). Successful use of percutaneous drainage and débridement of concealed degloving injuries (the Morel-Lavallée lesion) was reported in adult patients.
| 0 | Minimal soft tissue damage; indirect violence; simple fracture patterns (e.g., torsion fracture of the tibia in skiers) |
| I | Superficial abrasion or contusion caused by pressure from within; mild to moderately severe fracture configuration (e.g., pronation fracture-dislocation of the ankle joint with a soft tissue lesion over the medial malleolus) |
| II | Deep contaminated abrasion associated with localized skin or muscle contusion; impending compartment syndrome; severe fracture configuration (e.g., segmental “bumper” fracture of the tibia) |
| III | Extensive skin contusion or crush; underlying muscle damage may be severe; subcutaneous avulsion; decompensated compartment syndrome; associated major vascular injury; severe or comminuted fracture configuration |
Treatment Plan
Overview
Although most bony and soft tissue disruptions in children have a greater healing potential, the treatment goals and principles of open musculoskeletal injuries in children are the same as those for adults. The principal goals in managing open fractures are restoration and preservation of vital functions, prevention of wound infection, healing of the soft tissue injuries, restoration of bony anatomy and bone union, and recovery of optimal physical and psychosocial function.
These objectives are best attained by prompt initial resuscitation, thorough and complete evaluation of life-threatening injuries followed by a detailed assessment of the fracture site, appropriate antimicrobial therapy at presentation, extensive and possibly repeated wound débridement followed by wound coverage, fracture stabilization, autogenous bone grafting when needed, restoration of major bony defects, and comprehensive functional and psychosocial rehabilitation. These interventions often overlap or occur in a modified temporal sequence, depending on age, injury pattern, and associated lesions. They are also highly interdependent; the type and timing of wound closure, for instance, may affect the choice of fracture fixation.
Acute care follows the general guidelines that have been established for similar injuries in adults. In addition to appropriate and timely acute intervention, the final clinical outcome of these injuries depends on a comprehensive plan of rehabilitation that includes physical therapy as well as educational and socioeconomic support for the family.
Initial Care
At the scene of the injury, the open wound is covered with a sterile dressing, if available. Profuse bleeding is controlled by local compression. The fracture fragments are aligned by gentle traction and manipulation and are then splinted in a comfortable position for transport to the emergency department.
In the emergency department, the patient’s vital functions are assessed and monitored, and all organ systems are systematically evaluated. One or more intravenous lines are established. If wound dressings are removed at all, masks and gloves are required. Sterile dressings, if previously applied, are left in place. After the history is taken and the physical examination is completed, pertinent radiographs are obtained; blood is drawn for a complete blood count, typing, and crossmatching and for determination of serum electrolyte levels. Tetanus prophylaxis and the first intravenous dose of appropriate antibiotic(s) are then administered. Any patient with a suspected dysvascular limb is transferred to the operating room without delay for further assessment and possible vascular exploration and repair. Preoperative angiography is not routinely recommended because it further prolongs the warm ischemia time.
Wound Contamination and Antibiotics
Wound Contamination
It is prudent to assume that all open fractures and closed lesions covered with devitalized tissue are contaminated. Frank infections are more likely to develop if necrotic tissue remains in the wound. The infection rates in open pediatric fractures are somewhat lower than adults. Patzakis and Wilkins reported only one infection (1.8%) in 55 open fractures in children. In contrast, they had an overall infection rate of 7.2% in 1049 open adult fractures. In a series of 554 open pediatric fractures, Skaggs and colleagues reported a 3% overall infection rate, and the incidence was 2% in type I and II injuries and 8% in type III fractures. Typically, the infecting organisms are Staphylococcus aureus and aerobic or facultative gram-negative rods in fractures with less severe soft tissue injury, whereas mixed flora prevails in lesions of type IIIB and IIIC severity. Among all open fractures, Patzakis and Wilkins found the highest infection rate in tibial lesions. In two studies of open tibial fractures in children, the overall infection rates were 10% and 11%, similar to those reported in adults. No infections developed in type I fractures, whereas infection rates were approximately 12% in type II injuries and 21% to 33% in type III fractures.
