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Open fractures of the tibia in the pediatric population: A systematic review

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J Child Orthop (2009) 3:199–208
DOI 10.1007/s11832-009-0169-6
ORIGINAL CLINICAL ARTICLE
Open fractures of the tibia in the pediatric population:
a systematic review
Keith D. Baldwin Æ Oladapo M. Babatunde Æ
G. Russell Huffman Æ Harish S. Hosalkar
Received: 22 December 2008 / Accepted: 16 March 2009 / Published online: 3 April 2009
Ó EPOS 2009
Abstract
Purpose The management of open fractures of the tibia in
a pediatric population represents a challenge to the clini-
cian. Several case series over the course of many years
have been performed describing the results of treating these
injuries. It remains unclear, however, whether there is a
preferred modality of treatment for these injuries, if a more
severe injury confers a greater risk of infection, and if time
to union is affected by Gustilo type, although trends seem
to exist. The purpose of this study was to assemble the
available data to determine (1) the risk of infection and
time to union of various subtypes of open tibia fractures in
children and (2) the changes in treatment pattern over the
past three decades.
Methods A systematic review of the available literature
was performed. Frequency weighted mean union times
were used to compare union times for different types of
open fractures. Mantel Haentzel cumulative odds ratios
were used to compare infection risk between different
types of open fractures. Linear regression by year was used
to determine treatment practices over time.
K. D. Baldwin
G. Russell Huffman
H. S. Hosalkar (&)
Department of Orthopaedic Surgery, Hospital of the University
of Pennsylvania, 34th and Spruce, 2nd Floor,
Silverstein Building, Philadelphia, PA 19104, USA
e-mail: HHPEDPOD@gmail.com
O. M. Babatunde
University of Pennsylvania School of Medicine,
3620 Hamilton Walk, Philadelphia, PA 19104, USA
H. S. Hosalkar
Department of Orthopaedic Surgery, Children’s Hospital
of Philadelphia, 34th Street and Civic Center Boulevard,
2nd Floor, Wood Building, Philadelphia, PA 19104, USA
Results No significant change in practice patterns was
found for type I and III fractures, although type II fractures
were more likely to be treated closed in the later years of
the study compared to the earlier years. Type III fractures
conferred a 3.5- and 2.3-fold greater odds of infection than
type I and type II fractures, respectively. There was no
significant difference in odds of infection between type I
and II fractures. There was a significant delay in mean time
to union between type I and type II fractures, and between
type II and type III fractures.
Conclusions With the exception of type II fractures, the
philosophy of treatment of open fractures of the tibia has
not significantly changed over the past three decades.
Closed treatment or internal fixation are both viable options
for type II fractures based on their relatively low incidence
of infection. This study also demonstrates a strong rela-
tionship between Gustillo sub-types and odds of infection
in this population. Not surprisingly, union rates are also
delayed with increasing injury severity.
Keywords Children
Infection
Open tibia fracture(s)

Pediatric
Systematic review
Time to union
Introduction
The management of open fractures of the tibia in the
pediatric population is a challenging problem. Traditional
methods of managing these fractures, such as closed
treatment with plaster casts, have evolved from open irri-
gation and debridement, casting, either isolated or with
pins and plaster and, more recently, external or internal
fixation methods. Internal fixation, especially with intra-
medullary devices, is an emerging technique that has
rapidly gained popularity over the past decade.
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The biology of these fractures in children differs notably
from that in adults due to the presence of a thick perios-
teum, of better vascularity, better healing ability, and
improved potential to remodel. These characteristics have
long provided surgeons with the option to manage these
fractures by irrigation and debridement followed by cast-
ing. Interestingly, the changing pattern of injuries with
progressive urbanization, the increasing social demand on
children to return early to active athletics and sports, and
pressure from parents and family for the clinician to obtain
early, fast, and perfect results could potentially bias clini-
cians towards operative fixation of these fractures in some
cases.
Advances in knowledge in the areas of bacteriology and
microbiology, antibiotics, and wound care have propagated
a current era of thorough debridement under anesthesia
with wound irrigation and antibiotics. While patients are
under anesthesia, the clinician can easily be convinced to
opt for some sort of operative stabilization (either with
internal or external fixation) if moderate or severe soft
tissue injuries are present.
Open fractures of the tibia in a pediatric population can
be associated with notable morbidity, including but not
limited to compartment syndrome, deep infection, non
union, and even amputation [1–14]. Although some clini-
cians purport that these injuries may behave similarly in
children and adults, others feel that these injuries are better
tolerated in children, particularly young children [9]. Most
of the available literature seems to indicate that higher
Gustillo type fractures (in adults and children) tend to have
more complications and less predictable outcomes [1–14].
However, many of these studies have low numbers, and as
such, it is difficult to show a statistically significant dif-
ference, even though one almost certainly exists.
Our study was carried out to answer the following
questions: first, how has the treatment pattern for open
fractures of the tibia evolved in a pediatric population
(\18 years) during the past three decades based on their
Gustilo types? second, what is the comparative risk of
infection in different sub-types of open tibial fractures?
third, is there any difference in time to fracture healing for
different types of open tibia fractures in pediatric
population?
Materials and methods
We searched the Medline, EMBASE, and Cochrane com-
puterized literature databases from January 1980 to June
2008 for articles containing the following terms: open tibia
fracture(s), children, treatment(s), and outcome(s). Refer-
ence lists from the articles retrieved were further
scrutinized to identify any additional studies of interest. All
123
J Child Orthop (2009) 3:199–208
studies from these searches were then reviewed. Studies
were included in this systematic review if they matched the
following criteria: (1) they were in English; (2) they had a
level I, II, III, or IV study design by Journal of Bone and
Joint Surgery criteria (because the majority of studies in
clinical orthopedic literature are retrospective studies of
level III or level IV evidence, and our goal was to be
inclusive); (3) the series reported had a minimum of 15
open tibia fractures; (4) patients in the study had an open
tibia fracture or closed fractures and non-tibia fractures
could be easily separated in the body of the text; (5) all
patients included in the study were \18 years old; (6) the
minimum follow-up was 6 months. Studies were excluded
based on the following criteria: (1) closed fractures could
not easily be separated from open fractures in the body of
the text; (2) inadequate follow-up; (3) data were not cate-
gorized as open subtypes by the Gustilo and Anderson
classification (Table 1); (4) more than one type of fracture
was included (i.e. tibia and femur) and the tibia fractures
could not easily be separated. Two authors performed the
initial search (OB, KB), following which three of the
authors (OB, KB, HH) independently reviewed the results
and selected the appropriate studies based on the above
criteria.
We identified 61 articles from our search of the dat-
abases: 30 from PubMed [1, 11, 15–42], six from Cochrane
[43–48], and 25 from EMBASE [4–7, 9, 11, 31, 37, 49–
65]. Three of these studies were found in both the PubMed
and EMBASE databases [11, 31, 37]. Twenty-two studies
[21, 23, 24, 31–35, 38, 39, 41, 46, 51, 52, 54–56, 58–61,
64] were excluded because they reported closed tibia
fractures exclusively or in addition to open tibia fractures,
and not enough data was supplied to analyze the open tibia
fractures separately. Fifteen studies [15, 17–19, 22, 25–30,
36, 40, 42, 48] were excluded because they included adults,
and we were unable to separate the adult data from those of
patients \18 years of age. Three papers [29, 37, 43] were
excluded because they were review papers and not studies
that included patient treatment and follow-up information.
Three studies [50, 57, 62] were excluded because they did
not meet the inclusion criteria of having at least 15 patients
in the study. The Dubar et al. [20], Morton et al. [45], and
Rome et al. [47] studies were excluded from our review
because these were protocol/technique papers that did not
present patient data or follow-up. The Lobost et al. [53]
study was excluded because fractures were treated solely
with antibiotics, and no operative treatment occurred. Four
studies [44, 50, 63, 65] were not included in our review
because they included fractures other than open tibia
fractures. A thorough review of the bibliographies of the
remaining studies was carried out by all authors who
selected articles that had the words: open, tibia, fracture(s),
and children(s). Additional publications [2, 3, 8, 10, 12–14,
J Child Orthop (2009) 3:199–208 201

