Related Experiment Video
Updated: Jan 10, 2026
Minimally Invasive Treatment for Thoracolumbar Burst Fracture Using Sagittal Alignment Screws and A Trauma Reduction Device
Published on: November 8, 2024
Are We on the Same Page? Defining Consensus for Pediatric Open Fracture Management Among Level 1 Pediatric Trauma
Kristin S Livingston1,2, Emi Schwab3, Shanika DeSilva1
1Department of Orthopaedic Surgery, Boston Children's Hospital.
Insights
Pediatric trauma centers have protocols for open fracture antibiotic timing and selection, but success rates vary. Standardized, evidence-based protocols are needed, especially for severe injuries.
Area of Science:
- Orthopaedic Surgery
- Pediatric Trauma Care
- Infectious Disease Management
Background:
- Open fractures necessitate prompt antibiotic administration to prevent infection and reduce morbidity.
- Current pediatric open fracture management often relies on adult data, leading to variations in treatment protocols.
- This study investigated consensus on open fracture management at Level-1 Pediatric Trauma Centers in the US.
Purpose of the Study:
- To identify consensus among Level-1 Pediatric Trauma Centers regarding open fracture management protocols.
- To assess variations in antibiotic timing and selection for pediatric open fractures.
- To highlight the need for standardized pediatric-specific guidelines.
Main Methods:
- A survey was distributed to 17 Level-1 Pediatric Trauma Centers within the CORTICES network.
- Descriptive statistics were used to analyze survey responses, presenting data as frequencies and percentages.
- The survey focused on antibiotic administration timing, success rates, and selection criteria based on Gustilo-Anderson classification.
Main Results:
- All surveyed centers (100%) have protocols for IV antibiotics within 1 hour of presentation.
- 88% of centers monitor antibiotic administration success rates, with reported success varying widely (21%-100%).
- Consensus exists for Gustilo-Anderson type 1 and 2 antibiotic selection, but significant variation is noted for type 3 and contamination scenarios.
Conclusions:
- While protocols for antibiotic timing and basic selection are common, significant variability exists in achieving timely administration and managing complex open fractures (GA type 3).
- The findings underscore the need for pediatric-specific research to develop standardized, evidence-based protocols for open fracture management.
- Standardization is crucial for improving outcomes, particularly for severe pediatric open fractures with higher morbidity risks.
Background:
Open fractures require urgent management, including timely prophylactic antibiotics, to minimize infection and morbidity. Most pediatric treatment protocols are extrapolated from adult data, resulting in practice variation at pediatric centers regarding antibiotic timing and selection. In this study, we aimed to identify consensus regarding open fracture management protocols at Level-1 Pediatric Trauma Centers across the United States.
Methods:
A survey was administered to 17 institutions participating in "Children's Orthopaedic Trauma and Infection Consortium for Evidence-Based Study" (CORTICES), representing ~25% of all Level-I Pediatric Trauma Centers nationwide. Data analysis was conducted using descriptive statistics with responses presented as frequencies and percentages.
Results:
In 9/17 (53%) of participating centers, antibiotics for open fractures are ordered by Emergency Department (ED) physicians exclusively. All 17 centers (100%) surveyed have formal protocols to give IV antibiotics <1 hour of presentation to the ED. Fifteen of 17 centers (88%) monitored antibiotic administration success rates regularly, through a hospital or trauma quality committee. Success rates of <1 hour antibiotic administration in the last year were 21% to 40% in 2/15 centers (13%), 41% to 60% in 3/15 centers (20%), 61% to 80% in 3/15 centers (20%), and 81% to 100% in 7/15 centers (47%). Of 17 sites surveyed, 15 (88%) have formal protocols for Gustilo-Anderson (GA) type-based antibiotic selection. Most centers with antibiotic selection policies (13/15, 87%) involved multiple departments in policy development, primarily infectious disease, orthopaedic surgery, ED, pharmacy, and pediatrics in descending order. Across sites, antibiotic selection showed consensus for GA-type 1 (cefazolin) and near-complete consensus for GA-type 2 (14/15, 93% cefazolin), allergy alternatives for GA-type 1 (14/15, 93% clindamycin), and allergy alternatives for GA-type 2 (13/15, 87% clindamycin). There was minimal consensus in antibiotic recommendations for GA-type 3 (standard or allergy alternatives) or for soil/water contamination.
Conclusions:
While most surveyed Level-1 Pediatric Trauma Centers have formal protocols for timing and GA-type-dependent antibiotic selection, there is substantial variation among centers in success rates of prompt antibiotic administration and in selection of antibiotics for GA-type 3 open fractures. This variability highlights the need for pediatric-specific research to establish standardized evidence-based protocols, especially for severe injuries that carry a greater morbidity risk.
Related Concept Videos
01:27Fractures: Bone Repair
Minor fractures with no bone displacement are treated by immobilizing the fractured bone using a cast or splint. However, in the case of fractures with displaced bones, the broken bones are repositioned before immobilization to ensure successful healing without deformation and loss of function. The realignment of fractured bone ends is performed through a process called reduction. If the...
01:26Flail Chest-II
Assessment:
1. Clinical Evaluation:
History:
01:19Standards of Care II