[Operative treatment of pediatric open fractures of the lower limb using the Taylor spatial frame fixator]

Salvage procedures in lower-extremity trauma in a child with hereditary motor and sensory neuropathy type I: a case report

Introduction

Fractures of the lower extremity are a common type of childhood injury and many can be treated without surgery. Dislocated and open fractures are an indication for fracture stabilization via either intramedullary nailing or, in the case of complicated fractures, external fixation. But if complications are likely because of diseases and disabilities (for example, a neuropathy) that can complicate the post-operative procedure and rehabilitation, what options does one have?

Case presentation

We report a nine-year-old Caucasian girl who had hereditary motor and sensory neuropathy type I and who was admitted with a grade I open tibia fracture after a fall from a small height. Plain radiographs showed a dislocated tibia and fibula fracture. An open reduction with internal fixation with a compression plate osteosynthesis was performed, and soft tissue debridement combined with an external fixateur was undertaken. Three months later, she was re-admitted with localized swelling and signs of a local soft tissue infection in the middle of her tibia. Plain radiographs showed a non-union of the tibia fracture, and microbiological analysis confirmed a wound infection with cefuroxime-sensitive Staphylococcus aureus. Because of the non-union, the osteosynthesis was replaced with an Ilizarov external fixateur, and appropriate antibiotic therapy was initiated. Four months after the initial accident, the fracture was consolidated and we removed the external fixateur.

Conclusions

If there is a pre-existing neuropathy and if disease makes it difficult for a child to follow all post-operative instructions, salvage procedures should be kept in mind in case of complications. There are multiple therapeutic options, including osteosynthesis, intramedullary nailing systems, cast therapy, or an external fixateur like the Ilizarov or Taylor spatial frame system. The initial use of an external fixateur such as an Ilizarov or Taylor spatial frame in patients with pre-existing neuropathies should be kept in mind as a possible treatment option in complicated fractures, especially in a child with pre-existing neurological or endocrine pathologies.

Taylor spatial frame in the treatment of neglected fractures

BACKGROUND

The Taylor spatial frame (TSF, Smith and Nephew, Memphis, TN, USA) is a modern multiplanar external fixator that combines ease of application and computer accuracy. Many patients in our geographic area seek treatment for their fractures by traditional bonesetters and present in the middle of treatment with neglected malaligned fractures. These fractures were an average of 10 weeks old (range 6-14 weeks) fractures with callus that were allowed to heal in a poor position. The spatial frame is applied easily on the fracture bone fragments. The accuracy of fracture reduction and deformity correction is dependant on analyzing anteroposterior and lateral radiographs of the fracture. Our experience with this external fixator in the treatment of neglected fractures is summarized.

METHOD

Over a period of 6 years, the TSF was used in 24 neglected fracture cases which were collected from our prospective external fixator data base. All cases were followed for a minimum of 3 years. The data base and radiographs were reviewed in order to obtain demographic data, malalignment parameters, final correction, time in the TSF, and complications.

RESULT

The patients' ages ranged from 6 to 18 years. All were neglected fractures. The average delay in treatment was 10 weeks (range 6-14 weeks). All patients had closed osteoclasis. The time spent in the TSF varied according to the patient age and bone involved. Ten femoral and 14 tibial fractures were included. Ten patients had superficial pin site infections that resolved with oral antibiotics. Postoperatively, no patient was noted to be more than 5° malrotated on clinical examination and no functional leg length discrepancy was observed. All of the fractures united.

CONCLUSION

Anatomic alignment was achieved in all tibial fracture patients. At the final follow-up, fracture angulation and shortening were fully corrected, and some translational malalignment persisted in 67% of femur fractures. The TSF is an effective definitive method for the treatment of neglected fractures.

LEVEL OF EVIDENCE

IV.