Open fractures in children

• Children with open fractures should ideally be treated in specialized pediatric trauma units
• The wound in open children’s fractures is debrided (excised), as recommended for adults. There is no evidence to suggest that tissues with compromised viability are more likely to recover in children compared to adults
• Skeletal fixation is determined by the fracture configuration. The use of intramedullary devices may be limited by the presence of growth plates. External fixation is particularly useful in children’s open fractures
• The available evidence suggests that prepubertal children are likely to have shorter bone healing times
• Soft tissue reconstruction for major defects after open fractures in children of all ages relies on vascularized flaps, as it does for adults

The management of children’s open fractures follows the same principles as for adult open fractures, described below.

The treatment of high-energy injuries aims to preserve life, limb and function, in that order of priority.

The intermediate objectives are:

• Prevention of infection
• Fracture stabilization
• Soft-tissue coverage

As these goals are interdependent, a coordinated management plan is required, with early surgical intervention.

Achievement of these goals requires a coordinated, well-planned, sequential surgical approach. This starts with optimal first-responder care and then mature clinical judgment in the emergency and operating rooms.

The immediate surgery is predicated on the prevention of infection and includes wound debridement and fracture stabilization.

Secondary surgery addresses early skin cover and soft-tissue reconstruction, followed by bone reconstruction.

Rehabilitation with early movement and mobilization is started as soon as possible as part of this staged management protocol.

Stage 1 Initial assessment

• ABC's (according to ATLS: airways, breathing, circulation)
• Emergency room management
• Wound dressing and fracture splinting

Stage 2 Primary operations

• Staged wound debridement
• Fracture stabilization

Stage 3 Secondary operations

• Skin and soft-tissue reconstruction
• Bone reconstruction

Stage 4 Rehabilitation

As with adults, in evaluating a patient with a high-energy extremity injury, the first priority is to identify and treat life-threatening injuries. Survival of the patient is the fundamental goal, and a severe limb injury must be seen in this context. When any threat to life has been dealt with, assessment of the viability of the injured limb follows.

Brumback [1] defined the essential components of assessing any traumatized extremity, as:

• History and mechanism of injury
• Vascular and neurological status of the extremity
• Size of the skin wound
• Muscle crush or loss
• Periosteal stripping or bone necrosis
• Fracture pattern, fragmentation, and/or bone loss
• Contamination
• Compartment syndrome

Detailed assessment of all these factors enables the surgeon to make a proper categorization of the injury and leads to a logical treatment plan [1].

Assessment is a continuing process with step-by-step re-evaluation.

At the accident site, the first-responder personnel should splint the limb and protect the wound with a sterile dressing. This dressing should be disturbed as little as possible.

Pulses, peripheral capillary refill, limb color, temperature and the presence of bleeding from wounds will indicate the vascular condition of the limb. “On-table” arteriography in the operating room should be performed when indicated.

In the emergency room, details of all open wounds should be recorded. A photographic record of the open wound should be made and avoids repeated disturbances of the dressing, which increase the risk of infection.

The image on the left show an open supracondylar fracture of the humerus with median nerve stretched over the shaft fragment.

Extensive, or contaminated, wounds should be irrigated with copious volumes of Ringer lactate solution. Any easily accessible foreign bodies should be removed from the wound, using a sterile technique.

A sterile dressing is then applied to the wound and not removed until the patient is in the operating room. Preliminary reduction of a severely displaced fracture should be considered.

The reduced limb is then placed in a well-padded splint. Pulses should be recorded before and after fracture alignment.

Gross motor function and sensation of the limb should also be documented.

Tetanus prophylaxis should be considered.

Systemic administration

In open extremity trauma, systemic antibiotics that cover both gram-positive and gram-negative organisms should be administered as a matter of urgency [2, 3]. Guidelines for the use of antibiotics are often a matter of local policy, but it is essential to consult the local microbiologists, as antibiotic resistance will vary from unit to unit.

Initial broad-spectrum antibiotic therapy should start as early as possible, certainly less than 12 hrs. When used prophylactically, antibiotic administration should not exceed 72 hours, by which time microbiological studies will be available to guide drug choice. The duration of treatment should be a clinical decision and cannot be strictly stated here.

Local administration

The additional use of local aminoglycoside-impregnated polymethylmethacrylate (PMMA) beads has been shown significantly to reduce the overall infection rate in the Gustilo type III fractures in adults [5]. Aminoglycosides must be used with caution in children as they may cause dose-independent profound deafness.

The objectives of the initial surgical intervention are:

• Preservation of life and limb
• Wound debridement
• Definitive injury assessment
• Fracture stabilization

The stages of open fracture management in the operating room are:

Stage 1 Assessment

• Assessment of wound and limb, including traction X-rays and planning

Stage 2 Wound management

• Trauma scrub
• Surgical preparation and draping
• Surgical wound debridement
• Wound lavage

Stage 3 Fracture management

• Surgical preparation and draping: rescrub
• Fracture stabilization

Wound dressing and splintage

Timing of initial surgical management

The surgical treatment of open fractures is generally thought to be a surgical urgency. Most surgeons attempt to operate within 24 hours of the time of injury. The early administration of antibiotics is essential to reduce the incidence of infection; definitive surgery can be delayed until the appropriate surgical resources are available.