Clostridial Infections
Tetanus
Tetanus is a rare but potentially fatal disease. Wounds that are deemed tetanus prone include those contaminated with dirt, saliva, or feces; puncture wounds, including nonsterile injections; missile injuries; burns; frostbite; avulsions; crush injuries; and wounds undergoing delayed débridement. The causative organism is Clostridium tetani, a gram-positive rod that grows best under anaerobic conditions and in necrotic tissue. The clinical manifestations are caused by the effects of a neurotoxin on skeletal muscle, peripheral nerves, and the spinal cord. Generalized tetanus starts with cramps in the muscles surrounding the wound, neck stiffness, hyperreflexia, and changes in facial expression. Later, contractions of whole muscle groups cause opisthotonos and acute respiratory failure.
Tetanus is preventable through active immunization with a formaldehyde-treated tetanospasmin known as tetanus toxoid. The Immunization Practices Advisory Committee recommends routine active immunization for infants and children with diphtheria and tetanus toxoids and pertussis at the ages of 2 months, 4 months, 6 months, 15 months, and 4 to 6 years. Completion of a primary dose series confers humoral immunity to tetanus for at least 10 years in the majority of those who receive the vaccine. A child or adolescent with an open fracture who has not completed the primary series of immunizations or who has not received a booster dose in 10 years should receive tetanus toxoid, which is administered as a 0.5-mL intramuscular injection for patients of all ages. As has been shown in a population-based study, immunity cannot be presumed. Administration of tetanus toxoid immunizes the patient against the next wounding event but does not ensure tetanus prophylaxis from the acute injury. If the child has never received primary immunization against tetanus, passive immunization with human tetanus immune globulin (HTIG) is added. The intramuscular dose varies with age, but those older than 10 years receive 250 units, those 5 to 10 years receive 125 units, and those younger than 5 years receive 75 units. Tetanus immune globulin and tetanus toxoid should not be administered at the same site but may be administered on the same day. Vigorous débridement of open wounds and resection of all nonviable tissue are an integral part of tetanus prevention.
Gas Gangrene
Gas gangrene is most frequently caused by Clostridium perfringens or Clostridium septicum, anaerobic gram-positive spore-forming bacteria that produce numerous exotoxins. Gas gangrene is most frequently seen after primary wound closure, after open crush injuries, and in wounds contaminated by bowel contents or soil. The exotoxins produced by these organisms create local edema, muscle and fat necrosis, and thrombosis of local vessels. The clostridia also generate several gases that dissect into the surrounding tissue and facilitate rapid spread of the infection. In the terminal stages, clostridial infections cause hemolysis, tubular necrosis, and renal failure.
The early clinical manifestations of gas gangrene after an open fracture include excruciating pain in the affected area followed by high fever, chills, tachycardia, contusions, and evidence of toxemia. Initially, the skin about the wound is very edematous and cool but without crepitation. Later, the skin has a brown or bronze coloration, crepitation, and drainage of a thin brownish fluid with a pungent odor. Radiographs demonstrate gas formation within the muscle and intrafascial planes. Gram stain of the exudate reveals gram-positive rods with spores. However, not all posttraumatic crepitation is due to gas gangrene. It may also be caused by mechanical introduction of air related to trauma or surgery, especially in the first 12 hours after injury. Crepitation from gas gangrene usually occurs between 12 and 60 hours after injury. The crepitus is initially minimal but progresses with time.
The crucial steps in the treatment of early gas gangrene are emergent radical débridement with removal of all necrotic muscle and fasciotomies of all compartments to relieve pressure from the edema and enhance blood flow. Repeated débridement is usually necessary. In addition, the patient should receive intravenous penicillin. In patients allergic to penicillin, intravenous clindamycin or metronidazole are acceptable substitutes. Because wounds with clostridial contamination are often associated with a mixed flora, additional coverage against such organisms with additional antibiotics such as a cephalosporin and an aminoglycoside are typically necessary. The efficacy of polyvalent gas gangrene serum, which can cause sensitivity reactions, remains unproven. Administration of hyperbaric oxygen may be beneficial because elevated tissue oxygen tension appears to inhibit clostridial growth and the production of exotoxins. This technology, however, is no substitute for meticulous surgical débridement.
