Open fractures in children are rare and are typically associated with better prognoses compared with their adult equivalents. Regardless, open fractures pose a challenge because of the risk of healing complications and infection, leading to significant morbidity even in the pediatric population. Therefore, the management of pediatric open fractures requires special consideration. This article comprehensively reviews the initial evaluation, classification, treatment, outcomes, and controversies of open fractures in children.
Key points
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Open fractures pose a risk for contamination and can lead to significant complications in children.
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These fractures often have a better prognosis in children as compared with adults.
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Open fractures in children differ from open fractures in adults, with faster and more reliable bone healing, greater potential for periosteal bone formation, and lower reported infection rates.
Introduction
Open fractures are characterized by disruption of the skin and underlying soft tissues due to either a penetrating wound or a displaced bone fragment resulting in direct communication between the fracture and the external environment. These injuries are considered orthopedic emergencies because they are at high risk for contamination, potentially causing infection and significant morbidity. Open fractures constitute between 0.7% and 2% of all pediatric fractures. In a recent retrospective study of pediatric fractures admitted to 2 tertiary care centers, 33 of 2840 (1%) of all fractures were open. Most pediatric open fractures are a result of high-energy mechanisms, such as falls from heights and motor vehicle accidents. Although demographics and injury mechanisms vary widely, most studies report a higher incidence in male patients. A multicenter study of 554 pediatric open fractures by Skaggs and colleagues found the most common sites of injury were the fibula or tibia (190/554 fractures; 34%), ulna or radius (178/554; 32%), and hand or metacarpals (54/554; 10%).
Pediatric open fractures differ from adult open fractures in a variety of ways. Young children possess greater fracture stability and experience more rapid and reliable fracture healing compared with adults because of a thicker, more vascular periosteum. In addition, children heal faster, have a greater potential for periosteal bone formation, and regenerate bone more easily in the setting of bone loss. Children also have lower reported open fracture infection rates as compared with adults. These differences are important to consider when managing open fractures in children. The purpose of this article is to review the initial evaluation and management and the definitive treatment options for pediatric open fractures.
Introduction
Open fractures are characterized by disruption of the skin and underlying soft tissues due to either a penetrating wound or a displaced bone fragment resulting in direct communication between the fracture and the external environment. These injuries are considered orthopedic emergencies because they are at high risk for contamination, potentially causing infection and significant morbidity. Open fractures constitute between 0.7% and 2% of all pediatric fractures. In a recent retrospective study of pediatric fractures admitted to 2 tertiary care centers, 33 of 2840 (1%) of all fractures were open. Most pediatric open fractures are a result of high-energy mechanisms, such as falls from heights and motor vehicle accidents. Although demographics and injury mechanisms vary widely, most studies report a higher incidence in male patients. A multicenter study of 554 pediatric open fractures by Skaggs and colleagues found the most common sites of injury were the fibula or tibia (190/554 fractures; 34%), ulna or radius (178/554; 32%), and hand or metacarpals (54/554; 10%).
Pediatric open fractures differ from adult open fractures in a variety of ways. Young children possess greater fracture stability and experience more rapid and reliable fracture healing compared with adults because of a thicker, more vascular periosteum. In addition, children heal faster, have a greater potential for periosteal bone formation, and regenerate bone more easily in the setting of bone loss. Children also have lower reported open fracture infection rates as compared with adults. These differences are important to consider when managing open fractures in children. The purpose of this article is to review the initial evaluation and management and the definitive treatment options for pediatric open fractures.
Initial evaluation and management
Primary Survey and Resuscitation
The initial assessment of children with open fractures begins with performing a primary survey, which consists of the ABCs (airway, breathing, and circulation), a brief neurologic examination, and complete patient exposure. In addition, the cervical spine should be stabilized to protect the child with a potential cervical spine injury, taking care to avoid neck flexion.
Initial resuscitation of pediatric trauma patients follows the PALS (pediatric advanced life support) and ATLS (advanced trauma life support) guidelines. On arrival into the trauma bay, intravenous access should be obtained, and intravenous fluids should be promptly administered. For the patient with an obvious open fracture, intravenous antibiotics are also given (see Table 3 ).
