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Management of Pediatric Type III Tibial Shaft Fractures: A Cohort Study Utilizing the Trauma Quality Improvement
Molly F MacIsaac1, Joshua M Wright1, Jordan N Halsey1
1From the Division of Plastic and Reconstructive Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL.
Insights
Management of pediatric open tibial fractures shows similarities to adult cases, with soft-tissue coverage often exceeding 72 hours. Orthopedic fixation varies by age, considering growth concerns.
Area of Science:
- Orthopedic Surgery
- Pediatric Trauma
- Wound Management
Background:
- Pediatric open tibial fractures are complex injuries with limited guiding literature.
- The epidemiology, management, and outcomes of pediatric tibial shaft fractures require further description.
Purpose of the Study:
- To analyze demographics, injury patterns, and management strategies for pediatric open tibial fractures.
- To compare fracture management across different pediatric age groups and injury severities.
Main Methods:
- Retrospective analysis of the Trauma Quality Improvement Program Data Bank (2017-2020).
- Inclusion of 3480 pediatric open tibial fractures, categorized by age (0-5, 6-12, 13-17 years) and type (I/II vs. III).
- Subgroup analysis of type III open fractures, including type IIIb/c.
Main Results:
- Motor vehicle accidents were the most common injury mechanism (48%).
- For type IIIb/c fractures, common treatments included local flap reconstruction (25%) and skin grafts (25%), with soft-tissue coverage achieved at a median of 162 hours.
- Negative pressure wound therapy was used in 63% of cases, but rarely in isolation (23%).
- Intramedullary nailing was preferred for older adolescents (13-17 years), while plate fixation was more common in younger children.
Conclusions:
- Soft-tissue management for pediatric open tibial fractures resembles adult patterns.
- The median time to soft-tissue coverage surpasses the traditional 72-hour guideline.
- Orthopedic management strategies differ based on age, reflecting concerns for skeletal growth.
Background:
Pediatric open tibial fractures represent a challenging subset of injuries with limited literature to guide management. For children, the epidemiology, management, and outcomes of tibial-shaft fractures have not been fully described.
Methods:
A retrospective analysis of the Trauma Quality Improvement Program Data Bank from 2017-2020 was used to query demographics, injury patterns, and management strategies in pediatric open tibial fractures. Fractures were compared by age group (0-5, 6-12, 13-17 years) and type (I/II vs type III). A subgroup analysis was performed on patients with type III open fractures.
Results:
A total of 3480 open tibial fractures were identified, 3049 were type I/II, and 431 were type III. Motor vehicle accidents (48%) were the most common mechanism of injury (P < 0.001). Subanalysis of 128 type IIIb/c tibial fractures revealed local flap reconstruction (25%) skin graft (25%), and free tissue transfer were the most common management strategies and soft-tissue coverage was achieved after 162 hours (interquartile range = 109-231). Negative pressure wound therapy was utilized in 63% of cases but used in isolation in only 23% of cases. Immediate fixation with intramedullary nailing was more frequently used in the 13-17 age group while plate fixation was more commonly used in younger age groups.
Conclusions:
Soft-tissue management patterns following open tibial shaft fractures mirror those seen in adult cohorts. The median time to achieve soft-tissue coverage exceeds the traditional 72-hour target advocated by Godina. Age-based variation is seen in orthopedic management of these fractures based on growth maintenance concerns.
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