Complications and Outcomes of Open Pediatric Forearm Fractures

Author(s): Luhmann SJ, Schootman M, Schoenecker PL, Dobbs MB, Gordon JE

Source: J Ped Orthop 24:1-6, 2003.

Summary:

Only 0.5% to 4.5% of both bone forearm fractures (BBFF) in children are open. The higher energy imparted increases the risk of complications related to bone and the soft-tissue.  A single level 1 trauma center reviewed all their open BBFF over a 12-year period. Treatment consisted of gross superficial debridement initially with application of a sterile dressing, splint immobilization, and prophylactic antibiotics based on the grade of fracture. Grade I fractures were treated with cephalozin, grade II with cephalozin and gentamicin, and grade III with cephalozin, gentamicin, and penicillin. Surgical treatment was completed “as soon as possible.” In the operating room, debridement of all non-viable tissue, removal of devascularized bony fragments, and internal stabilization of unstable fractures were performed.  Repeat debridements were performed until soft-tissues and bones were “satisfactory.”

Seventy-eight patients were identified and 65 fulfilled the inclusion criteria and had adequate follow-up. Mean age was 10 years (range 3–17 years). Grading was based on fracture healing, forearm motion, and complications. Less than 10-degrees loss of forearm rotation without complaints was considered “excellent.” Loss between 11-degrees and 30-degrees and mild complaints was deemed “good.” Loss of between 31-degrees and 90-degrees and mild complaints was noted to be “fair.” All other outcomes were considered “poor.”  The fractures were proximal in 2, midshaft in 47, and distal in 16 forearms. Fractures were classified as 52 grade I, 12 grade II, 1 grade IIIA. The fracture grade was NOT associated with infection, angulation, or outcome. Time from injury to irrigation and debridement was NOT associated with infection or outcome. There were nine nerve injuries and all resolved spontaneously. No compartment syndromes were noted. Only one deep infection occurred. This fracture was felt to be grossly contaminated at admission and underwent only a single debridement. Implants were used to stabilize the fractures in 40 forearms. Twenty-five forearms did not have internal fixation and five required re-operation for loss of alignment. Complications occurred in 11 patients (1 infection, 5 re-operations for loss of alignment, 1 re-fracture, 1 malunion, 3 delayed unions). Results reported 47 children excellent, 11 good, 7 fair, and 0 poor at follow-up.

This article reports exceptional outcome after treatment for pediatric open BBFF. However, the results must be taken in content. The treatment was rendered at a level 1 trauma center with a uniform approach. All patients were taken to the operating room, irrespective of the grade of fracture. All patients were placed on intravenous antibiotics, irrespective of the grade of fracture. In addition, the majority of the fractures were grade 1 open with less periosteal stripping and less contamination than higher grades. Although the grade of fracture did not correlate with infection or outcome, the rigors of statistical analysis would not support this conclusion with only a single grade III fracture. Nonetheless, operative debridement and intravenous antibiotics is the mainstay for open pediatric BBFF.

 

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