Table 1 Gustilo and Anderson classification of open tibia fractures
[70, 71]
Type Description
Type I Clean wound \1 cm in diameter with simple
fracture pattern and no skin crushing
Type II A laceration [1 cm and \10 cm without significant
soft tissue crushing. The wound bed may appear
moderately contaminated
Type III An open segmental fracture or a single fracture with
extensive soft tissue injury [10 cm. Type III
injuries are subdivided into three types
Type IIIA Adequate soft tissue coverage of the fracture despite
high energy trauma or extensive laceration or skin
flaps
Type IIIB Inadequate soft tissue coverage with periosteal
stripping
Type IIIC Any open fracture that is associated with vascular
injury that requires repair
66, 67] were identified via this method, and the full text of
each paper was subsequently reviewed to determine which
studies met the inclusion criteria. Eight studies met our pre-
determined inclusion criteria and were included in our
systematic review. The Blaiser and Barnes [66] study was
excluded from our systematic review because the authors
did not break down fracture outcome by Gustillo type. We
also excluded the Cramer et al. [67] study because the
paper included fractures of the femur and presented the
data in a way in which we could not extract or isolate data
concerning tibia fractures. In contrast, the study of
Robertson et al. [12] was included because the data were
well separated, enabling the data pertaining to open tibia
fractures to be extracted, and the remainder of our inclu-
sion and exclusion criteria were satisfied. The Yasko paper
[14], while having limited treatment data, was included in
our study because after discussion among the four authors
of this review, the consensus opinion was that this study
had adequate data, satisfied all inclusion criteria, and met
no exclusion criteria. This left 14 papers that met all of our
inclusion criteria and none of our exclusion criteria [1–14].
There were a total of 726 open fractures of the tibia in
patients younger than 18 years of age that met all of the
inclusion criteria in the 14 studies. Table 2 summarizes
the demographics of these studies. For studies that pro-
vided the ages of the pediatric patients (12 studies,
n = 581), the weighted average age at time of injury was
9.3 years (range 2–18 years) [1–6, 8–13]. Gender infor-
mation was provided for 675 patients (13 studies), of
whom 173 (26%) were female and 502 (74%) were male
[1–13]. There were 723 open tibia fractures that were
classified by Gustillo type, of which 231 were type I
fractures (31.9%), 267 were type II fractures (37.0%), and
225 were type III fractures (31.1%). Of the type III
fractures, 209 were further subclassified into IIIA (108;
51.7%), IIIB (76; 36.4%), and IIIC (25; 12%). The pres-
ence of a fibula fracture was not routinely documented in
the respective studies; for consistency, we therefore chose
to eliminate this from the focus of the study. In those
studies that had average follow-up information (nine
studies, n = 435), the frequency weighted mean follow up
was 18.9 months (range 1–150 months) [1–6, 9, 11–13].
Frequency weighted mean union (defined by clinical,
radiological, or both criteria) rates for all tibia fractures
was 14.6 weeks (range 9.1–21.0 weeks).