Secondary Survey
Once the primary survey is completed and the resuscitation process has been initiated, a secondary survey that includes a thorough history and physical examination is conducted. The history should include confirmation of the patient’s tetanus status. For all patients with an obvious open fracture, a dose of tetanus toxoid (0.5 mL intramuscular injection) is administered to patients who have not received a tetanus immunization within the past 5 years or if their status is unknown ( Table 1 ). Inspection, palpation, neurologic and vascular examination should be performed on all extremities. Compartments should be palpated to ensure that they are soft and compressible. Compartment syndrome should be suspected if compartments are tense, if the patient is reporting severe and escalating pain, and if passive stretch of the digits causes a significant increase in pain, among other signs. If suspected, compartment pressures should be measured promptly.
| Clean, Minor Wounds | All Other Wounds a | |||
|---|---|---|---|---|
| Vaccination History | Td b | TIG | Td b | TIG |
| Unknown or <3 | Yes | No | Yes | Yes |
| ≥3 | Only if last dose >10 y | No | Only if last dose >5 y | No |
a Wounds >1 cm, incurred >6 h earlier, crush injuries, devitalized tissue, gross contamination with dirt, feces, and other.
b If patient is <7 years old, give DTaP (diphtheria, tetanus, and pertussis). If patient is between 7 and 10 years old, give Td. Older children, give Tdap (tetanus, diphtheria, and pertussis).
The open wound is inspected for bleeding, obvious injury to underlying structures, crush injuries to the soft tissues, bone exposure, and contamination. A sterile dressing is applied after wound assessment and bedside irrigation. Repeat wound inspections requiring dressing changes are minimized to avoid additional contamination risk and soft tissue injury. Before the patient is taken for advanced imaging or to the operating room, extremities with gross deformity should be realigned with gentle traction and splinted to minimize soft tissue injury and decrease pain.
Damage Control Orthopedics
Open fractures in children are often associated with polytrauma. In a retrospective study of children with open fractures, Cullen and colleagues found that 58% (48/83) of the children in this series had other major injuries. Robertson and colleagues reported that 82% (9/11) of children with an open femur fracture and 56% (18/32) with an open tibia fracture had associated injuries. In addition, the open fracture itself may be significantly unstable or involve extensive soft tissue injury. For these complicated cases, damage control orthopedics has been suggested. Damage control orthopedics is a well-recognized concept in adult orthopedic trauma that advocates for temporary fracture stabilization with external fixation until the patient is medically stabilized enough to allow for definitive fracture treatment. Damage control orthopedics is based on the philosophy that early definitive fixation acts as a second major physiologic stressor (“second hit”) that may be detrimental to a critically injured patient already affected by a significant injury (“first hit”).
There is a paucity of literature demonstrating the use of damage control orthopedics in pediatrics. However, the delay of definitive surgery in critically ill pediatric patients is practical in certain situations. At the authors’ institution, a damage control protocol is used for children with
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A traumatic brain injury with intracranial pressure measuring greater than 30 mm Hg despite medical intervention;
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Persistent hemodynamic instability despite resuscitation efforts;
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The “triad of death” (acidosis, hypothermia, and coagulopathy).
Classification
The modified Gustilo and Anderson classification system is used for the classification of open fractures in both adults and children ( Table 2 ). A type I open fracture is a low-energy puncture wound less than 1 cm in length, with minimal soft tissue injury, fracture comminution, or contamination. Type II open fractures have wounds measuring 1 to 10 cm, without significant periosteal stripping or comminution, and have soft tissue quality adequate for wound coverage. Type III open fractures include subtypes A, B, and C. A type IIIA open fracture has adequate soft tissue coverage despite having a heavily contaminated wound measuring greater than 10 cm, and segmental or comminuted fractures. Type IIIB fractures have extensive soft tissue damage requiring coverage procedures typically associated with periosteal stripping, exposed bone, and significant contamination. Type IIIC open fractures have an associated vascular injury requiring immediate repair. In general, low-energy gunshot wounds are not classified as open fractures and may be safely treated nonoperatively. However, high-energy wounds mandate immediate and aggressive treatment that follows an open fracture protocol.
