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Management of Pediatric Type I Open Fractures in the Emergency Department or Operating Room: A Multicenter
Jenna Godfrey1, Paul D Choi1, Lior Shabtai1
1Children's Hospital Los Angeles, Los Angeles, CA.
Insights
Pediatric type I open fractures have similar infection and complication rates whether managed operatively or nonoperatively with emergency department (ED) debridement. Both approaches offer comparable safety profiles for treating these pediatric fractures.
Area of Science:
- Orthopedic Surgery
- Pediatric Traumatology
- Emergency Medicine
Background:
- Management of pediatric type I open fractures is debated.
- This study compares operative versus nonoperative (ED debridement) treatment outcomes.
Purpose of the Study:
- To compare infection and complication rates in pediatric type I open fractures managed with operative debridement versus superficial wound debridement in the ED.
Main Methods:
- Multicenter retrospective review of 219 pediatric type I open fractures (forearm, wrist, tibia) from 2000-2015.
- Exclusion criteria: multiple trauma, immunocompromise, lack of healing radiographs.
- Comparison of operative (n=170) versus nonoperative (n=49) management groups.
Main Results:
- Infection rate: 2.0% (nonoperative) vs. 0% (operative) (P=0.062).
- Overall complication rate: 4.1% (nonoperative) vs. 5.4% (operative) (P=0.107).
- Shorter antibiotic duration and hospital stay in the nonoperative group.
Conclusions:
- No significant difference in infection or complication rates between operative and nonoperative management for pediatric type I open fractures.
- Superficial wound debridement in the ED with antibiotics is a safe alternative to operative debridement.
- Similar safety profiles support considering nonoperative management for these injuries.
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.
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