Table 2 Demographics of studies meeting inclusion criteria

Study authors Year Age, years Number of Female/male Average follow-up, Level of
(range) fractures months (range) evidence

Bartlett et al. [1] 1997 9 (3.5–14.5) 23 5/18 34 (6–85) IV

Buckley et al. [2] 1990 9.8 (2.9–16.2) 42 9/32 15 (3–96) IV
Buckley et al. [3] 1996 9.1 (2.9–16.2) 20 4/16 20 (3–108) IV
Cullen et al. [4] 1996 9.0 (3.0–17.0) 83 18/65 14 (2–75) IV
Fujita et al. [5] 2001 7.4 (4.0–13.0) 16 3/13 48 (12–150) IV
Grimard et al. [6] 1996 10.6 (3.1–18.0) 90 32/58 18 (2–100) IV
Hope et al. [7] 1992 (3.1–16.0)a 92 21/74 Not mentioned IV
Irwin et al. [8] 1995 8 (3.2–15.0) 58 26/32 Not mentioned IV
Jones et al. [9] 2003 7.2 (2–12) 83 21/62 7 (1–35) IV
Kreder et al. [10] 1995 10.0 (3.0–17.0) 56 9/47 Not mentioned IV
Levy et al. [11] 1997 10.1 (5.0–15.0) 40 8/32 26 (18–84) IV
Robertson et al. [12] 1996 10.8 (5.0–15.0) 32 7/25 Not mentioned IV
Song et al. [13] 1996 11.0 (4.0–15.0) 38 10/28 33 (9–122) IV
Yasko et al. [14] 1989 10.0b 53 N/A Not mentioned III
a
No mean age given
b
No age range given

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All fractures were managed with irrigation and
debridement, and standard of care antibiotics. Three hun-
dred and ninety-seven fractures were treated in a cast
[1–14] or pins and plaster [6, 9] after irrigation and
debridement, 198 were treated with external fixation only,
31 were treated with internal fixation alone, and one frac-
ture was treated with both internal and external fixation.
Nine fractures underwent amputation. For the remainder of
the fractures, insufficient information was available to
assess the modality of treatment. Data were provided on
wound closure in 385 patients. Of these patients, 198 were
closed primarily, 187 were closed after initially being left
open or healed by secondary intention, and 109 required
some type of soft tissue coverage. Information on the
treatment of wounds was lacking for the remainder of the
fractures. Practice patterns seem to indicate a willingness
to close type I and type II fractures primarily, with 43.2 and
52.3% of these fractures types, respectively, closed pri-
marily in the three studies that provided this information.
In contrast, only 16.7% of type III fractures were closed
primarily, Bartlett et al. [1] and Levy et al. [11] both per-
formed either delayed primary closure after a second
irrigation and debridement or a plastic surgical procedure
(flap or graft) to close the wound.
Method of treatment was also considered in some
studies based on the fracture type. One hundred and eleven
type I fractures were treated with casting methods (a cast or
pins and plaster following irrigation and debridement), 15
were treated with external fixation, and seven were treated
with open reduction internal fixation (ORIF) techniques.
Type II fractures were treated with casting methods in 125
cases, with external fixation in 48 cases and with ORIF in
eight cases. Type III fractures were treated with casting
methods in 40 cases, with external fixation in 94 cases and
with ORIF in 13 cases. Table 3 summarizes the treatment
patterns by Gustillo type. Not all studies specified treat-
ment by type. There were very few studies that stratified
infections by treatment type, although some infections (i.e.,
pin tract infections) were restricted to some treatment types
(external fixation). Open reduction internal fixation was
accomplished with Ender’s nails [2], dynamic compression
plating [3, 13], interfragmentary screws or pins [4–6, 13],
K wires [4, 5, 7, 10], or intramedullary nailing [4, 12].
Table 3 Definitive treatment
Gustillo type Closed treatment (%)a
modalities by the Gustillo type
of open tibia fractures in Type I 111 (83.5)a
children
Type II 125 (69.1)
Type III (all) 40 (27.2)
Type IIIA 18 (29.5)
a
Includes casting or pins and Type IIIB 1 (2.9)
plaster following irrigation and Type III C 0 (0)
debridement
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J Child Orthop (2009) 3:199–208
Linear regression analysis was performed to determine if
there was a trend in treatment pattern over time.
Fisher’s exact test was used to assess for the significance
of differences between infection rates among the types of
open fractures. A student’s t test using frequency weighted
data, with equal variances not assumed, was used to com-
pare union rates among different types of open fractures. A
cumulative meta-analysis fixed effects model was then
constructed with the Mantel Haenszel technique to describe
the odds of infection by type of open fracture. Forrest plots
were created to qualitatively assess for study heterogeneity
(Fig. 1). Funnel plots were also created to assess for pub-
lication bias, and symmetric plots with no significant
publication bias were found. We also regressed number of
patients by year of publication to assess for publication bias
by year; this regression found no significant publication bias
by year (p = 0.898). Because the methods of each study
were similar, and the populations were all children under
the age of 18 years, we performed a fixed effects model.
Meta-analytic statistics were calculated with MIX software
(Kitasato Research Center, Sagamihara, Kanagawa, Japan)
[68, 69], and other statistics were calculated with SPSS
processor, ver. 15.0 (SPSS. Chicago, Il).
Results
Linear regression analysis revealed no significant changes
in the treatment pattern of type I and type III fractures over
time. Between 1989 and 2003 (the first study and the last
study), there was an increasing trend to treat type II frac-
tures by casting methods (p = 0.044) and a decreasing
linear trend to treat type II fractures with an external fixator
(p = 0.018), but there was no change in the percentage of
patients treated by ORIF.
The overall infection rate for open tibia fractures in
these studies ranged from 3.6 to 30.4%. Type I tibia frac-
tures had low infection rates (6/231; 2.6%) for all
infections, and no deep infections or osteomyelitis were
reported. The superficial infection rate in type II tibia
fractures was significantly higher than that in type I
fractures (18/261; 6.9%; p = 0.0374) and non-significantly
higher for deep infections or osteomyelitis (2/261; 0.8%;
External fixation (%) Open treatment (%)
15 (11.3) 7 (5.3)
48 (26.5) 8 (4.4)
94 (63.9) 13 (8.8)
36 (59.0) 7 (11.5)
31 (88.6) 3 (8.6)
11 (84.6) 2 (15.4)
J Child Orthop (2009) 3:199–208 203

Exposed Control Weight Association measure

Study ID Year n[e](E=1)/n[e] n[c](E=1)/n[c] (%) with 95%CI

Yasko et al 1989 4/12 0/24 2.66% | 25.94 (1.26, 533.76)

Buckley et al 1990 1990 3/12 0/12 4.35% | 9.21 (0.42, 200.59)

Hope et al 1992 4/19 0/22 4.29% | 13.06 (0.66, 260.49)

