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 tures which, unlike closed fractures, are known to be associated with a high complication rate.3.8J6J8 Although the general management, principles, and prognosis of open tibial fractures in the adult population have been extensively described in the literature,l,2,5,6,7,9.12,'3,19,22 there still remains very little information on these fractures in children. Only recently have several centers begun to address the management of these fractures in the pediatric pop~lation.3.8.'6.1~.'~ The present study reviews the authors' experience with these fractures in children, to determine the characteristics of this population and to clarify the contributing factors that may affect the process of fracture healing. 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 external fixator, and 18 (20.2%) with casts and internal 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 regression analysis showed that only age of the patient 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 injuries in children younger than 6 years of age. MATERIALS AND METHODS All open fractures of the tibia treated at the University 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 retrospectively reviewed. Ninety fractures in 90 patients 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 bicycle versus motor vehicle accidents (83.3%), followed by sports related trauma (13.3%). Various other accidents were the cause of the remaining 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 Closed fractures of the tibia in children are reported to heal rapidly with few complications. 14 Unfortunately, the thin soft tissue envelope 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. 62 Number 332 November, 1996 Factors Affecting Union Time 63 TABLE 1. Details of Wound Closure According to the Grade of the Fracture Grade I II IllA Ill5 IllC Fig 1. Number of patients and gender are shown according to age distribution. 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 patients 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 fractures 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 classificationl2 was used to classify fractures according to their severity as shown in Table 1. Treatment At admission, the fractured limbs were splinted and all patients received analgesics, broadspectrum antibiotics, and tetanus prophylaxis if necessary. The average duration of antibiotics was 5 days (range, 1-24 days). The average delay from the accident to time of the operation was approximately 6 hours, ranging from 1 to 17 hours. All patients had debridement and lavage of the fracture 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 injury). The average delay from time of injury to skin grafting was 8.8 days (range, 1-18 days). Total (%) Wound Closed Primarily 12 5 0 Wound Left Open Total Number of Cases 0 26 30 10 2 1 17 (19.8) 69 86* (80.2) (100.0) 0 38 35 10 2 1 *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 configuration was a double frame using '12 pins (16 of 3 1, or 52%). No transfixing pins were used. The average 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 components 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' institution). The average hospital stay was 13.7 days (range, 2-57 days). Union of the fracture was determined clinically and radiologically. The absence of pain, tenderness, 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. 64 Clinical Orthopaedics and Related Research Grirnard et al 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 RESULTS Internal Total Fixation Number and of Plaster External Grade Casts Fixator Cast Cases ~~~~~ I ~ 24 13 2 1 0 7 15 6 2 1 7 7 4 0 0 38 35 12 3 1 Total (%) 40 (45.0) 31 (34.8) 18 (20.2) 89* (100.0) II IllA Ill6 IllC *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 complications 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 regression 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 between 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 predictors. All predictive factors were tested and the least significant was dropped 1 at a time. Determinants were kept in the model if the P value was less than 0.05. The interactions between variables were not assessed. The denominator was restricted as appropriate 1 patient had an amputation, 1 was transported to another hospital, and 3 died). The analysis was performed with Statisti- Fatalities Three patients (2 boys and 1 girl; aged 10, 14, and 15 years) died within 72 hours of the accident 