CLINICAL ORTHOPAEDICS AND RELATED RESEARCH
Number
332,
pp
62-70
0
1996
Lippincott-Raven
Publishers
Open
Fractures
of
the
Tibia
in Children
Guy
Grimard, MD; Douglas Naudie,
BSc;
Louise
C.
Luberge, MD;
and Reggie
C.
Hamdy, MD
Ninety open fractures of the tibia treated at the
authors' institution between
1985
and
1994
were
retrospectively reviewed. There were
38
Grade
I,
35
Grade
11,
and
17
Grade
I11
fractures.
All
patients had debridement and lavage
of
the
wound under general anesthesia. Seventeen
wounds
(19.8%)
were closed primarily and
69
(80.2%)
were left open. Forty fractures
(45.0%)
were stabilized in
casts,
31
(34.8%)
in an exter-
nal fixator, and
18
(20.2%)
with casts and inter-
nal fixation. Six patients
(7.1
%)
had superficial
infection occur,
2
had vascular injuries,
1
of
whom required an amputation, and only
1
had a
neurologic injury. The average time to union
was
4.5
months (range,
1.2-28.3
months). There
were
10
delayed and
7
nonunions. Multiple re-
gression analysis showed that only age of the pa-
tient and grade of the fracture were significantly
associated with union time. Open fractures of
the tibia in children older than
12
years of age
have a high risk of developing delayed
or
nonunion when compared with the same in-
juries in children younger than
6
years of age.
Closed fractures of the tibia in children are
reported to heal rapidly with few complica-
tions.
14
Unfortunately, the thin soft tissue en-
velope covering the tibial shaft makes this
bone particularly susceptible to open frac-
From
the
Department
of
Orthopaedics
and
Plastic
Surgery,
Ste-Justine
Hospital,
University
of
Montreal,
Montreal,
Quebec,
Canada.
Reprint
requests
to
Reggie
C.
Hamdy.
MD,
Shriner's
Hospital for
Crippled
Children,
1529
Cedar
Avenue,
Montreal,
Quebec,
H3G
lA6,
Canada.
tures which, unlike closed fractures, are
known to be associated with
a
high compli-
cation rate.3.8J6J8 Although the general man-
agement, principles, and prognosis of open
tibial fractures in the adult population have
been extensively described in the litera-
ture,l,2,5,6,7,9.12,'3,19,22
there still remains very
little information
on
these fractures in chil-
dren. Only recently have several centers be-
gun
to address the management of these frac-
tures in the pediatric pop~lation.3.8.'6.1~.'~ The
present study reviews the authors' experi-
ence with these fractures
in
children,
to
de-
termine the characteristics
of
this population
and to clarify the contributing factors that
may affect the process of fracture healing.
MATERIALS AND METHODS
All open fractures
of
the tibia treated at
the
Uni-
versity Hospital Centre of Ste-Justine, Montreal
(a 540-bed primary and tertiary pediatric care
center for
a
large part of the province of Quebec,
Canada),
in
the period 1985
to
1994 were retro-
spectively reviewed. Ninety fractures in
90
pa-
tients were identified. There were
58
boys
(64.4%)
and
32
girls
(35.6%).
Age and gender
distribution
is
shown
in
Figure
1.
The average age
of the patients was
10.6
years, ranging from
3.1
to
18
years.
Most injuries were
caused
by
pedestrian or bi-
cycle versus motor vehicle accidents
(83.3%),
followed
by
sports related trauma
(13.3%).
Vari-
ous
other accidents were the cause of the remain-
ing injuries (3.4%). The open fracture of the tibia
was the only significant injury
in
66
patients
(73.3%).
The ipsilateral fibula was fractured
in
71
62
Number
332
November,
1996
Factors Affecting Union Time
63
Fig
1.
Number
of
patients and gender are
shown according to age distribution.
TABLE
1.
Details
of
Wound Closure
According to the Grade of the Fracture
Wound Wound
Total
Closed Left
Number
Grade Primarily
Open of
Cases
I
12 26
38
II
5
30
35
IllA
0 10
10
Ill5
0
2
2
IllC
0
1
1
Total
(%)
17
69
86*
(19.8)
(80.2)
(100.0)
patients (79%), and 24 patients (27%) sustained
other fractures in the same or contralateral limb.