Irwin et al 1995 3/10 0/25 2.41% | 23.80 (1.10, 514.23)

Kreder et al 1995 6/26 1/14 11.90% |||| 3.90 (0.42, 36.24)

Buckley et al 1996 1996 3/20 0/0 9.47% | 0.20 (0.00, 11.89)

Studies
Cullen et al 1996 2/20 0/24 4.79% | 6.62 (0.30, 146.37)

Grimard et al 1996 1/17 3/38 20.78% |||||||| 0.73 (0.07, 7.56)

Robertson et al 1996 2/11 0/10 4.92% | 5.53 (0.23, 130.34)

Song et al 1996 1/14 0/8 6.70% | 1.89 (0.07, 51.92)

Levy et al 1997 1/14 0/16 5.02% | 3.57 (0.14, 97.48)

Fujita et al 2001 4/16 0/0 8.27% | 0.36 (0.01, 20.96)

Jones et al 2003 1/18 2/38 14.45% |||| 1.06 (0.09, 12.50)

META-ANALYSIS: 35/209 6/231 100% ||||||||||||||||||||||||||||| 3.48 (1.68, 7.20)

0.001 0.1 10 1000

OR (log scale)

Fig. 1 Representative Forrest plot for odds of infection in type III fractures compared to type I fractures, listed by year. CI Confidence interval,
OR odds ratio

p = 0.501). The infection rate for all type III fractures was
also significantly higher than that for type I fractures
(34/208; 16.3%; p \ 0.0001) and significantly higher for
deep infections or osteomyelitis (15/208; 7.2%; p\0.0001).
In studies which reported infection rates for Gustillo type
III subtypes, the infection rate for IIIA fractures for all
infections was 5/81 (6.2%) and for deep infections, 2/81
(2.5%); for IIIB fractures, for all infections, 10/47 (21.3%),
and for deep infections, 2/47 (4.2%); for IIIC fractures, for
all infections, 7/20 (35%), and for deep infections, 3/20
(15%). One study had only type II and type III fractures
and claimed no infections, but it did report a few
‘‘impending’’ infections which were treated with antibiot-
ics and resolved; the specific types involved were not
mentioned [1]. Two other studies had no type I or type II
fractures [2, 5]. Of the remaining 11 studies, four reported a
significant difference in infection rate in type III fractures
compared to type I, and no study showed a significant
difference between type I and type II fractures, or between
type II and type III fractures [1, 3, 4, 6–14]. A cumulative
fixed effects model was calculated using the Mantel
Haenszel to determine cumulative odds of any infection by
Gustillo type. The results are summarized in Table 4. Type
III fractures were 3.48-fold more likely to have an infec-
tious complication than type I fractures (p = 0.0008) and
2.28-fold more likely to have an infectious complication
than type II fractures (p = 0.009). There was no statistically
significant difference between type I and type II fractures
in terms of overall infection rate (deep plus superficial).
There was no specific temporal pattern to the infectious
complications (Fig. 1).
Studies were reviewed to determine which treatments
were associated with higher rates of infection. Bartlett et al.
[1] noted seven ‘‘impending’’ infections that were associ-
ated with external fixation; this was defined as erythema
and drainage that resolved with local care. Buckley et al.
[2, 3] found four pin tract infections, two deep infections,
and four cases of osteomyelitis; all of these patients had
been treated with external fixation. Cullen et al. [4] noted
one patient who had pin tract drainage associated with an
external fixator and one patient who had drainage with pin
and screw fixation which resolved after removal of the
pins. Fujita et al. [5] noted two superficial infections (one
IIIA, one IIIB) and two cases of osteomyelitits (both IIIB);
all patients had been initially treated with an external fix-
ator. Grimard [6] noted six infections: three pin tract
infections (all external fixation patients) and three super-
ficial infections. Two of these patients were treated with
external fixation with screws, and one was treated with
external fixation. Both Irwin et al. [8] and Jones et al. [9]
noted two pin tract infections associated with external
fixation, with Irwin et al. noting one other superficial
infection and three deep infections, which were not clas-
sified by treatment. Jones et al. noted two other superficial
infections but did not mention the surgical stabilization
treatment the patients had received. Kreder et al. [10] had