Antimicrobials
Systemic Antibiotics
The majority of open fractures are contaminated with bacteria at the time of injury. Aerobic gram-positive and gram-negative bacteria are the major pathogens of infections associated with fractures. The risk of development of an infection in an open fracture depends directly on the severity of the soft tissue injury, the extent of the contamination, the virulence of the involved flora, timely administration of appropriate antibiotics, and the adequacy of surgical débridement.
Timely administration of antibiotics has been demonstrated to be effective in decreasing the risk of infection in open fractures. Administration of appropriate antibiotics as soon as possible after an open fracture is currently considered best practice. The effectiveness of early administration of appropriate antibiotics was confirmed in a large multicenter study of pediatric open fractures. Intravenous antibiotics delivered within 3 hours of injury was found to be the single most important factor in reducing the infection rate in these children. Patzakis and Wilkins found the infection rate to be 13.9% in 79 patients who received no antibiotics versus 5.5% in 815 patients who were treated with broad-spectrum antibiotics (cephalothin alone or cefamandole plus tobramycin). Antibiotics are restarted when another procedure such as delayed primary or secondary wound closure or delayed internal fixation related to the open fracture is performed. However, prolonged antibiotic therapy, beyond 48 to 72 hours postoperatively, does not reduce the rate of wound infections and may promote the development of resistant organisms.
A cephalosporin (100 mg/kg/day cefazolin divided into doses given every 8 hours, to a maximum dose of 2 g every 8 hours) is currently recommended as baseline therapy for all open fractures. Alternately, clindamycin may be used (15 to 40 mg/kg/day divided into doses given every 8 hours, up to a maximum dose of 2.7 g/day). For Gustilo type I lesions, this therapy is initially continued for 24 to 48 hours. While lacking robust studies, Gustilo type II or III open fractures are treated with a cephalosporin and an aminoglycoside (5 to 7.5 mg/kg/day gentamicin divided into doses given every 8 hours) to cover both gram-positive and gram-negative bacteria. This combined antibiotic therapy is also continued for 24 to 48 hours. Penicillin (150,000 units/kg/day divided into doses given every 6 hours, to a maximum of 24 million units/day) is added if the patient is at risk of a clostridial infection. Resection of all devitalized soft tissue, copious irrigation, and the use of systemic antibiotics remain the principal tools in preventing posttraumatic wound infection.
Wound Care
Irrigation and Débridement
The dogma of irrigating all pediatric open fractures, especially type I injuries, in the operating room within 6 hours of occurrence has been recently questioned. Two retrospective case series have reported similar outcomes, including a less than 5% infection rate for type I open pediatric fractures that were treated nonoperatively with wound irrigation and cast immobilization in the emergency department and 24 to 48 hours of intravenous or oral antibiotics. Although no infections were reported with type I open upper extremity fractures in children, until more robust evidence confirms these findings, such clinical practice should not be considered “routine” at this time. On the basis of a multicenter retrospective cohort study of 554 open pediatric fractures, Skaggs and colleagues have suggested that irrigation and débridement of certain pediatric open fractures can be delayed up to 24 hours after the injury without any adverse effects as long as intravenous antibiotics are administered on arrival in the emergency department. However, these recommendations remain controversial. A web-based survey of accredited orthopaedic residency program directors in the United States reported that the majority of responders were not willing to wait 6 or more hours when managing type III pediatric open fractures. A recent animal study noted that earlier irrigation in a contaminated wound model resulted in superior bacterial removal.
In the operating room, after induction of anesthesia, the injured extremity is prepared and draped with the use of sterile technique. Avoiding contamination of the fracture site requires that a separate set of instruments be used for the initial part of the procedure, the débridement. Once débridement is completed, the surgical team changes gloves and gowns along with redraping of the operative site before proceeding with fracture fixation and applying the final wound dressing. A pneumatic tourniquet is applied as a safety measure but is not inflated unless massive bleeding occurs. The most important process in the management of an open fracture then begins: a search for the extent of the “real injury,” which often exceeds the apparent injury by a factor of 2 to 3. Many clues alert the surgeon to the true size of the injury zone, including an estimate of the energy dissipated at the fracture site at the time of injury, the size and location of bruises and secondary skin openings, and such radiographic features as degree of comminution, air pockets extending along tissue planes, and the relationship of bony fragments to neurovascular structures.
