The best questions often stem from the inquisitive learner. As educators, we love, and are always humbled by, those moments when we get to say, “I don’t know.” For some of these questions, you may already know the answers. For others, you may never have thought to ask the question. For all, questions, comments, concerns, and critiques are encouraged. Welcome to the Kids Korner.
Explore This IssueACEP Now: Vol 38 – No 07 – July 2019
Question: In children, can open forearm fractures be nonoperatively managed?
Open fractures are classified according to the Gustilo-Anderson scheme into three types: type I (small wound <1 cm; eg, poke hole), type II (wound >1 cm without significant soft tissue damage), and type III (extensive). For types II and III, operative fixation is the general consensus. For type I, though, potential nonoperative treatments are being evaluated. For this question, we are only exploring type I open fractures.
A retrospective article by Iobst et al reviewed 40 type I open fractures—32 forearm and eight tibial—in children ages 4 to 15 years.1 All children received IV antibiotics, cleansing/irrigation of the wound with betadine and saline solution, bacteriostatic petrolatum gauze over the wound (no wounds were closed primarily), tetanus as needed, and closed reduction and splinting. Children were admitted for 48 to 72 hours for IV antibiotics (most commonly cefazolin) and observation. At discharge, most children were not prescribed oral antibiotics (36 of 40). Their postoperative infection rate was 2.5 percent (1 of 40), consistent with other studies.2,3 Since this study, Iobst et al have standardized a protocol for the management of nonoperative type I open fractures at their institution, including IV antibiotics at ED presentation, irrigation, closed reduction, admission with administration of three doses of IV antibiotics, followed by discharge without antibiotics.4 They prospectively managed 45 children with this protocol from 2004–08 and reported no infections (0 of 45).
Another retrospective study by Doak and Ferrick evaluated the nonoperative management of 25 children (ages 2 to 15 years) with type I open fractures who were discharged from the emergency department or admitted to the hospital for less than 24 hours.5 ED management of the patients included irrigation of the wound with saline, application of an antibiotic-embedded dressing, and IV antibiotics. The patients were discharged with oral antibiotics for one to seven days. Injuries included five tibial fractures and 20 forearm fractures. Of these 25 patients, 11 were immediately discharged from the emergency department and 14 were admitted and discharged in less than 24 hours. A 4 percent (1 of 25) infection rate was observed, and the typical follow-up time was seven to 10 days. Fracture union was not adversely affected by nonoperative management. Another retrospective study by Bazzi et al found similar results.6
A multicenter retrospective study (four sites) by Godfrey et al evaluated type I open fractures in 219 children ages 2 to 18 years.7 Fracture locations included forearm 59.8 percent (131 of 219), wrist 32.4 percent (71 of 219) and tibia 7.8 percent (17 of 219). Twenty-two percent (49 of 219) were managed nonoperatively. Cefazolin was the first antibiotic given in most cases, and the average irrigation volume for ED washout was 1,518 mL. There were no wound infections in the operative group and one infection in the nonoperative group (P=0.06). In the operative group, though, there were nine complications, including compartment syndromes, neuropraxia, malunion, and delayed union. In the nonoperative group, one patient lost reduction, requiring repeat reduction in the surgical suite.
While the data are limited, overall these studies suggest that nonoperative management of type I open fractures might be a reasonable option compared to surgical correction.