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Management of Pediatric Type I Open Fractures in the Emergency Department or Operating Room

A Multicenter Perspective

Godfrey, Jenna MD, MSPH*; Choi, Paul D. MD*; Shabtai, Lior MD*; Nossov, Sarah B. MD; Williams, Amy MD; Lindberg, Antoinette W. MD; Silva, Selina MD§; Caird, Michelle S. MD; Schur, Mathew D. BA*; Arkader, Alexandre MD

Journal of Pediatric Orthopaedics: August 2019 - Volume 39 - Issue 7 - p 372–376
doi: 10.1097/BPO.0000000000000972
Trauma
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Background: The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management).

Methods: A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded.

Results: In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P<0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P<0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group.

Conclusions: There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures.

Level of Evidence: Level III.

*Children’s Hospital Los Angeles, Los Angeles, CA

Shriner’s Hospital for Children

Children’s Hospital of Philadelphia, Philadelphia, PA

Seattle Children’s Hospital, Seattle, WA

§Carrie Tingley Children’s Hospital, University of New Mexico, Albuquerque, NM

CS Mott Children’s Hospital, University of Michigan, Ann Arbor, MI

J.G.: data collection, data analysis, manuscript writing and review. L.S. and A.W.: data collection and manuscript review. P.D.C., S.B.N., A.W.L., S.S., M.S.C., and A.A.: manuscript review. M.D.S.: data collection. J.G. and A.A.: study design, methods, and idea.

All figures in this manuscript are reproduced with permission of the Children’s Orthopaedic Center, Los Angeles.

This study has been carried out with approval from the Institutional Review Board at Children’s Hospital Los Angeles.

There are no sources of funding for this study.

The authors declare no conflicts of interest.

Reprints: Paul D. Choi, MD, Children’s Orthopaedic Center, Children’s Hospital Los Angeles, 4650 Sunset Boulevard, Mailstop #69, Los Angeles, CA 90027. E-mail: pchoi@chla.usc.edu.

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