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, sustained 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 latest followup, 13 months after the injury, he did not have any sequelae from the accident. The second patient, a 15-year-old boy involved in a motor vehicle accident, sustained a Grade IIIA fracture of the middle third of the left tibia. After stabilization of the fracture with an intramedullary nail in a peripheral 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 series: 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 common 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 TABLE 3. Factors Affecting Union Time Details of the 6 Patients in Whom Infections Developed Type Grade of of Fracture Infection Method of Stabilization Delay From Accident to Surgery (hours) External fixation External fixation External fixation Screws and cast Screws and cast External fixation 7.00 ~ II Ill5 II I I I 65 Pin tract Pin tract Pin tract Superficial Superficial Superficial 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 responded favorably to antibiotics and local debridement. 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 infections. This difference in incidence of infection 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 occur, whereas of the 34 wounds (8.8%) that were debrided more than 6 hours after the injury, 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 (11.8%) developed 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 fractures was 3 months (range, 1.3-8.7 months); Grade 11, 4.6 months (range, 1.4-21.2 Method of Wound Closure Healing Time (days) ~~~ 3.00 9.10 6.00 4.45 7.00 Secondary Secondary + skin graft Secondary + skin graft Primary Primary Secondary 121 218 276 43 49 100 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 injuries, delay to surgery, type of fixation, and method of wound closure) were not statisti- TABLE 4. Groups HealingTime of Various Age Age Group Healing Time c6 6-72 >72 (months) years years years 0-5 6-1 2 >I2 Total 7 1 0 8 40 2 1 43 21 10 3 34 Total Numberof Cases (%) 68 (80.0) 13(15.3) 4 (4.7) 85*(100.0) '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 _ _ Clinical Orthopaedics and IRelated Research Grimard et al _ _ _ TABLE 5. _ _ ~ ~ Summary of Results Average Ageof Patient (years) Grade Number of of Fracture Fractures ~~~ 9.8 34 9.9 IllA 10 10.8 IllB 2 11.7 IllC 1 12.0 8Y 10.6 Total Initial Treatment ~ 38 Average Time to Union (months) (range) Complications (number o’f cases) lnfection PO) Delayed Union Nonunion (“A) 6) ~ 24 casts 7 external fixation 7 internal fixation + casts 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 37 casts 31 external fixation 17 internal fixation + casts ~~~~~~~~~~~~ 3.0 (1.3-8.7) 3 3 0 4.6 (1.4-21.2) 2 4 3 6.2 (1.2-28.3) 0 2 3 17.8 (1.2-20.9) 1 1 1 11.6 0 0 0 4.5 (1.2-28.3) 6 (7.1%) 10 (11.8%) 7 (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 statistical results of the multiple regression analysis model. The intercept of the model was 4.7. The estimated time to union can be calculated by using the following equation: estimated time to union (months) = intercept [4.7] + (age in years x estimated coefficient for age [0.3]) + estimated coefficient for grade of fracture. 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 equation, R2, which is the proportion of the variation 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- Number 332 November, 1996 TABLE 6. HealingTime of Different Types of Fixation and Different Age Groups Healing Time (months) Age External Group Casts Fixation (years) (37 cases) (31 cases) <6 6-12 >I2 Average (all cases) 67 Factors Affecting Union Time Internal Fixation and Casts (1 7 cases) 2.6 2.8 3.4 4.5 4.6 8.6 2.9 2.7 3.3 3.0 6.6 2.9 TABLE 7. Results of Multiple Linear Regression Analysis of HealingTime of Tibial Fractures on Selected Predictors Predictor Variable Estimated Coefficient* ~ ~ Age (years) Gustilo Grade I** Gustilo Grade II p RZ ~~~~~~~~ 0.3 -4.8 -3.1 0.02 0.0002 0.02 0.222 *Coefficient for age reflects changes in healing time in months. **Gustilo grade coefficients are in reference to Gustilo Grade 111. All Grade 111 fractures were combined for this analysis. tion in healing time is because of other unknown factors. delayed and nonunion were older than 6 years of age. Delayed Union Ten patients (11.8%) had a delayed union. The grade of the 10 fractures is shown in Table 5. The incidence of delayed union was slightly higher in fractures treated with an external fixator (5 of 31 fractures, or 16.1%) than those treated with casts (only 4 of 37 