Children with open distal tibia fractures experienced longer hospital stays and double the reoperation rate (after index surgery, excluding hardware removal and vac changes) compared with shaft fractures, according to a recent study.
Researchers conducted a retrospective comparative study to determine whether open distal tibia fractures in pediatric patients are more severe than open tibial shaft fractures. The study, published in the Journal of Pediatric Orthopaedics, reviewed 93 operatively treated open tibia fractures at a level 1 pediatric trauma center between January 2007 and May 2017. Children younger than 18 years with open distal third or diaphyseal tibial fractures were included, while those with physeal, articular, bilateral, or pathologic fractures were excluded. Management was performed by 13 fellowship-trained pediatric orthopaedic surgeons. "The treating surgeon should consider having several fixation options for both the tibia and fibula available in the operating room, given the increased frequency of alternative fixation other than flexible nails seen in our cohort. Families should also be counseled on a possibly prolonged treatment course, both in the hospital as well as during outpatient postoperative management," noted lead author Taylor K. Zak, MD, of the Children’s Medical Center Dallas, Department of Orthopaedics at the University of Texas Southwestern Medical Center, and colleagues.
The cohort consisted of 39 distal tibia fractures (D group) and 54 tibial shaft fractures (S group). Mean patient age was approximately 9 years, and most injuries resulted from high-energy trauma. Demographic features and injury severity were comparable between groups. However, the D group demonstrated a greater proportion of Gustilo-Anderson type III injuries (46% vs 26%).
Treatment patterns differed between groups. The D group had longer average operative times (2.5 vs 2.1 hours) and hospital stays (8.7 vs 6.5 days). Time to full weight-bearing was also longer in distal fractures (11.4 vs 7.2 weeks). Distal fractures more frequently underwent open reduction internal fixation (15% vs 4%), external fixation (15% vs 7%), and adjunctive wound management, including vacuum-assisted closure (31% vs 15%) and free flap coverage (18% vs 7%).
Complications were frequent in both groups. Delayed union occurred in 26% of distal fractures and 31% of shaft fractures, while nonunion developed in 38% and 28%, respectively. Infections occurred in 10% of distal and 7% of shaft fractures. A notable difference was the higher rate of return to the operating room in the D group (41% vs 20%). Amputations were required in two patients in each group, all with Gustilo-Anderson IIIB or IIIC injuries. Final radiographic alignment was similar between groups.
“This study highlights challenges in treating open distal tibia fractures compared with open tibial shaft fractures in children, with statistically significantly longer initial operative time, longer length of hospitalization delayed time to weight-bearing, and increased return to the operative room in distal tibia fractures,” the researchers wrote.
The researchers reported no conflicts of interest.
Source: Journal of Pediatric Orthopedics