Twenty-two patients (24.4%) had an associated
head injury and
18
(20%) had in addition chest,
abdominal, or maxillofacial injuries. Three pa-
tients died within 72 hours of the accident from
severe head injuries.
Details
of
the Fractures
The left tibias were more commonly injured than
the right tibias (54.4% versus 45.6%). Most frac-
tures occurred in the middle and distal thirds of the
tibia (45.6% and 43.3%, respectively), whereas
fractures of the proximal third accounted for only
1
1.1
%
of all cases. The Gustilo and Anderson clas-
sificationl2 was used to classify fractures accord-
ing to their severity as shown in Table
1.
Treatment
At admission, the fractured limbs were splinted
and all patients received analgesics, broadspec-
trum antibiotics, and tetanus prophylaxis if neces-
sary. The average duration of antibiotics was 5
days (range, 1-24 days). The average delay from
the accident to time of the operation was approxi-
mately
6
hours, ranging from
1
to 17 hours. All
patients had debridement and lavage of the frac-
ture site under general anesthesia. Only 17
wounds
(19.8%)
were closed primarily, and
69
wounds (80.2%) were left open. Details of wound
closure are shown in Table
1.
Ten wounds needed
a skin graft (11.8%), 1 of which also required a
local rotational flap
(8
days after the injury) and
another, a free vascular flap (14 days after the in-
jury). The average delay from time of injury to
skin grafting was 8.8 days (range, 1-18 days).
*Four patients are excluded:
3
who died
(2
Grade
IllA
and
1
Grade
IllB)
and
1
who had an amputation (Grade
IIIA).
Stabilization
of
the Fracture
As shown in Table 2, 40 fractures (45.0%) were
immobilized in a plaster cast and 31 (34.8%) had
an external fixator applied. The Hoffman external
fixator (Howmedica, Geneva, Switzerland) was
always used. The most commonly used configu-
ration was a double frame using
'12
pins (16
of
3
1,
or 52%).
No
transfixing pins were used. The aver-
age time the fixator was kept on was 46 days
(range, 20-92 days). The fixator was removed
and a plaster cast applied when stability of the
fracture was obtained and the soft tissue compo-
nents of the injury healed.
Eighteen fractures (20.2%) were stabilized
with minimal internal fixation and supplemented
with plaster casts, 12 (13.5%) had Kirschner
wires
(K
wires) or Steinmann pins (Zimmer
Canada Ltd, Quebec, Canada), and 6 (6.7%) had
interfragmentary screws.
No
patients were treated
in traction or by internal fixation with plates or
intramedullary nails (except the patient whose
fracture was stabilized with an intramedullary
nail and then transferred to the authors' institu-
tion). The average hospital stay was 13.7 days
(range, 2-57 days).
Union of the fracture was determined clini-
cally and radiologically. The absence of pain, ten-
derness, and motion at the fracture site indicated
clinical union, whereas the presence of bridging
callus across the fracture site indicated radiologic
union. Union was considered to be delayed when
the fracture took more than
6
months
to
heal.
Clinical Orthopaedics
64
Grirnard et
al
and Related Research
TABLE
2.
Methods
of
Stabilization
According
to
the Grade
of
the Fracture
cal Analysis System version
6.04
(General Linear
Models Procedure, Quebec, Canada).
~~~
Method
of
Stabilization
Plaster
Grade
Casts
Internal
Total
Fixation
Number
External and
of
Fixator Cast
Cases
I
24
II
13
IllA
2
Ill6
1
IllC
0
Total
(%)
40
(45.0)
~~~~~ ~
7
7
38
15
7
35
6
4
12
2
0
3
1
0
1
31
18
89*
(34.8)
(20.2)
(100.0)
*One
patient had an intramedullary nail
of
the
tibia (Grade
IllA
fracture) in
a
peripheral hospital and was then transferred
to
the
authors’ institution.
Nonunion was considered
to
be present when
there was an absence or arrest of fracture healing
as seen on serial radiographs. All patients (except
1
who was transferred after initial treatment
in
the
authors’ institution) were observed to complete
union of the fracture and resolution of the compli-
cations if present. The average followup was 18.6
months (range, 1.5-1
00
months).