fractures, or 10.8%), and casts and internal fixation (only 1 of 17 fractures, or 5.9%). This difference in delayed union of various methods of stabilization was not statistically significant (p > 0.05). All 10 fractures healed with prolonged immobilization, none requiring surgical intervention. Average time to union was 7.3 months (range, 6.3-8.8 months). Malunion and Limb Length Discrepancy None of the patients in this series required treatment for malunion or limb length discrepancy. Nonunion Seven patients (8.2%) had a nonunion at the fracture site. All were treated with an external fixator and all required additional surgical procedures for healing of the fracture. Six cases needed a fibular osteotomy and bone grafting procedures, whereas 1 patient who had a segmental bone loss required an Ilizarov bone transport. All 7 nonunions ultimately healed. The average time to union for these 7 patients was 13 months (range, 7.9-28.6 months). All 17 patients who had DISCUSSION This review of 90 fractures is comparable in size with the group of 95 patients described by Hope and Cole,l6 but larger than most other series in this area.338J7J8 The mean age (10.6 years) and range (3-18 years) of the patients in the present study were not different from those reported in the literature.3.8.16.'7,18 The finding that 64.4% of fractures occurred in boys in the present series was slightly lower than that reported by other authors,3J6J* but still consistent with a higher overall incidence in males compared with females. Most of the fractures in the present series (83.3%) were caused by pedestrian or bicycle versus motor vehicle accidents, a finding similar to the 64% reported by Kreder and Armstrong18 and the 76% reported by Buckley et a l . 3 This information supports the view of Kreder and Armstrong18 that preventive strategies should target this high risk group of individuals, namely, teenaged boys either running or rid- 68 Grimard et al ing their bicycles into the streets while attempting to cross. A low preponderance of Grade I11 injuries (17 of 90, or 18.9%) occurred in the present study; this was similar to the 17% described by Irwin et a1,17 21% by Hope and Cole,l6 and 28% by Buckley et al,3 but much less than the 46% in the Kreder and Armstrong series.18 The results in the present study showed that open tibial fractures were associated with other fractures in 27% of patients, head injuries in 24.4%, and other systemic injuries in 20% of the cases. This is comparable with the 28% incidence of associated injuries reported by Irwin et al,17 but almost '12 the figure (52%) reported by Hope and Cole.16 The authors were unable to explain this large difference in the incidence of associated injuries between their series and that reported by Hope and Cole.16 The case fatality rate in this study was 3.3% (3 cases) in 90 patients. This was similar to the 3.2% reported by Hope and Cole,16 but much lower than the 7.1% reported by Kreder and Armstrong.18 The higher mortality rate in the Kreder and Armstrong series could be explained by the much higher incidence of Grade I11 fractures reported in their series. In the present review, only 3 of 90 patients suffered neurovascular injuries. This finding is consistent with the single vascular injury reported by Hope and Cole16 in their series of 95 patients. Thus, the results reported here support the hypothesis proposed by these authors that neurovascular injuries are rare in the pediatric population because of the relative elasticity of children's vessels and nerves. In the present series, 6 of 85 patients (7.1%) had superficial infections develop; no patients had deep infections or osteomyelitis develop. Hope and Colel6 and Kreder and Armstrong18 reported similar rates of superficial infection, 8% and 7% respectively, but they also reported deep infections. Numerous studies have attempted to identify factors that may predispose to infection.3.16.'7,18.2'.23 Patzakis and Wilkins2' reported that the extent of soft tissue damage increased the risk of infec- Clinical Orthopaedics and Related Research tion in open fracture wounds, the lowest rates being seen in Grade I and the highest in Grade 111. Although most studies have supported this finding,3.16J7>18Yokoyama et a123 reported no relationship between the severity of injury and infection rate. The results in the present study tend to agree with Yokoyama et a123 because only 1 of the Grade I11 fractures in the series got infected. Kreder and Armstrong18 reported that infection was significantly correlated with the amount of