| Type | Definition |
|---|---|
| I | Wound <1 cm; minimal contamination, soft tissue damage, no comminution |
| II | Wound >1 cm; moderate soft tissue damage, minimal periosteal stripping |
| IIIA | Wound >10 cm; extensive soft tissue damage, substantial contamination, adequate coverage |
| IIIB | Wound >10 cm; extensive soft tissue damage, substantial contamination, inadequate coverage |
| IIIC | Wound >10 cm; extensive soft tissue damage, vascular injury requiring repair |
On initial examination, the extent of soft tissue injury tends to be underestimated. It has been shown that stage diagnosed at the time of debridement often differs from the initial preoperative classification, with definitive staging more accurately done in the operating room. It is particularly important in small children to focus not on the length of the wound but, more importantly, on the extent of soft tissue damage and periosteal stripping. Regardless, initial staging should be performed expeditiously and as accurately as possible because it dictates the initial choice of antibiotic therapy.
Prevention of infection
Factors Influencing Infection
Most pediatric open fractures are potentially contaminated at the time of injury, increasing the risk of subsequent wound infection. Infection rates based on the Gustilo-Anderson fracture type in children vary, but generally type III fractures have been associated with higher infection rates compared with type I and II fractures. In a study of 44 pediatric open femur fractures by Hutchins and colleagues, infections were associated with type III open fractures (5/10), but not with the type I (0/25) or type II (0/9) fractures. A retrospective study of 554 pediatric open fractures reported a 3% overall infection rate, with an incidence of 2% (5/302) in type I fractures, 2% (3/154) in type II fractures, and 8% (8/98) in type III fractures. In addition, age has been reported to be correlated with infection rate in open fractures. In a retrospective study of 31 pediatric open fractures, Blaiser and Barnes demonstrated that children 12 years of age or older had a higher infection rate compared with those younger than 12 years old, with rates of 31% and 7% ( P = .065), respectively. Therefore, it may be important to distinguish between younger and older children when determining open fracture infection risk.
Antibiotic Therapy
Prompt administration of prophylactic antibiotic therapy decreases the risk of infection in children with open fractures. In the study of 1104 open fractures by Patzakis and Wilkins, an infection rate of 7.4% (49/661) was reported when antibiotics were started more than 3 hours after injury and 4.7% (17/364) when antibiotics were started within 3 hours after injury. The investigators concluded that the single most important factor in reducing infection rate in these patients was early administration of antibiotics. Today, most surgeons agree that prophylactic antibiotics should be started as soon as possible.
Although there is a strong consensus on the timely initial administration of antibiotics, the ideal duration of therapy remains somewhat controversial. A randomized, double-blind prospective trial by Dellinger and colleagues compared a 1-day versus 5-day course of postoperative antibiotics in 248 patients with open fractures. No reduction in infection rates was found with the longer 5-day versus 1-day course of cefonicid (13% vs 12%, respectively). These findings were consistent across all 3 Gustilo-Anderson types of open fractures. However, it is important to note that patients less than the age of 14 were excluded from this study. Currently, many investigators advise that initial antibiotic prophylaxis should be limited to a 24- to 72-hour course. Skaggs and colleagues recommend administration of antibiotics for 24 hours after wound closure; at the authors’ institution, children with open fractures typically receive 48 hours of antibiotic therapy.
Antibiotic Selection
A first-generation cephalosporin is typically administered to patients with an open fracture (see Table 3 ). In the classic study by Patzakis and colleagues, 3 groups of patients with open fractures were randomized to receive placebo, penicillin and streptomycin, or cephalothin. Infection rates were 13.9%, 9.7%, and 2.3%, respectively. This finding provided evidence for the use of cephalosporins directed against gram-positive organisms in open fractures and has since been supported in the literature. Patients with type II or III open fractures are additionally given an aminoglycoside to enhance gram-negative coverage. Penicillin or one of its derivatives is added to cover anaerobes and Clostridium species when dealing with dirty wounds, such as those exposed to soil. Patients allergic to cephalosporins or penicillin are commonly given clindamycin. The increasing incidence of community-acquired methicillin-resistant Staphylococcus aureus (MRSA) has led to the concern that traditional prophylactic antibiotic recommendations may not be sufficient. However, the benefits of prophylactic regimens against MRSA have not been established in the literature, and currently, there is a paucity of high-quality studies that support the routine use of clindamycin, vancomycin, or other antibiotics instead of cephalosporins for pediatric open fracture prophylaxis. Therefore, the decision to include MRSA coverage for pediatric open fracture prophylaxis is made by the surgeon and should be based on individualized risk factors.