Statistical Analysis
A
univariate analysis was first performed in
which dichotomous variables were compared by
chi square test and continuous variables were
compared by student’s t-test. Multiple linear re-
gression models were then used to examine the
relationship between the healing time of the tibial
fracture and the following predictive variables:
age, gender, side, mechanism of injury, delay be-
tween trauma and surgery, Gustilo and Anderson
grade, localization of the fracture, presence
of
an
associated fibular fracture, head injury, type of
stabilization, and method of wound closure.
A
step down procedure was used to identify the pre-
dictors. All predictive factors were tested and the
least significant was dropped
1
at a time. Deter-
minants were kept in the model if the P value was
less than
0.05.
The interactions between variables
were not assessed. The denominator was re-
stricted as appropriate
1
patient had an amputa-
tion,
1
was transported to another hospital, and
3
died). The analysis was performed with Statisti-
RESULTS
Fatalities
Three patients (2 boys and
1
girl; aged
10,
14,
and 15 years) died within 72
hours
of the acci-
dent from severe head injuries. All
3
patients
were involved in motor vehicle accidents and
sustained multiple injuries to other systems.
Vascular Complications
Two patients suffered vascular injuries. The
first, an 11 -year-old boy struck by a car, sus-
tained an isolated Grade IIIA fracture of his
distal left tibia. At surgery, it
was
noticed
that he also had avulsion of the dorsalis pedis
artery. However, the leg was well perfused
and no surgical intervention was necessary.
His
fracture was stabilized with
K
wires and
a cast and healed within
5
months. At the lat-
est followup,
13
months after the injury, he
did not have any sequelae from the accident.
The second patient, a 15-year-old boy in-
volved in a motor vehicle accident, sustained
a Grade IIIA fracture of the middle third of
the left tibia. After stabilization
of
the frac-
ture with an intramedullary nail in a periph-
eral hospital, thrombosis of the popliteal
artery and ischemia of the
leg
developed the
patient was then transferred to the authors’
institution. After
3
failed vascular attempts
to reestablish the circulation, a below knee
amputation was performed. At 17-months
followup, he was ambulating well with his
prosthesis.
Neurologic Complications
There was only
1
neurologic injury in the se-
ries: a 7-year-old boy who was struck by a
car and sustained a Grade
I
injury
of
the right
tibia. He also had
a
partial injury to the com-
mon peroneal nerve with inability to extend
the toes. The fracture was stabilized with
Steinmann pins and a cast, and healed within
55 days. The patient completely recovered
from the nerve injury.
Number
332
November,
1996
Factors Affecting Union
Time
65
TABLE
3.
Details of the
6
Patients in Whom Infections Developed
Grade Type Method Delay From Healing Method
of
of
of
of Accident
to
Time Wound
Fracture Infection Stabilization Surgery (hours) (days) Closure
~ ~~~
II
Pin tract External fixation
7.00
121
Secondary
Ill5
Pin tract External fixation
3.00 218
Secondary
+
skin graft
II
Pin tract External fixation
9.10 276
Secondary
+
skin graft
I
Superficial Screws and cast
6.00
43
Primary
I
Superficial Screws and cast
4.45 49
Primary
I
Superficial External fixation
7.00
100
Secondary
Infections
Six patients (7.1%) had infections occur: 3
superficial, and 3 pin tract infections from
external fixators. There were
5
boys and 1
girl. Average age of the patients was 12.6
years (range, 10.2-14.8 years). All
6
cases re-
sponded favorably to antibiotics and local de-
bridement. Details
of
the
6
cases are shown in
Table 3. Of 17 wounds closed primarily, 2
(11.8%) got infected, whereas 4 of
69
wounds (5.8%) left open developed infec-
tions. This difference in incidence of infec-
tion and type of wound closure, however, was
not statistically significant (p
>
0.05).
Of
the
52 wounds that were debrided within 6 hours
of the accident, 3
(5.8%)
had infections oc-
cur, whereas
of
the 34 wounds
(8.8%)
that
were debrided more than
6
hours after the in-
jury, 3
(8.8%)
had infections occur.
Healing Time
The average time to union for all fractures
was 4.5 months (range, 1.2-28.3 months).