time taken to get the patient to surgery for debridement. Patzakis and Wilkins,21 and Yokoyama et al,23 however, were unable to show a significant relationship between the time interval from injury to surgical debridement and the development of infection, provided early antibiotic treatment had been initiated. In the present series, 3 of 52 patients (5.8%) who underwent debridement had infection develop in less than 6 hours, as did 3 of the 34 patients (8.8%) who underwent debridement more than 6 hours after injury. Hence, the data neither proves nor disproves the relationship between time to surgical debridement and infection rate. Several authors16~17have reported a higher incidence of infection in wounds left open than in wounds closed primarily, although others18.21,23 have reported that the type of wound closure has no effect on the occurrence of infection in open fracture wounds. In the present series, of the 17 wounds closed primarily, 2 (1 1.8%) got infected, whereas of the 69 wounds that were left open, 4 (5.8%) got infected. This was not statistically significant (p > 0.05). Nonetheless, it is recommended that all open fractures should be left open after initial debridement. In cases of severe Grade I11 fractures, where the soft tissue damage is so extensive that bone cannot be covered, early (within a few days of the injury) or even immediate, if possible, soft tissue coverage of the wound with a local or free flap is recommended.4,10J1.20 The average time to union for all fractures in the present series was 4.5 months, with 80% of fractures healing in less than 6 Number 332 November, 1996 months. This value was consistent with the healing times, ranging from 2.2 to 5 months, reported in the literature.17.18 Multiple regression analysis of the data showed that only age of the patient and grade of the fracture were significantly associated with union time. Seven of the 8 patients younger than 6 years of age (87.5%) healed within 6 months of injury. Conversely, almost 40% of patients older than 12 years of age (13 of 34) failed to heal within this period. These findings are in agreement with those of Kreder and Armstrong,l8 who found that the age of the patient was the most significant factor affecting union time, even when controlling for the Gustilo grade of injury. They are also in agreement with Hope and Cole16 who stressed the relationship between age and healing time, even though no statistics were given. Curiously, Buckley et a13 found no association between the age of the patient and the time to union. In the present series, the average union times for Gustilo Grade 111 fractures (6.2 months for IIIA, 17.8 for IIIB, and 11.6 for IIIC) were significantly longer than those for Grade I (3 months) and Grade I1 (4.6 months). In general, union times have been shown to be slower when open tibial fractures are associated with extensive soft tissue damage.3J6J318 In the present series, statistical assessment by multiple regression analysis did not show any other significant correlation between time to union and other predictive variables. However, fractures treated in an external fixator had nearly twice the average healing time (6.6 months) as those treated in casts (3 months) or internal fixation and casts (2.9 months). These results support those of Buckley et al,3 who found union time to be directly related to the use of external fixation. Kreder and Armstrong18 found no significant correlation between union time and method of fixation. In the present series 11.8% of the patients had a delayed union. This figure was lower than the 16% incidence reported by Hope and Cole16 and the 20.8% by Kreder and Factors Affecting Union Time 69 Armstrong.18 Also, 8.2% of the patients in the present series developed a nonunion at the fracture site. This was similar to the 8.3% reported by Kreder and Armstrong18 and the 7.5% by Hope and Cole.I6 All 17 patients who had a delayed or nonunion in the present series were older than 6 years of age. This supports the findings of Kreder and Armstrong,ls who reported that age was the most important variable correlated with delayed union, and of Hope and Cole,l6 who found that the frequency of delayed or nonunion was influenced by the age of the child, occurring in 39% of children between 13 and 16 years of age. In the present series, the incidence of delayed union in fractures treated with external fixation (16.1 %) was higher than treated by casts (10.8%) or internal fixation and casts (5.9%). However, this difference was not statistically significant (p > 