Definitive assessment, initial debridement and irrigation

Definitive injury assessment is completed in the operating room and under anesthesia, if necessary with additional x-rays. Traction views may be very helpful. The limb and wound are cleansed with a “trauma scrub”, using soap and Ringer lactate to remove all obvious debris, and contamination. The limb is then formally prepared and draped.

The concept of “the zone of injury” is important. This comprises the whole volume of the deeper wounding, as opposed to just the skin wound. The skin wound may be small but the underlying soft-tissue injury zone larger. This is particularly true in fractures with deep coverage by muscle (eg, of the femoral or humeral shaft, and posterior wounds with tibial fractures).

Assessment of the whole injury zone usually necessitates surgical extensions of the traumatic wound, which must be planned carefully to minimize any further damage and should be undertaken bearing in mind any planned fixation and potential plastic surgery procedures for wound covering. In severe open injuries the plastic surgeon should attend the initial debridement.

The goal of surgical debridement and irrigation of the injury zone is to remove all foreign material, all devitalized tissue, including avascular bone fragments, and thereby reduce the bacterial load.

The debridement starts with careful excision of the skin margins of the traumatic wound. The subcutaneous tissue, fascia and muscle are then methodically debrided as necessary to produce a clean, viable wound. Muscle of dubious viability must be resected down to healthy tissue as assessed by color, consistency, capacity to bleed and contractility.

Major neurovascular structures should be preserved and repaired if necessary. The bone ends should always be exposed and carefully cleaned. The whole zone is then irrigated with warm Ringer’s solution in an attempt further to reduce the bacterial load.

Larger wounds benefit from larger volumes of irrigation. The traditional recommendation of 10 liters is reasonable for Gustilo type III open wounds.

At the completion of debridement and irrigation, the injury should be reassessed and the open fracture more accurately classified. Serial wound debridement is frequently necessary. If there is any question about the viability of the wound after the initial debridement, a second look procedure should routinely be performed.

In high-energy, or severely contaminated, injuries, serial debridement may be necessary every 24–48 hours until wound viability is assured.

The initial trauma scrub in the operating room consists of a formal scrub of the limb with soap and Ringer lactate solution.

The limb is then formally prepared and draped, and the injury zone is carefully excised, starting with the skin and progressing layer by layer to bone. The traumatic wound may require surgical extension to allow full assessment and complete debridement.

The bone ends are exposed and debrided.

The wound is copiously irrigated.

There is little debate about the need for reduction and stable fixation in the management of severe open fractures. As soon as primary wound surgery has been completed, treatment should proceed to fracture reduction. Depending on the extent of the injury, the fracture pattern, the location and the general condition of the patient, preliminary or definitive stabilization will be chosen.

Returning the limb to its normal length, alignment and rotation, as well as providing stability, facilitates soft-tissue recovery, reduces the risk of wound infection and inhibits the inflammatory response.

External fixation

External fixation is useful in children for stabilizing open fractures and can be applied almost universally. In children, because of more rapid union, external fixation can sometimes be used as the definitive fixation of open fractures, but is also used for preliminary stabilization.

The advantages of external fixation are:

• It can be applied relatively easily and quickly.
• It provides relatively stable fracture fixation.
• There is no further damage done, if applied correctly.
• It avoids implantation of hardware into the open wound.

The major problems with external fixation are related to pin track infections, malalignment, delayed union, and poor patient compliance.

Ring fixators can be useful for periarticular fractures.

Joint-spanning external fixation is a popular strategy for temporary stabilization of fractures of the proximal and distal tibia as well as for fractures around the knee, elbow and wrist.

The limb should be prepared and redraped as for a new procedure. The surgeons rescrub, regown, and reglove. A fresh set of sterile instruments, different from those used for the debridement, is necessary.

The fixator should be placed outside the zone of injury and any region of potential future surgery. As soon as the soft-tissue condition permits, definitive fixation can be considered.

Intramedullary nails

In adults, locked intramedullary nailing has been established as the treatment of choice for most diaphyseal fractures in the lower extremity [6, 7, 8]. It is less applicable in children, due to the need to respect the integrity of the physes. Elastic nailing can avoid such concerns in selected cases of Gustilo type I open fractures.

Open physeal injuries

Depending on the injury pattern, the age of the child and the anatomical location, transphyseal wires, intra-epiphyseal or metaphyseal lag screws may be chosen as the skeletal stabilization procedure.

Open wound coverage after primary surgery

By the end of the initial operation, the full extent of the injury zone should have been carefully assessed, meticulously debrided, washed out and the fracture stabilized. The predictive value of wound culture is low. In a prospective trial, only 18% of subsequent infections were caused by an organism identified on the initial wound cultures [2, 13].

Surgical extensions of the original open wound can be closed primarily, only if it is possible to do so without tension.