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Table 4 Mantel Haenszel pooled cumulative odds ratios for risk of infection by fracture type
Comparison
Odds of infection in type II fracture compared to type I
Odds of infection in type III fracture compared to type I
Odds of infection in type III fracture compared to type II
six infections, with two of the deep infections treated with
external fixation; this paper did not explicitly state what
surgical stabilization the others had received. In the
Robertson et al. [12] series, one girl had bilateral IIIC tibia
fractures which necessitated amputation; these developed
deep infections requiring several irrigation and debride-
ments. In the Song et al. [13] series, there were six pin tract
infections associated with external fixation. Only one case
resulted in operative debridement, and three patients with
deep infection all had internal fixation with DCP plates or
lag screws. The remainder of the studies whose patients
experienced infections, whether deep or superficial, pro-
vided insufficient information in the body of the paper to
ascertain the treatment that was associated with the infec-
tion [7, 11, 14].
The frequency weighted time to mean union was
11.6 weeks [95% confidence interval (CI)11.3–12.0 weeks]
for type I fractures and 13.5 weeks (95% CI 13.2–
13.9 weeks) for type II fractures. This indicates a significant
delay in the healing of type II fractures compared to type I
fractures (p \ 0.001). Type III fractures had a frequency
weighted mean time to union time of 16.1 weeks (15.5–
16.7 weeks), which represents a significant delay compared
to both type I fractures (p \ 0.001) and type II fractures
(p\0.001). When type III fractures were broken down into
their subcategories, the frequency weighted mean time to
union of IIIA fractures was 17.7 weeks (95% CI 16.5–
18.9 weeks), that of type IIIB fractures was 27.6 weeks
(95% CI 23.0–32.2), and that of type IIIC fractures was
33.7 weeks (95% CI 27.1–40.2 weeks). It should be noted,
however, that 10/25 type IIIC fractures in these series were
documented to have ended in amputation, so union rates
only reflect fractures that did not end in amputation [2, 3, 6,
9, 10]. Of note, Bartlett et al. [1] seem to have removed all
type I fractures (26 in total) from their study. The Hope et al.
[7] study did not include in their statistical analysis three
patients who eventually died. Cullen et al. [4] excluded nine
patients due to reasons of inadequate follow-up, primary
amputation, or death.
Discussion
The management of open fractures of the tibia in a pedi-
atric population remains a complex and challenging
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J Child Orthop (2009) 3:199–208
Mantel Haenszel 95% Confidence p value Number of
odds ratio interval studies
1.899 0.794, 4.540 0.149 8
3.482 1.682, 7.206 0.0008 13
2.284 1.224, 4.260 0.009 13
problem. Traditionally, open tibia fractures in children
have been managed with closed reduction and casting
techniques following irrigation and debridement. With
increasing advances in pediatric sedation and anesthesia,
wound care and antibiotics and a large armamentarium
available for both internal and external fixation of these
fractures, one would think that the approach to treatment of
these fractures would have trended towards fixation in
more recent years. In reality, only type II fractures have
seen a significant change in treatment pattern over the
course of time, and the change has been increasingly to
treat these fractures in a closed fashion (pins and plaster or
casting after irrigation and debridement). Interestingly,
data from several studies investigating open tibia fractures
in children have low numbers and often do not have
enough power to make meaningful conclusions.
This systematic review was performed to answer the
following questions: how has the treatment pattern for open
fractures of the tibia in children evolved during the past
three decades based on their Gustilo types? What is the
comparative risk of infection in different sub-types of open
tibial fractures? Is there any difference in time required for
fracture healing in different sub-types of open tibia frac-
tures? Therefore, this systematic review represents a
synthesis of the available data and provides the reader with
valuable information that will likely help the clinician in
decision-making and in setting family expectations.
As far as changing patterns of treatment are concerned,
multiple speakers in sub-specialty meetings over recent
years have suggested that there is a current trend towards
changes in the fracture fixation of these fractures. How-
ever, based on the factual data reported in this study, we
found that the reverse is true—at least for type II open tibia
fractures. The treatment pattern of type I and III fractures
has not significantly changed over the past two decades.
Although it may be intuitive that the infection rates are
likely higher with increasing Gustilo class of injury, there
has been a lack of adequately powered data to support this
contention. We found in this systematic review that the
odds of any type of infection were significantly greater in
type III fractures than in type I and II fractures. Based on
this study, the pooled data did not provide any evidence of
a significant difference in infection rate between types I
and II fractures. This result seems to support the trend
observed in treating type II fractures by casting methods,
J Child Orthop (2009) 3:199–208
following irrigation and debridement, which is similar to
the typical approach used to treat type I fractures. An
increasing trend in performing internal fixation of type II
fractures for early mobilization and rapid healing could
also then be justified in the current scenario, as there does
not appear to be a higher likelihood of infection compared
to type I injuries.
In this systematic review we have also attempted to
provide objective data towards ‘fracture-healing time’ for
different classes of open tibia fractures in children. The
frequency weighted pooled mean time to union was
11.6 weeks for type I fractures, 13.5 weeks for type II, and
16.1 weeks for type III fractures. This result indicates a
significantly longer time to union as the severity of the
injury increases. Again, this may be intuitive to a certain
extent, especially considering that the higher the Gustilo
type, the worse the nature of bony and soft-tissue injury.
