Recommendations regarding the treatment of open fractures in children have been primarily based on the adult literature. Although little controversy exists regarding urgent/emergent operative debridement accompanied by prompt administration of antibiotics in pediatric patients with Gustilo types II and III fractures, management of type I fractures is more controversial.1–6
Open fractures in children are uncommon, comprising approximately 2% to 9% of all pediatric fractures.7,8 Upper extremity fractures, specifically forearm and wrist, and tibia fractures are the most common open fractures seen in pediatrics.6,7,9 Type I open fractures are the most common type of open fracture seen in pediatric patients and are typically caused by low-energy mechanisms such as falls, bicycle or skateboarding injuries, or injuries sustained during a sporting event.9,10
For a summary of the results reported below, please refer to Table 1.
A HISTORICAL PERSPECTIVE
Gustilo and Anderson’s19 classic article describes the authors’ experience in treating long bone open fractures over a 18-year period between 1955 and 1973. Their efforts led to the now commonly used Gustilo and Anderson19 open fracture classification system (types I, II, and III).19 After instituting a treatment protocol for open fractures which included immediate antibiotic administration, operative debridement, primary wound closure in types I and II fractures, secondary wound closure in severe soft tissue injuries (type III fractures), intraoperative wound cultures, and a 3-day perioperative course of oxacillin-ampicillin, the authors found a significant drop in the infection rate from 12% to 2.4%.19 The most significant drop in infection rate was noted in type III fractures, from 44% to 9% after institution of the treatment protocol.19
Gustilo and Anderson’s contribution to our understanding of open fracture management cannot be understated as is evident by the fact that their recommended protocol for treatment of open fractures that has changed only minimally over the years. However, the applicability to low-energy open fractures (type I) seen in pediatric patients can be questioned.
CHILDREN ARE NOT SMALL ADULTS
Fractures in children differ from adult fractures in several ways.6,20 Children’s thick periosteum contributes to improved ability to both obtain and maintain reduction when compared with adult fractures.20 Also, the periosteum is rarely circumferentially torn. The improved blood flow results in improved ability to resist infection and more robust fracture healing.20 Infection rates in pediatric open fractures are lower than their adult counterparts, 1.8% versus 7.2%, respectively.13 For these reasons, pediatric “inside-out” type I fractures may not require the same aggressive wound debridement as fractures with more severe soft tissue injury.20
PRINCIPLES OF MANAGEMENT
Prompt Administration of Antibiotics Matters
In 1989, Patzakis and Wilkins reviewed 1104 open fractures and identified, then studied, 77 adult and pediatric patients with infection (7.2%) to look for predisposing factors. Although the findings were not statistically significant, the infection rate in patients who received antibiotics within 3 hours of injury was nearly half the rate of those receiving antibiotics later (4.7% and 7.4%, respectively).13 Despite the lack of statistical significance, the authors felt this trend to be important and recommended “the administration of broad-spectrum antibiotics as soon after injury as possible.”
A Cochrane review similarly recommended the prompt administrationof antibiotics to reduce the incidence of infection in open fractures.15 Eight randomized-controlled studies were included in the review (1106 patients), with pediatric patients included in 2 of the studies. Antibiotics reduced the incidence of infection when compared with controls [risk ratio, 0.43%; 95% confidence interval (CI), 0.29-0.65], with an absolute risk reduction of 0.7 (95% CI, 0.03-0.10), and number needed to treat of 13.15 The recommendations made were limited, as the authors did not stratify their results by age or injury severity, with the primary purpose of the review to make a broad statement generally endorsing antibiotic administration. Although no study has been able to pinpoint an ideal time window for administration of antibiotics, best practice would suggest that prompt administration upon presentation to the hospital is the standard of care.5,6,13,15
Antibiotic Choice and Duration
First generation cephalosporins have repeatedly been recommended as the first line antibiotic administered for open fractures.5,6,13,15,17,18 During Patzakis and Wilkins’ 11 year study, several different antibiotic regimens were used for open fractures. The lowest infection rate was seen in the group receiving antibiotics offering both gram-positive and gram-negative coverage, specifically cefamandole and tobramycin (4.5%).13 However, the Cochrane review stated that antibiotics directed at gram-positive organisms, specifically narrow spectrum β-lactam penicillin derivatives or first generation cephalosporins, were the most effective in preventing infection in simple open fractures.15
The Surgical Infection Society published their recommendations regarding prophylactic antibiotic use in open fracture management in 2006. After an extensive literature review, the authors cautiously recommended prompt administration of first generation cephalosporins for open fracture management.17 The authors highlight that they were unable to find any level 1 evidence supporting specific antibiotic choice, and instead made the recommendation based on a handful of small studies, all with significant limitations They further noted that they could find no good evidence to recommend gram-negative coverage for type III open fractures or anaerobic coverage for barnyard injuries.17
As of now, it seems prudent to recommend a first generation cephalosporin or clindamycin in allergic patients for type I open fractures and to exercise clinic judgment for types II and III open pediatric fractures on a case by case basis.
