1. The initial management of a child’s open fracture is the same as is recommended for adults. There is no evidence children have greater resistance to infection once the barrier of soft tissue cover of the fracture has been compromised by injury.
2. The soft tissues of children do not have a greater regenerative potential and soft tissue reconstruction techniques involve the same strategies as in adults.
3. Fracture fixation will need to consider the presence of physes. Flexible intramedullary nails, Kirschner wires, plates introduced by minimally invasive methods, and external fixators have their indications.
4. Bone loss in very young children (under 6 years) may be managed expectantly if the defect is small as spontaneous periosteal bone formation may occur. In older children, bone replacement by autografts or bone regeneration methods is required.
5. Skeletal injuries in children older than 12 years behave as in adults and have higher complication rates. Delayed or non-unions will require a more active treatment strategy.
Timing of wound excision after injury
An early publication reported a halving of infection rates in children with open fractures if debrided within 6 hours of injury (1). This was contested by a multicentre review of 554 open paediatric fractures where there was no significant difference in the incidence of infection when wound excision was performed on either side of the 6-hour threshold (2). A recent publication from the UK that reported compliance with the last issue of Standards of Treatment (British Orthopaedic Association/British Association of Plastic, Reconstructive and Aesthetic Surgeons (BOA/BAPRAS)) in 2009 had antibiotics given intravenously on arrival in the emergency department and had all injuries debrided on the day of admission or the next day if the patient arrived after midnight. The injuries were managed jointly by orthopaedic and plastic surgery consultants. The incidence of deep infection was reported at 4.9%, which is—considering that 70% of the 61 open tibial fractures were of Gustilo–Anderson grade 3—commendably low (3). We recommend antibiotics are given within 1 hour of injury and the timing of wound excision for high-energy open fractures (presumed Gustilo–Anderson grade III) in children and adults is the same: immediately for those compromised by compartment syndrome, ischaemia of the limb, heavy contamination, or as part of a multiple injury, and within 12 hours if a solitary injury.
Reports of low-grade Gustilo–Anderson open fractures being treated successfully by superficial wound excision and irrigation with antibiotics and cast stabilisation are misleading (4). These reports are a heterogeneous mix of open injuries with, in one report, tibial fractures constituting only 4% of the injuries (5). Non-operative management of open tibial fractures in children remains contentious and potentially dangerous (6).
Flexible intramedullary nails, plate and screws, Kirschner wires, and external fixators have proponents for use in fracture stabilisation. With flexible intramedullary nails, choosing the suitable injury type is important; stability depends on an intact soft tissue envelope and these nails are less effective for stabilisation in children over 50 kg weight (7). For those injury patterns and patients where this method is considered suitable, immediate flexible nailing and primary wound closure is associated with a low rate of complications. Classic plate fixation may appear to be linked to higher infection although it is unclear in the report admonishing this method of stabilisation if the injuries were significantly contaminated or if definitive soft tissue cover was accomplished at the same time as fixation (3). Use of plates in a minimally invasive manner on the lateral side of the tibia may be best suited to the less severe types of open injury (8).
External fixation may be used as a temporary stabilisation device or definitively. Monolateral and circular devices have their roles. Tensioned wires with circular fixators are able to capture short metaphyseal segments well, whereas monolateral devices based on half-pins are easier to apply for most surgeons. Circular fixators can also be used for reconstruction when managing bone defects (9, 10, 11).
The choice of definitive skeletal stabilisation will depend on the fracture location and pattern, the degree of comminution or bone loss, contamination, and the availability of definitive soft tissue cover. In the event that definitive stabilisation and soft tissue cover cannot be performed at the time of initial wound excision, we recommend temporary spanning external fixation is used in conjunction with temporary dressings. In fractures contaminated heavily at the time of injury, definitive external fixation is recommended.
Soft tissue reconstruction
Several studies have confirmed early definitive soft tissue cover is as necessary for children as it is for adults (3, 9, 12, 13, 14, 15). Delayed involvement of a plastic surgeon in management leads to more complications (14). The choice of cover will depend on the size and location of the defect, local tissue conditions, and the zone of injury. Split-thickness skin grafts, local fasciocutaneous, and free flaps are used. The overriding principles are the same as for adults and include: wound extension by incision; meticulous excision of contaminated and devitalised tissues; and early definitive cover (16). Grade 3B and 3C injuries are particularly challenging and demand the highest levels of input from all areas. A systematic review of free tissue transfer for open tibial fractures in children found that the commonest choice appears to be muscle flaps followed by perforator flaps. There is an increasing use of perforator flaps (e.g. anterolateral thigh flap) citing advantages of consistent anatomy, reduced donor site morbidity, and the supply of durable native skin that is ideal for the foot and ankle regions. The overall free flap failure rate for children’s open tibial fractures is similar to that for adults at approximately 5% (12).
Bone defects occur from loss at the scene of injury or after wound excision. The critical size of the defect that results in a non-union in children is unknown but it is recognised that young children can bridge defects from periosteal new bone formation in a manner that occurs rarely in adults (6). In very young children (possibly under 6 years) an expectant approach in the first 6 weeks after definitive stabilisation and wound closure may be taken if serial radiographs indicate increasing contributions of periosteal new bone formation across the defect, thereby avoiding further surgery (17). In older children, and certainly those over the age of 11 years (18), these defects should be managed by autologous bone grafts or through bone regeneration using distraction osteogenesis. The choice of technique will depend on the size of the defect, soft tissue envelope for bone grafting, availability of autogenous graft material, and familiarity of the surgeon with the techniques of bone transport or acute shortening across the defect and bone lengthening from an osteotomy at a different level (9, 19). Small defects of <3 cm where the underlying bone and covering soft tissue are amenable to further surgery may be treated simply with autologous bone graft harvested from the posterior iliac crest.
The objective in treating open fractures in children is the same as in adults—infection-free union. Healing in young children is different; fracture union times are shorter. However, there is evidence to suggest this advantage is lost by the age of 10–12 years and, especially with high-energy tibial fractures, there is an increasing likelihood for complications including non-union (3, 16, 17, 20, 21). Overall infection rates across the fracture types can vary between 3 and 8% (17, 18, 22). These figures may mislead as Gustilo–Anderson type I and II fractures are the most common and do not usually become infected. Infection rates are higher with Gustilo–Anderson type IIIB fractures and can reach 21% (23, 24). However, the combined orthoplastic approach as advocated here resulted in deep infection rates of less than 7% for type IIIB fractures in children (3).
There are greater similarities than differences when the treatment of open tibial fractures in children is compared with adults. The emphasis remains on early antibiotic administration, prompt and meticulous wound excision by orthopaedic and plastic surgery consultants, and early definitive soft tissue cover. It is important to note that children do not have an enhanced regenerative capacity in their soft tissues and, as in adults, all non-viable tissue should be excised. The techniques for soft tissue reconstruction in children are the same as with adults. The method of fracture stabilisation can vary depending on the fracture pattern and location, degree of contamination, presence of bone loss, and age of the child. Very young children may recover from bone loss spontaneously by periosteal new bone formation. Older children will require bone grafting or bone regeneration.
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