However, having meaningful data from a larger number of
cases certainly helps to enhance the evidence-based liter-
ature. Such data also helps set expectations for the treating
clinician as well as the patient and the family members.
Current trends in clinical practices have demonstrated a
somewhat paradigm shift in the treatment of tibial fractures
in children, with some types of open fractures being treated
on similar grounds as closed injuries. There is no question
that various modalities of fixation, particularly internal
fixation devices, are gradually making their way into the
management of these fractures and that these are being
used more now than a few decades ago. Although a certain
degree of consensus seems to exist supporting irrigation
and debridement in the operating room in open fractures of
the tibia in children, there is still controversy in the liter-
ature regarding specific aspects of optimal surgical
treatment in these fractures. The management of these
fractures is likely to remain situational (based on patient
circumstances, available healthcare resources and surgeon
judgment) until good level I or II data are available. For the
most part, huge changes in clinical practices are unlikely
since the current treatment strategies seem to work well
from the perspective of patient care.
A number of points become evident from this systematic
review of the available literature. The increased rate of
casting in the later years of this study did not result in an
increased infection rate between type I and type II frac-
tures. This suggests that casting following irrigation and
debridement as a management modality for type I and II
open fractures seems to give adequate and comparable
results as far as soft-tissue healing and fracture healing is
concerned—at least in terms of infectious complications.
This evidence is probably more important in scenarios
where healthcare systems may not be fortunate enough to
have all of the resources available for advanced fixation
techniques. In these situations, the clinicians need to
205
understand that the timely and appropriate administration
of antibiotics, irrigation and debridement of the wounds,
gentle handling of soft-tissues, and appropriate wound
dressings with casting (with or without cast windows as
needed) may be all that is needed for fracture care and will
give the child an equal opportunity for a good outcome in
terms of infection control, healing (soft-tissues and frac-
ture), and functional restoration.
The review of literature also seems to point out that
external fixation is associated with a number of additional
clinical problems, such as pin tract infections, when com-
pared to other modalities of treatment. It is equally clear
that severe injuries (IIIB and IIIC) are often not appropriate
for casting, and in some of these cases, internal fixation
may prove to be perilous as well. This seems to be the best
case scenario for the usage of external fixation with deli-
cate care of soft-tissues. In fact, all type III fractures in
general could be lumped into a separate entity based on this
systematic review in which the personality of soft-tissue
damage requires a comprehensive and case-dependent
strategy. Further studies are necessary to accurately define
this relationship.
This study has a number of significant limitations. We
did not have access to the raw data for each study, which
in some ways limited our analysis. Specifically, we would
have liked to have presented the results on infections rates
in relation to the size of the wound, type of wound clo-
sure, and Gustillo type. Limitations in the manner the data
of the individual studies were presented prevented us
from doing so. Secondly, problems with inference,
including bias, confounding, and random chance inherent
to the individual observational studies utilized in this
review are not improved by pooling the data. Third, we
were not able to assess for malunion, as key information,
such as presence or absence of a fibula fracture, radio-
graphic information, or information regarding residual
deformity, was absent. Fourth, ten of the 14 studies had
patients older than 15 years, and there was no clear way
to eliminate patients whose growth plate was closed in the
absence of radiological data. In addition, some studies
would have needed to be eliminated altogether because
they lacked lists which would have allowed us to manu-
ally eliminate patients above a certain age if we lowered
our age requirement. This would decrease the external
validity of our study significantly; therefore, we had to
select patients who might present to a pediatric hospital
and use the age of 18 years as our limit as opposed to
growth plate closure. This weakens our study slightly
because several authors have supported the contention
that the biology of open fractures in a patient with open
physes differs from that in adults [9]. As there is no clear
answer to whether or not closed treatment will yield
similar results to operative treatment for different types of
123
206
open tibia fractures in a pediatric population, a random-
ized trial may be appropriate.
With the exception of type II fractures, the philosophy
of treatment of open fractures of the tibia has not signifi-
cantly changed during the past three decades. Closed
treatment or internal fixation are both viable options for
type II fractures based on their relatively low incidence of
infection. Type III fractures are more severe injuries that
require more thought on a case-by-case basis. Our study
also demonstrates a strong relationship between Gustillo
sub-types and odds of infection in this population. Not
surprisingly, union rates are also delayed with increasing
injury severity.
Conflict of interest statement There were no grants or external
sources of funding utilized for this study. This study is a systematic
review of available literature and does not require IRB review.
References
1. Bartlett CS 3rd, Weiner LS, Yang EC (1997) Treatment of type II
and type III open tibia fractures in children. J Orthop Trauma
11(5):357–362. doi:10.1097/00005131-199707000-00010
2. Buckley SL, Smith G, Thompson JD, Griffin PP (1990) Open
fractures of the tibia in children. J Bone Jt Surg Am 72:1462–
1469
3. Buckley SL, Smith GR, Sponseller PD, Thompson JD, Robertson
WW Jr, Griffin PP (1996) Severe (type III) open fractures of the
tibia in children. J Pediatr Orthop 16(5):627–634. doi:10.1097/