Antibiotic duration has been minimally studied and remains poorly defined. Dellinger et al in 1988 found no difference in infection rate in patients with open fractures who received intramuscular cephonicid sodium for 1 or 5 days (13% and 12%, respectively) versus cefamandole nafate for 5 days (13%).12 Hauser et al17 in the Surgical Infection Guidelines state that insufficient evidence existed to support prolonged antibiotic courses or repeated short course administration. Similarly the Cochrane review was unable to find sufficient evidence relating to the optimal duration of antibiotic prophylaxis.15
A more recent systematic review of antibiotic prophylactic regimens in open fractures performed by Chang et al18 was able to find level I evidence strongly supporting the administration of antibiotics (as compared with no antibiotic proxphylaxis) in open fractures, with no difference in a short course versus long course of antibiotics. Three randomized control trials (1104 patients) looked at long duration antibiotic administration (3 to 5 d) compared with short duration (1 d). All 3 trials used first or second generation cephalosporins. The results indicated similar infection rates in both the short and long duration treatment groups (risk ratio=0.97; 95% CI, 0.69-1.37).18 On the basis of these findings, it seems reasonable to recommend a short course of antibiotics for open pediatric fractures.
An Emergent Trip to the Operating Room May Not Matter
Patzakis and Wilkins13 did not find any correlation between time to operative debridement of less than or greater than 12 hours and infection rate (6.8% and 7.1%, respectively) in their study of adult and pediatric open fractures. Skaggs and colleagues reviewed open fracture management exclusively in pediatric patients at their institution over a 5-year period and found no significant difference in infection rate in fractures treated within 6 hours of injury compared with those treated later (2.5% and 1%).21 This study was then repeated as a multicenter retrospective review and similarly found that a delay in surgical management >6 hours did not result in an increased infection rate (0% and 3%, respectively).16 This finding held true across all open fracture types. The authors attributed the low infection rates to the prompt administration of intravenous antibiotics upon presentation to the emergency department.
Conversely, Kreder and Armstrong14 reviewed 56 open tibia fractures in children. The average patient age was 10, and the most common mechanism of injury was pedestrian versus automobile (48%). The overall infection rate was 14% (8 patients). The majority of infections were seen in type III open fractures (6/8), with 1 superficial infection in a type I (1/8) and type II (1/8) fracture, respectively. No deep infections occurred in the types I and II open fracture groups. There was a significantly higher rate of infection in patients in which surgery was delayed >6 hours (25% vs. 12%).14 This number must be taken in context, however, because 50% of the infections occurred in patients with a concomitant neurovascular injury, which would suggest a more severe soft tissue injury. It is likely that these patient’s injuries differ significantly from the “poke hole” open type I tibia fractures.
Operative Debridement is (Not) Necessary in Pediatric Type I Fractures; the Great Debate
In 2005, Iobst et al3 published a series of pediatric patients with type I open fractures managed nonoperatively. A total of 40 patients were treated with a protocol consisting of early antibiotic administration, wound debridement in the emergency department using a mixture of saline and betadine, a xeroform dressing, reduction with cast immobilization, and admission for 24 to 48 hours of intravenous antibiotics. The infection rate in this cohort overall was 2.5%, with a 0% rate in upper extremity fractures, and 1 deep infection in a 12-year-old patient with an open tibia fracture. The authors recommended nonoperative management of type I open fractures in pediatrics, with the caveat that infections may be more common in type I open fractures of the lower extremity in children 12 years and older.