0.05). All the fractures that developed a nonunion were treated with an external fixator. Hope and Cole16 also reported that delayed and nonunion were more frequent in fractures treated by external fixation (35% and 19%) than in those treated in plaster immobilization (8% and 3%). Buckley et a13 reported similar findings. Kreder and Armstrong's found that 13 of the 14 fractures complicated with delayed or nonunion had been treated initially with external fixation. Taken together, this information would seem to suggest an association between the use of external fixation and the prevalence of delayed or nonunion. It would be incorrect to conclude, however, that external fixation is associated with delayed or nonunion because this method of stabilization is used for the most severe and unstable fractures. It is not known, for instance, if those fractures that had been treated with external fixation would have done better in a cast, and healed without complications. This is in agreement with Heiser and Jacobs,15 who have shown no obvious cause and effect relation between external fixators and the development of delayed or nonunion. 70 Grirnard et al CONCLUSIONS The results from this study have shown that only age of the patient and grade of fracture were statistically significant factors associated with time to union. Parents of injured children aged 12 years or older should be warned of the possible development of delayed and nonunion, even with Grades I and I1 fractures. References I . Blachut PA, Meek RN, O’Brien PJ: External fixation and delayed intramedullary nailing of open fractures of the tibial shaft: A sequential protocol. J Bone Joint Surg 72A:729-735, 1990. 2. Brumback RJ: Open tibial fractures: Current Orthopaedic Management. AAOS Instr Course Lect 41:101-107, 1992. 3. Buckley SL, Smith G , Sponseller PD, Thompson JD, Griffin PP: Open fractures of the tibia in children. J. Bone Joint Surg 72A:1462-1469, 1990. 4. Byrd HS, Spicer TE, Cierney G: Management of open tibial fractures. Plast Reconstr Surg 76:719-730, 1985. 5. Caudle RJ, Stem PJ: Severe open fractures of the tibia. J Bone Joint Surg 69A:801-807, 1987. 6. Clancey GJ, Hansen ST: Open fractures of the tibia: A review of one hundred and two cases. J Bone Joint Surg 60A:118-122, 1978. 7. Court-Brown CM, Wheelwright EIF, Christie J, McQueen MM: External fixation for Type Ill open tibial fractures. J Bone Joint Surg 72B:801-804, 1990. 8. Cramer KE. Limberd TJ, Green NE: Open fractures of the diaphysis of the lower extremity in children. J Bone Joint Surg 74A.2218-232, 1992. 9. Edwards CC, Simmons SC, Browner BD, Weifel MC: Severe open tibial fractures: Results treating 202 injuries with external fixation. Clin Orthop 230:98-115, 1988. Clinical Orthopaedics and Related Research 10. Fischer MD, Gustilo RB, Varecka TF: The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg 73A:I316-1322, 1991. 11. Godina M: Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg 78:285-292, 1986. 12. Gustilo RB, Anderson J T Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: Retrospective and prospective analyses. J Bone Joint Surg 58A:453458, 1976. 13. Gustilo RB, Mcrkow RT, Templeman D: Current concepts review: The management of open fractures. J Bone Joint Surg 72A:299-303, 1990. 14. Hansen BA, Greiff J, Bergman F: Fractures of the tibia in children. Acta Orthop Scand 47:448453, 1976. 15. Heiser TM, Jacobs RR: Complicated extremity fractures: The relationship between external fixation and non-union. Clin Orthop 178:89--95, 1983. 16. Hope PG, Cole WG: Open fractures of the tibia in children. J Bone Joint Surg 74B:546-553, 1992. 17. Irwin A, Gibson P, Ashcroft P: Open fractures of the tibia in children. Injury 26:21-24, 1995. 18. Kreder HJ, Armstrong P: A review of open fractures in children. J Pediatr Orthop 15:482488, 1995. 19. McGraw JM, Lim EVA: Treatment of open tibialshaft fractures: External fixation and secondary intramedullary nailing. J Bone Joint Surg 70A:900-911,1988. 20. Moda SK, Kalra GS, Gupta RS, et al: The role of early flap coverage in the management of open fractures of both bones of the leg. Injury 25:83-85,1994. 21. Patzakis MJ, Wilkins J: Factors influencing infection rate in open fracture wounds. Clin Orthop 243: 36-40,1989. 22. Sanders R, Swiontkowski M, Nunley J, Spiegel P: The management of fracture with soft-tissue disruptions. J Bone Joint Surg 75A:778-789, 1993. 23. Yokoyama K, Itoman M, Shindo M, Kai H Contributing factors influencing Type III open tibial fractures. 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