The current standard of care for all open fracture wounds is that definitive cover is achieved within 72 hours, and no later than 7 days. [14]

There are several strategies available for temporary coverage of an open wound after the initial procedure, pending further debridement and eventual definitive coverage.

Vacuum-assisted wound closure (VAC), if available, is recommended for temporary management of open fracture wounds.

The wound bed is exposed to mechanically-induced negative pressure in a closed system. The system removes fluid from the extravascular space, reduces edema, improves microcirculation, and enhances the proliferation of reparative granulation tissue. An open-cell polyurethane foam dressing is placed into the wound and ensures an even distribution of negative pressure. The results of this technique in open fracture wound care are encouraging [9].

The antibiotic “bead pouch” technique [10] as an alternative has already been discussed.

Skin cover and soft-tissue reconstruction

Skin cover and soft-tissue reconstruction procedures should be performed early. The risk of infection increases if the wound is left open for longer than 7 days. Small Gustilo type I wounds can be left open to granulate and heal quickly by secondary intention. Gustilo type II and type IIIA wounds may sometimes be closed by delayed primary suture, provided there is no tension in the skin. Frequently, these types of wounds require coverage with a split-thickness skin graft. By definition, Gustilo type IIIB wounds expose bone and require flap coverage.

Local transposition flaps or free tissue transfer may be necessary, depending on the size and location of the wound, as well as on the condition of the surrounding soft tissues. Local fasciocutaneous flaps play a minor role in open fracture management.

Muscle flaps have the great advantage of introducing a rich local blood supply to the wound and the underlying bone and are therefore generally the preferred option in suitable wounds and locations. Free vascularized flap coverage is required in large wounds and those not suitable for a local flap.

After-care

Infection remains the major risk and can lead to delayed union, nonunion, malunion, and loss of function. Delayed union and nonunion more often occur after open fractures than in closed fractures, although less so in children compared with adults: the frequency also increases with the severity of injury. In severe injuries— particularly those with major bone loss—nonunion can be predicted. Surgical intervention to reconstruct bone defects and to stimulate fracture healing should be performed early.

Bone grafting—when used—is usually delayed for about 6 weeks after injury when the soft tissues have soundly healed. Autogenous cancellous bone grafting is an option for managing bone defects and nonunions, but many are treated by bone transport using a circular frame.

Open fractures with vascular injuries

The principles of management of these open fractures have to be combined with the principles of management of vascular injuries, and treatment must always be undertaken in concert with vascular surgeons.

Gustilo type IIIC open fractures are frequently associated with devastating damage to bone and soft tissues. Despite strict adherence to principles and techniques, poor functional outcomes are frequent sequelae of these severe injuries. Gustilo type IIIC open tibia fractures have a particularly poor prognosis because of the large zone of injury and the relatively fragile soft-tissue envelope.

Gustilo type IIIC open fractures require extremely careful assessment. In children, limb salvage is preferred over amputation and is more likely to succeed than in adults. The operative strategy should be determined by the consensus judgment of experienced pediatric orthopaedic, plastic, and vascular surgeons.

Factors important in decision-making include:

• the general condition of the patient (the presence of shock);
• the warm ischemia time (more than 6 hours);
• the cut to crush ratio (blunt injuries have a large zone of crush).

The Mangled Extremity Severity Score (MESS) has proved of value in children in aiding such decision making [11, 12].

Gunshot injuries

The severity of damage resulting from a gunshot injury is related to the amount of kinetic energy transferred to the tissues at the time of impact.

High-velocity rifles and close-range shotgun blasts may cause devastating injuries because of the high kinetic energy, the secondary cavitation produced, and the secondary missile effects of shattered bone fragments. Most gunshot wounds encountered in civilian practice are caused by lower-velocity handguns and are less severe unless neurological or vascular structures are damaged. Cavitation is not significant and although bone fragmentation may be considerable, the secondary missile effects of the fragments are minimal and bone fragments are rarely stripped of their soft-tissue attachments and blood supply.

High velocity weapons, close-range shotguns, and blast injuries produce severely contaminated Gustilo type III open fractures, which should be managed intensively. Low-velocity weapons may produce significant fracture comminution but, since soft-tissue attachments are not disrupted, these fractures behave in a relatively benign way. The associated soft-tissue injuries are not severe and skin wounds are small. Widespread experience in violent communities has shown that these wounds can be managed by debridement and the fracture treated on its individual merits. Bullets lodged in joints should be removed to avoid lead arthropathy and systemic lead poisoning.

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[12] Behdad S, Rafiei MH, Taheri H, et al. Evaluation of Mangled Extremity Severity Score (MESS) as a predictor of lower limb amputation in children with trauma. Eur J Pediatr Surg. 2012 Dec;22(6):465-469.

[13] Valenziano CP, Chattar -Cora D, O’Neill A, et al. Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value? Arch Orthop Trauma Surg. 2002 Jun;122(5):259-561.

[14] The management of severe open fractures. 2009 British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons, London.