A 2014 follow-up study with a prospective cohort of 45 consecutive patients managed with the above stated protocol (with the exception of standardizing the antibiotic administration to 4 doses of intravenous antibiotic and home oral antibiotics) reported an infection rate of 0%.2
In 2009, Doak and Ferrick1 retrospectively reviewed 25 pediatric patients with type I open fractures managed using a similar nonoperative protocol. Patients were treated with early antibiotic administration, debridement using saline only, xeroform guaze, reduction with cast application, and admission for <24 hours of antibiotics. The resultant infection rate was 4%; an 8-year old boy with a tibia fracture presented with serosanguanous drainage 6 days following his injury. This resolved with 2 days of intravenous antibiotics followed by oral antibiotics at home. The authors also recommended nonoperative management for type I fractures, citing benefits of nonoperative management including significant cost savings and decreased risk of anesthesia to young children.
Bazzi et al4 lent further support to the notion of nonoperative treatment of type I open pediatric fractures in 2014. Forty patients were treated at their facility with a protocol consisting of: intravenous antibiotics started in the emergency department, bedside irrigation with saline or iodine/saline mixture, xeroform dressing, and casting. Twenty-eight (70%) patients were sent home with oral antibiotics, 36 (90%) received a dose of intravenous antibiotics in the emergency department. The infection rate was 0%. The authors did acknowledge the need for a randomized control trial and pointed out that to detect a 1% change in infection rate (using 1% to 2% infection rate as the baseline reported in the literature), a cohort of 3210 patients would need to be enrolled. Therefore, their recommendation was to cautiously recommend nonoperative management, and that a large multicenter randomized–controlled trial be considered.
As of the writing of this article, enrollment in the first multicenter prospective randomized control trial for treatment of pediatric type I fractures (the PROOF study) is underway.22 The hypothesis is that type I fractures can be safely treated in the emergency department with irrigation, closed reduction, and home antibiotics without an increased risk of infection.
Because of the paucity of level 1 evidence supporting nonoperative management in type I open fractures in conjunction with historical reports of gangrene, many authors continue to recommend against nonoperative management. In 1977, Fee et al23 reported on 5 devastating cases of gas gangrene following nonoperative management of open forearm fractures. Skaggs and colleagues stated that they “view non-operative management in open fractures as potentially dangerous.”6 They further site the anecdotal reports of gangrene as the major deterrent.
A survey of 181 (of 503) POSNA members at the annual meeting in 2012 indicated that 86% admitted patients for at least 24 hours of antibiotics, and between 19% and 34% have treated these injuries in the emergency department alone.24 Of those surveyed, 81% admit they would consider changing their standard management of these patients if a level 1 trial indicated that nonoperative management was equally safe and effective.
The infection rates most recently reported for type I fractures in pediatrics is between 0% and 4%.1,3,4 Although there is a paucity of data specifically in pediatric patients, prompt administration of antibiotics seems to be the most important factor in reducing infection in open fractures.13,15,18 Waiting longer than 6 hours for operative debridement of these injuries does not result in an increased infection rate.16,21 Antibiotics directed at gram-positive organisms, commonly a first generation cephalosporin or clindamycin, are the most commonly used and effective treatment in uncomplicated patients with type I open fractures.15,18
Nonoperative management of type I open fractures in pediatric patients has not resulted in an increased rate of infection, but the only data currently available are small retrospective review studies.1–4 Open tibia fractures may differ from their upper extremity counterparts. Kreder and Armstrong14 did report findings contradictory to the other studies presented here. However, the data from other reports suggests that uncomplicated open type I tibia fractures do not need an emergent debridement.1,3,4 The ongoing prospective randomized control trial (PROOF) will help elucidate which type I open fractures can be safely managed nonoperatively.
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