Sixty-eight fractures (80.0%) healed within
6
months of the injury, whereas
10
(1
1.8%)
de-
veloped delayed union and
7
(8.2%) a
nonunion. In patients younger than 6 years of
age,
7
of the
8
fractures (87.5%) healed in
less than
6
months. However, in patients
older than 12 years, only 21 of the 34
(61.8%)
fractures in that age group healed in less than
6 months (Table 4).
The average healing time for Grade
I
frac-
tures was 3 months (range, 1.3-8.7 months);
Grade
11,
4.6
months (range, 1.4-21.2
months); Grade IITA, 6.2 months (range,
1.2-28.3 months); Grade IIIB,
17.8
months
(range, 1.2-20.9 months) and the only Grade
IIIC
in the study healed at 11.6 months (Table
5).
The average healing time of fractures
treated in an external fixator (average, 6.6
months, range, 4.5-8.6 months) was nearly
twice as long as those treated in casts (average,
3 months, range, 2.6-3.4 months) or casts and
internal fixation (average, 2.9 months, range,
2.7-3.3 months)
as
shown in Table 6.
Both univariate and multiple regression
analyses showed that only age of the patient
and grade of the fracture had significant
association with time to union. All other
variables (gender, side and location of the
fracture, mechanism of injury, associated in-
juries, delay to surgery, type of fixation, and
method of wound closure) were not statisti-
TABLE
4.
Healing Time of Various Age
Groups
Age Group
Healing Total
Time
c6
6-72
>72
Numberof
(months)
years years years
Cases
(%)
0-5
7
40 21 68
(80.0)
6-1 2 1 2 10 13(15.3)
Total
8
43 34
85*
(100.0)
>I2
0
1
3
4 (4.7)
'Three patients died within
72
hours
of
admission,
1
had an
amputation, and
1
was transferred
to
another hospital after
initial treatment at
the
authors' institution.
66
Grimard
et
al Clinical Orthopaedics
and IRelated Research
_______~~
TABLE
5.
Summary
of
Results
Complications
Average (number
o’f
cases)
Average Time to
Grade Number Ageof Union
Delayed
of
of
Patient Initial (months)
lnfection Union Nonunion
Fracture Fractures (years) Treatment (range)
PO)
(“A)
6)
IllA
10 10.8
IllB
IllC
Total
~~~ ~ ~
38
9.8 24
casts
7
external
fixation
7
internal
fixation
+
casts
34 9.9 13
casts
15
external
fixation
6
internal
fixation
+
casts
0
casts
6
external
fixation
4
internal
fixation
+
casts
0
casts
2
external
fixation
0
internal
fixation
+
casts
0 casts
1
external
fixation
0
internal
fixation
+
casts
8Y
10.6 37
casts
31
external
fixation
17
internal
fixation
+
casts
2 11.7
1 12.0
3.0
3
3
0
(1.3-8.7)
4.6 2 4
3
(1.4-21.2)
6.2
0
2
3
(1.2-28.3)
17.8 1 1 1
(1.2-20.9)
11.6
0 0
0
4.5
6
10 7
(1.2-28.3) (7.1%) (11.8%) (8.2%)
~~~~~~~~~~~~ ~~
*This number excludes the
3
Datients who died the
1
who had an amputation and the
1
who was transferred from the authors’
institution
cally significant. Table 7 shows the statisti-
cal results of the multiple regression analysis
model. The intercept of the model was 4.7.
The estimated time to union can be calcu-
lated by using the following equation:
estimated time to union
years
x
estimated coefficient for
age
[0.3])
+
estimated coefficient
for grade of fracture.
(months)
=
intercept [4.7]
+
(age in
For
example, the estimated time to union
for a 6-year-old
boy
with a Grade
I
fracture
is
4.7
+
(6
x
0.3)
+
(-4.8)
=
1.7
months;
whereas that for a 12-year-old boy with a
Grade
111
fracture
is
4.7
+
(12
x
0.3)
+
0
=
8.3 months. According to this analysis, the
coefficient of determination for this equa-
tion,
R2,
which is the proportion
of
the varia-
tion in healing time that is explained by the
age of the patient and grade of the fracture
is
only 22%. The remaining
78%
of the varia-
6
7
8
9
1
/
9
100%