| Antibiotic | Pediatric Dose | Indication |
|---|---|---|
| Cefazolin (Ancef) | 25–100 mg/kg/dose every 8 h | All open fractures |
| Clindamycin | 25–40 mg/kg/d every 6-8 h | PCN or cephalosporin allergy |
| Gentamicin | 5–7.5 mg/kg/d every 8 h | Type II and III open fractures |
| Penicillin | 50,000–100,000 units/kg IV every 4 h | Soil/fecal contamination |
| Vancomycin | 15 mg/kg/dose every 6 h | Suspected MRSA infections |
Local antibiotic therapy has been shown to be valuable in the prevention of infection in open fractures when used as an adjunct to systemic antibiotics. Antibiotic-laden polymethylmethacrylate (PMMA) beads are commonly used and have been shown to decrease infection risk of severe type III open fractures in adults. In a retrospective study of 1085 open tibial fractures, Ostermann and colleagues found an infection rate of 3.7% in patients treated with both gentamicin bead chains and systemic antibiotics compared with a 12% infection rate for those that received systemic antibiotics alone ( P <.001). In a more recent study of 75 open fractures, patients were randomized to receive either traditional systemic antibiotics or antibiotic-PMMA bead chains. Infection occurred in 5.3% (2/38) of fractures treated only with systemic antibiotics and in 8.3% (2/24) of those treated only with antibiotic bead chains. These findings suggest that although antibiotic beads may provide protection against infection, they should not be considered a substitute for systemic therapy. Moreover, antibiotic-PMMA bead chains may be most useful in the setting of open fractures with extensive bone loss, where they provide local therapy and occupy dead space that would otherwise serve as a potential nidus for infection before definitive surgery can be performed. Unfortunately, there is a paucity of literature on the use of antibiotic beads for the treatment of pediatric open fractures, and the decision to use them should be made on a case-by-case basis. It is important to note, however, that local antibiotic therapy is generally considered safe and that high local antibiotic concentrations with low systemic levels are often achieved.
Topical vancomycin powder has shown efficacy in decreasing postoperative infections in spine surgery, but has not yet been fully studied in open fracture surgery. Singh and colleagues conducted a retrospective review assessing the efficacy of vancomycin powder in reducing surgical site infection (SSI) rates in adult patients with high-energy tibial plateau and pilon fractures, which included 83 patients in the control group (23/83; 28% with open fractures) and 10 (3/10; 30% open fractures) in the vancomycin group. There was no statistically significant difference in the rate of SSI between the vancomycin group, 10% (1/10), and the control group, 16.7% (14/83). Moreover, it is unknown whether the infected cases were open or closed fractures. There is a clear need for studies to delineate the role of vancomycin powder as a modality to reduce postoperative infection in pediatric open fractures.
Timing of surgery
In the treatment of open fractures, traditional teaching is that all open fractures must be treated by irrigation and debridement within 6 to 8 hours from the time of injury. Although this practice is widely accepted, little evidence supports it. In fact, several current studies in children have demonstrated no significant difference in infection rates when surgery was delayed for greater than 6 hours and even as long as 24 hours after injury as long as intravenous antibiotics are started on presentation. Therefore, irrigation and debridement of pediatric open fractures can be performed within the first 24 hours after injury without significantly increasing the risk for infection, provided antibiotics are given early. However, emergent surgery should be considered in cases involving gross contamination, vascular compromise of the extremity, large bone exposure, and severe soft tissue injury.