00004694-199609000-00015
4. Cullen MC, Roy DR, Crawford AH, Assenmacher J, Levy MS,
Wen D (1996) Open fracture of the tibia in children. J Bone Jt
Surg Ser A 78(7):1039–1047
5. Fujita M, Yokoyama K, Tsukamoto T, Aoki S, Noumi T,
Fukushima N, Itoman M (2001) Type III open tibial fractures in
children. Eur J Orthop Surg Traumatol 11(3):169–175. doi:
10.1007/BF02747661
6. Grimard G, Naudie D, Laberge LC, Hamdy RC (1996) Open
fractures of the tibia in children. Clin Orthop Relat Res 332:62–
70. doi:10.1097/00003086-199611000-00009
7. Hope PG, Cole WG (1992) Open fractures of the tibia in children.
J Bone Jt Surg Ser B 74(4):546–553
8. Irwin A, Gibson P, Ashcroft P (1995) Open fractures of the tibia
in children. Injury 26(1):21–24. doi:10.1016/0020-1383(95)
90547-B
9. Jones BG, Duncan RDD (2003) Open tibial fractures in children
under 13 years of age—10 years experience. Injury 34(10):776–
780. doi:10.1016/S0020-1383(03)00031-7
10. Kreder HJ, Armstrong P (1995) A review of open tibia fractures
in children. J Pediatr Orthop 15:482–488
11. Levy AS, Wetzler M, Lewars M, Bromberg J, Spoo J, Whitelaw
GP (1997) The orthopedic and social outcome of open tibia
fractures in children. Orthopedics 20(7):593–598
12. Robertson P, Karol LA, Rab GT (1996) Open fractures of the
tibia and femur in children. J Pediatr Orthop 16(5):621–626. doi:
10.1097/00004694-199609000-00014
13. Song KM, Sangeorzan B, Benirschke S, Browne R (1996) Open
fractures of the tibia in children. J Pediatr Orthop 16(5):635–639.
doi:10.1097/00004694-199609000-00016
123
J Child Orthop (2009) 3:199–208
14. Yasko AW, Wilber JH (1989) Open tibial fractures in children.
Orthop Trans 13:547–548
15. Alonge TO, Ogunlade SO, Salawu SA, Adebisi AT (2003)
Management of open tibia fracture–Anderson and Hutchins
technique re-visited. Afr J Med Med Sci 32(2):131–134
16. Buehler KC, Green J, Woll TS, Duwelius PJ (1997) A technique
for intramedullary nailing of proximal third tibia fractures. J Ort-
hop Trauma 11(3):218–223. doi:10.1097/00005131-199704000-
00014
17. Castillo RC, Bosse MJ, MacKenzie EJ, Patterson BM, LEAP Study
Group (2005) Impact of smoking on fracture healing and risk of
complications in limb-threatening open tibia fractures. J Orthop
Trauma 19(3):151–157. doi:10.1097/00005131-200503000-
00001
18. Cole PA, Zlowodzki M, Kregor PJ (2004) Treatment of proximal
tibia fractures using the less invasive stabilization system: surgical
experience and early clinical results in 77 fractures. J Orthop
Trauma 18(8):528–535. doi:10.1097/00005131-200409000-
00008
19. Collinge C, Kuper M, Larson K, Protzman R (2007) Minimally
invasive plating of high-energy metaphyseal distal tibia frac-
tures. J Orthop Trauma 21(6):355–361. doi:10.1097/BOT.
0b013e3180ca83c7
20. Dunbar RP, Nork SE, Barei DP, Mills WJ (2005) Provisional
plating of Type III open tibia fractures prior to intramedullary
nailing. J Orthop Trauma 19(6):412–414. doi:10.1097/01.bot.
0000153446.34484.70
21. Finkemeier CG, Schmidt AH, Kyle RF, Templeman DC, Varecka
TF (2000) A prospective, randomized study of intramedullary
nails inserted with and without reaming for the treatment of open
and closed fractures of the tibial shaft. J Orthop Trauma 14(3):
187–193. doi:10.1097/00005131-200003000-00007
22. Gicquel P, Giacomelli MC, Basic B, Karger C, Clavert JM (2005)
Problems of operative and non-operative treatment and healing in
tibial fractures. Injury 36[Suppl 1]:A44–A50. doi:10.1016/j.
injury.2004.12.012
23. Gregory P, DiCicco J, Karpik K, DiPasquale T, Herscovici D,
Sanders R (1996) Ipsilateral fractures of the femur and tibia:
treatment with retrograde femoral nailing and unreamed tibial
nailing. J Orthop Trauma 10(5):309–316. doi:10.1097/00005131-
199607000-00004
24. Harris IA, Kadir A, Donald G (2006) Continuous compartment
pressure monitoring for tibia fractures: does it influence outcome?
J Trauma 60(6):1330–1335. doi:10.1097/01.ta.0000196001.
03681.c3 discussion 1335
25. Harvey EJ, Agel J, Selznick HS, Chapman JR, Henley MB (2002)
Deleterious effect of smoking on healing of open tibia-shaft
fractures. Am J Orthop 31(9):518–521
26. Kai H, Yokoyama K, Shindo M, Itoman M (1998) Problems of
various fixation methods for open tibia fractures: experience in a
Japanese level I trauma center. Am J Orthop 27(9):631–636
27. Kakar S, Firoozabadi R, McKean J, Tornetta P 3rd (2007)
Diastolic blood pressure in patients with tibia fractures under
anaesthesia: implications for the diagnosis of compartment
syndrome. J Orthop Trauma 21(2):99–103. doi:10.1097/BOT.
0b013e318032c4f4
28. Kakar S, Tornetta P 3rd (2007) Open fractures of the tibia treated
by immediate intramedullary tibial nail insertion without ream-
ing: a prospective study. J Orthop Trauma 21(3):153–157. doi:
10.1097/BOT.0b013e3180336923
29. Kakar S, Tornetta P 3rd (2007) Segmental tibia fractures: a
prospective evaluation. Clin Orthop Relat Res 460:196–201
30. Khatod M, Botte MJ, Hoyt DB, Meyer RS, Smith JM, Akeson
WH (2003) Outcomes in open tibia fractures: relationship
between delay in treatment and infection. J Trauma 55(5):949–
954. doi:10.1097/01.TA.0000092685.80435.63
J Child Orthop (2009) 3:199–208
31. Manninen MJ, Lindahl J, Kankare J, Hirvensalo E (2007) Lateral
approach for fixation of the fractures of the distal tibia. Outcome
of 20 patients. Technical note. Arch Orthop Trauma Surg
127(5):349–353. doi:10.1007/s00402-006-0278-3
32. O’Brien T, Weisman DS, Ronchetti P, Piller CP, Maloney M
(2004) Flexible titanium nailing for the treatment of the unstable
pediatric tibial fracture. J Pediatr Orthop 24(6):601–609. doi:
10.1097/00004694-200411000-00001
33. Ostrum RF (2000) Treatment of floating knee injuries through a
single percutaneous approach. Clin Orthop Relat Res 375:43–50.
doi:10.1097/00003086-200006000-00006
34. Parekh AA, Smith WR, Silva S, Agudelo JF, Williams AE, Hak
D, Morgan SJ (2008) Treatment of distal femur and proximal
tibia fractures with external fixation followed by planned con-
version to internal fixation. J Trauma 64(3):736–739. doi:
10.1097/TA.0b013e31804d492b
35. Qidwai SA (2001) Intramedullary Kirschner wiring for tibia
fractures in children. J Pediatr Orthop 21(3):294–297. doi:
10.1097/00004694-200105000-00006
36. Sen C, Kocaoglu M, Eralp L, Gulsen M, Cinar M (2004) Bifocal
compression-distraction in the acute treatment of grade III open
tibia fractures with bone and soft-tissue loss: a report of 24 cases.
J Orthop Trauma 18(3):150–157. doi:10.1097/00005131-