This information is used to guide the initiation of débridement: a carefully planned and systematic process that removes all foreign and dead material from the wound. As the first step, the wound edges are liberally extended to allow unobstructed access to the entire injury zone ( Fig. 6-4 ). These incisions should be extensile, should not create flaps, and should respect vascular and neurologic territories. All nonviable and necrotic skin is resected to a bleeding edge, and necrotic or contaminated subcutaneous tissue and fat are sharply débrided. Contaminated fascia is resected and prophylactic fasciotomies and epimysiotomies are performed to allow the injured tissue to swell without causing secondary vascular compromise and tissue necrosis. Ischemic muscle is the principal culture medium for bacteria and is radically resected where compromised. The four C s—consistency, contractility, color, and capacity to bleed—are classic guides to viability but are, unfortunately, not always reliable. The capacity to contract after a gentle pinch with forceps and the presence of arterial bleeding seem to be the best signs of viability.
The intramedullary canal of the principal fracture fragments is carefully inspected and cleansed of any contaminated material. Large cortical fragments with limited soft tissue attachments are often retained, especially if they provide intrinsic bony stability. Even if major cortical fragments need to be discarded because of gross contamination, an attempt should be made to preserve the surrounding periosteum because this can contribute to subsequent reconstitution of the missing bone. Major neurovascular structures must be carefully identified and preserved, whenever possible. Débridement is completed when all contaminated and nonviable tissues are resected and the remaining wound cavity is lined by viable and well-perfused soft tissues.
Along with débridement, the wound is irrigated with ample amounts of isotonic saline solution. Investigators have questioned the practice of irrigating open fractures with antibiotic solutions over soap solutions. The use of low-pressure pulsating irrigation with a sprinkler head is optimal, and high-pressure pulsatile lavage may be used selectively in highly contaminated wounds. In an animal study, low-pressure irrigation resulted in less damage to underlying bone and was as equally effective as high-pressure lavage in removing bacteria from an open femur fracture model.
Nerves, vessels, tendons, articular cartilage, and bone, if exposed, are covered with local soft tissue or skin. The surgical extension of the wound is usually closed, and the remainder of the wound cavity can either be closed loosely over drains, “laced” with the use of rubber bands ( Fig. 6-5 ) so that retraction of the skin edges is prevented, or dressed with a bandage soaked in isotonic saline or an antiseptic. The use of an antibiotic bead pouch and negative pressure wound therapy (NPWT) ( Fig. 6-6 ) for providing temporary wound coverage after surgical débridement of open fractures is gaining popularity. Antibiotic-impregnated beads deliver an extremely high local concentration of antibiotics to the wound, lower the infection rate, and also help with dead space management. NPWT, often referred to as vacuum-assisted closure (VAC), helps stabilize the local wound environment, decreases edema, improves tissue perfusion, lowers the bacterial load, and stimulates formation of healthy granulation tissue ∗ In a prospective, randomized study comparing traditional wet-to-dry dressing changes with NPWT in 62 type II or higher open fractures in adults, the control group had a higher deep infection rate (28% vs. 5.4%,
∗
P = 0.024). Based on a review of literature dealing specifically with the use of NPWT in children, there was no consensus regarding the frequency of dressing changes, optimum amount of negative pressure, and selection of interposing contact layer in these younger patients. Irrespective of the choice of such ancillary measures, thorough surgical débridement and removal of all devitalized and contaminated tissues are critical before application of any type of wound dressing.
Related posts:
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Anesthesia and Analgesia for the Ambulatory Management of Children’s Fractures
Private: Fractures and Dislocations about the Hip and Pelvis
Private: Fractures around the Knee in Children
Private: Fractures and Dislocations of the Forearm, Wrist, and Hand
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