200403000-00005
37. Setter KJ, Palomino KE (2006) Pediatric tibia fractures: current
concepts. Curr Opin Pediatr 18(1):30–35
38. Tornetta P 3rd, Collins E (1996) Semiextended position of
intramedullary nailing of the proximal tibia. Clin Orthop Relat
Res 328:185–189. doi:10.1097/00003086-199607000-00029
39. Tornetta P 3rd, Weiner L, Bergman M, Watnik N, Steuer J,
Kelley M, Yang E (1993) Pilon fractures: treatment with com-
bined internal and external fixation. J Orthop Trauma 7(6):489–
496. doi:10.1097/00005131-199312000-00001
40. Vranckx JJ, Misselyn D, Fabre G, Verhelle N, Heymans O, Van
den hof B (2004) The gracilis free muscle flap is more than just a
‘‘graceful’’ flap for lower-leg reconstruction. J Reconstr Micro-
surg 20(2):143–148. doi:10.1055/s-2004-820770
41. Yue JJ, Churchill RS, Cooperman DR, Yasko AW, Wilber JH,
Thompson GH (2000) The floating knee in the pediatric patient.
Nonoperative versus operative stabilization. Clin Orthop Relat
Res 376:124–136. doi:10.1097/00003086-200007000-00018
42. Ziran BH, Darowish M, Klatt BA, Agudelo JF, Smith WR (2004)
Intramedullary nailing in open tibia fractures: a comparison of
two techniques. Int Orthop 28(4):235–238. doi:10.1007/s00264-
004-0567-9
43. Jainandunsing JS, van der Elst M, van der Werken CC (2005)
Bioresorbable fixation devices for musculoskeletal injuries in
adults. Cochrane Database Syst Rev 2:CD004324
44. Manzur AY, Kuntzer T, Pike M, Swan A (2008) Glucocorticoid
corticosteroids for Duchenne muscular dystrophy. Cochrane
Database Syst Rev 1:CD003725
45. Morton L, Bridgman S, Dwyer J, Theis J (2002) Interventions for
treating femoral shaft fractures in children and adolescents.
Cochrane Database Syst Rev 1:CD003473. doi:10.1002/
14651858.CD003473
46. Rome K, Handoll HHG, Ashford R (2005) Interventions for
preventing and treating stress fractures and stress reactions of
bone of the lower limbs in young adults. Cochrane Database Syst
Rev 2:CD000450. doi:10.1002/14651858.CD000450.pub22005
47. Rome K, Ashford RL, Evans A (2007). Non-surgical interven-
tions for paediatric pes planus. ochrane Database Syst Rev 1:
CD006311
48. Willett KM, Pandit H, Upadhyay A (2008) Internal versus
external fixation for treating distal tibial pilon fractures in adults
(protocol). Cochrane Database Syst Rev 1:CD006948. doi:
10.1002/14651858.CD006948
207
49. Annan IH, Moran M (2006) (I) Indications for internal fixation of
fractures in children. Curr Orthop 20(4):241–255. doi:10.1016/j.
cuor.2006.07.001
50. Arslan H, Kapukaya A, Kesemenli C, Subasi M, Kayikci C
(2003) Floating knee in children. J Pediatr Orthop 23(4):458–463.
doi:10.1097/00004694-200307000-00009
51. Coles CP, Gross M (2000) Closed tibial shaft fractures: man-
agement and treatment complications. A review of the
prospective literature. Can J Surg 43(4):256–262
52. De Sanctis N, Della Corte S, Pempinello C (2000) Distal tibial
and fibular epiphyseal fractures in children: prognostic criteria
and long-term results in 158 patients. J Pediatr Orthop B 9(1):40–
44
53. Iobst CA, Tidwell MA, King WF (2005) Nonoperative manage-
ment of pediatric type I open fractures. J Pediatr Orthop
25(4):513–517. doi:10.1097/01.bpo.0000158779.45226.74
54. Janarv P-M, Westblad P, Johansson C, Hirsch G (1995) Long-
term follow-up of anterior tibial spine fractures in children. J
Pediatr Orthop 15(1):63–68
55. Karrholm J (1997) The triplane fracture: four years of follow-up
of 21 cases and review of the literature. J Pediatr Orthop B 6(2
Part B):91–102
56. Kubiak EN, Egol KA, Scher D, Wasserman B, Feldman D, Koval
KJ (2005) Operative treatment of tibial fractures in children: are
elastic stable intramedullary nails an improvement over external
fixation? J Bone Jt Surg Ser A 87(8):1761–1768. doi:10.2106/
JBJS.C.01616
57. Liow RYL, Montgomery RJ (2002) Treatment of established
and anticipated nonunion of the tibia in childhood. J Pediatr
Orthop 22(6):754–760. doi:10.1097/00004694-200211000-
00012
58. Moran M, Macnicol MFII (2006) Paediatric epiphyseal fractures
around the knee. Curr Orthop 20(4):256–265. doi:10.1016/j.cuor.
2006.03.002
59. Myers SH, Spiegel D, Flynn JM (2007) External fixation of high-
energy tibia fractures. J Pediatr Orthop 27(5):537–539
60. Nenopoulos SP, Papavasiliou VA, Papavasiliou AV (2005)
Outcome of physeal and epiphyseal injuries of the distal tibia
with intra-articular involvement. J Pediatr Orthop 25(4):518–522.
doi:10.1097/01.bpo.0000158782.29979.14
61. Patari SK, Lee FY-I, Behrens FF (2001) Coronal split fracture of
the proximal tibia epiphysis through a partially closed physis: a
new fracture pattern. J Pediatr Orthop 21(4):451–455. doi:
10.1097/00004694-200107000-00007
62. Skoll PJ, Hudson DA (2000) Combined pedicled flaps for grade
IIIB tibial fractures in children: a report of two patients. Ann Plast
Surg 44(4):422–425. doi:10.1097/00000637-200044040-00012
63. Taylor AH, Gargan MF (2003) Plate and screw fixation in pae-
diatric fractures. CME Orthop 3(3):77–82
64. Vallamshetla VRP, De Silva U, Bache CE, Gibbons PJ (2006)
Flexible intramedullary nails for unstable fractures of the tibia in
children. J Bone Jt Surg Ser B 88(4):536–540. doi:10.1302/0301-
620X.88B4.17363
65. Vanderhave KL, Miller D (2005) Foot and ankle problems in the
adolescent athlete. Curr Opin Orthop 16(2):45–49. doi:
10.1097/01.bco.0000157074.54110.43
66. Blaiser RD, Barnes CL (1992) Open tibia fractures in children.
Orthop Trans 16:83
67. Cramer KE, Limbird TJ, Green NE (1992) Open fractures of the
diaphysis of the lower extremity in children. J Bone Jt Surg Am
74:218–231
68. Bax L, Yu LM, Ikeda N, Tsurata H, Moons KGM MIX (2008)
Comprehensive free software for meta-analysis of causal research
data: version 1.7. Available at: http://mix-for-meta-analysis.info
69. Bax L, Yu LM, Ikeda N, Tsurata H, Moons KGM (2006)
Development and validation of MIX: comprehensive free
123
208 J Child Orthop (2009) 3:199–208

software for meta-analysis of causal research data. BMC Med
Res Methodol 6:50
70. Gustilo RB, Anderson JT (1976) Prevention of infection in the
treatment of one thousand and twenty-five open fractures of long
bones: retrospective and prospective analyses. J Bone Jt Surg Am
58(4):453–458
71. Gustilo RB, Mendoza RM, Williams DN (1984) Problems in the
management of type III (severe) open fractures: a new classifi-
cation of type III open fractures. J Trauma 24(8):742–746. doi:
10.1097/00005373-198408000-00009

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