A protocol for the management of pediatric type I open fractures

Management of Open Fractures of the Extremities and Pediatrics

The modern management of open fractures was established after the foundational work of Gustilo and Anderson, but we continue to strive to determine the optimal treatment of open fractures to diminish the risk of infection. The ideal timing of antibiotics, presentation to the operating room, and timing of procedures such as flap coverage continue to be investigated with incremental changes recommended over the years. This article aims to provide the most recent review of the literature regarding the timing and management of both upper and lower extremity open fractures, pediatric open fractures, current topics of controversy, and the data supporting current treatment recommendations.

Pediatric Type I Open Both Bone Forearm Fractures: Predicting Failure of Nonoperative Management

BACKGROUND

In recent years, nonoperative treatment of pediatric type I open both bone forearm fractures (OBBFFs) with bedside irrigation, antibiotics, closed reduction, and casting has yielded low infection rates. However, risk factors for failure of type I OBBFF closed reduction have not been well described. Our purpose was to describe management of patients with type I OBBFFs at our institution and determine what factors are associated with failure of closed reduction in this population.

METHODS

This was a review of patients between 5 and 15 years of age who received initial nonoperative management for type I OBBFFs at one institution between 2015 and 2021. Primary outcome was success or failure of nonoperative management (defined as progression to surgical management). Secondary outcomes included infections, compartment syndromes, and neuropraxias. Other variables of interest were demographic information, prereduction and postreduction translation and angulation of the radius and ulna, cast index, and antibiotic administration.

RESULTS

Sixty-one patients (67.7% male) with 62 type I OBBFFs were included in this study. Following initial nonoperative management, 55 injuries (88.7%) were successfully treated in casts, while the remaining 7 (11.3%) required surgical intervention following loss of acceptable reduction in cast. Median cast index (0.84, IQR 0.8 to 0.9 vs. 0.75, IQR 0.7-0.8, P =0.020) and postreduction radius translation on anteroposterior films (32.0%, IQR 17.0% to 40.0% vs. 5.0%, IQR 0.0% to 26.0%, P =0.020) were higher among those who failed nonoperative management. Multivariable logistic regression models identified increased odds of failure for every SD (0.7) increase in cast index (OR 3.78, P =0.023, 95% CI: 1.4-14.3) and 25% increase in postreduction radius translation on anteroposterior films (OR 7.39, P =0.044, 95% CI 1.2-70.4). No infections or compartment syndromes and 2 transient ulnar neuropraxias occurred.

CONCLUSIONS

Closed reduction of type I OBBFFs was successful in 88.7% of cases. There were no infections after nonoperative management. Increases in cast index of 0.7 and postreduction radius translation on anteroposterior radiographs of 25% were associated with increased likelihood of failure, thus requiring surgery; age was not.

LEVEL OF EVIDENCE

Level IV-retrospective comparative study.

Risk Factors for Failure of Closed Forearm Fracture Reduction in the Pediatric Emergency Department

OBJECTIVES

This study aimed to explore risk factors for failure of forearm fracture closed reduction in the pediatric emergency department (ED) and to suggest indications for initial surgery.

METHODS

This retrospective cohort study included all patients aged 0 to 18 years who presented to our pediatric ED with an extraarticular forearm fracture treated with closed reduction between May 2017 and April 2021. We explored risk factors for procedural failure, defined as a need for surgical intervention within 6 weeks of the closed reduction attempt.

RESULTS

Of 375 patients (median age 8.1 years, 294 [78.2%] boys), 44 (11.7%) patients sustained a reduction failure, of whom 42 (95.5%) had both radius and ulna fractures. Of the 259 patients with fractures of both bones, the following parameters were independent predictors for reduction failure: refracture (adjusted odds ratio [aOR] 17.6, P < 0.001), open fracture (aOR 10.1, P = 0.007), midshaft fracture (aOR 2.6, P = 0.004), radial translation rate 37% and higher in either plane (aOR 5.1, P = 0.004), and age of 10 years and older (aOR 2.9, P = 0.01).

CONCLUSIONS

Most pediatric forearm fractures can be successfully managed by closed reduction in the ED. Two-bone fractures had the strongest association with reduction failure. Refracture, open fracture, midshaft location, initial radius bone translation of 37% and higher (and not initial angulation), and patient age of 10 years and older are independent risk factors for reduction failure in two-bone fractures. We propose a risk score for reduction failure that can serve as a decision-making tool.

Traffic Accidents in Children and Adolescents: A Complex Orthopedic and Medico-Legal Approach

Traffic accidents involving children and adolescents present complex challenges from both the medico-legal and orthopedic standpoints. Despite the implementation of road traffic safety laws, pediatric road traffic injuries continue to be a significant contributor to mortality rates, physical harm, and hospitalization on a global scale. For children and young people, automobile accidents are considered to be the primary culprit of mortality in developed nations. Even in highly developed nations, trauma is a significant factor in infant mortality. Each age category, from childhood to young adulthood, has its fracture patterns, as their skeletons are considerably different from those of adults. The consequences of traffic accidents extend beyond the immediate physical trauma. The medico-legal aspects surrounding these incidents add another layer of complexity, as legal repercussions may affect the responsible adult or parent, particularly in cases involving child fatalities. To effectively address traffic accidents in children and adolescents, a comprehensive approach is necessary. This approach should involve not only medical professionals but also legal experts and policymakers. Collaboration between orthopedic specialists, medico-legal professionals, law enforcement agencies, and relevant government bodies can facilitate the development and implementation of strategies aimed at prevention, education, the enforcement of traffic laws, and improved infrastructure. By addressing both the medical and legal aspects, it is possible to enhance road safety for children and adolescents, reducing the incidence of injuries and their associated long-term consequences. In this review, we aimed to summarize traffic accidents in children and adolescents from a complex orthopedic and medico-legal approach.

Open fractures of the upper limb - do the BOAST guidelines need an update?

AIMS

This scoping review aims to explore the published literature on the current management strategies and outcomes of open upper limb injuries using the BOAST 4 guidelines as a structure.

MATERIALS AND METHODS

A comprehensive search of the MEDLINE, EMBASE, Cochrane and OrthoSearch computerised literature databases (from January 2012 through April 2022) was performed. The medical subject headings used were "open fracture"/ "Gustilo Anderson" and "forearm" or "radius" or "ulna" or "elbow" or "humerus" or "clavicle" or "shoulder" or "scapula". Abstract titles were reviewed for relevance. If the article was deemed eligible, the article was retrieved and reviewed in full.

RESULTS

The literature reveals lower rates of infection for upper limb injuries compared to their lower limb counterparts. Early antibiotic administration remains a key component of their management. Those without significant soft tissue injury (Gustilo Anderson 1) can often be treated as per their closed counterparts and timing to definitive fixation can be safely delayed in selected cases.

DISCUSSION

There is limited high quality evidence available on the management of open upper limb injuries with guidelines built on borrowed principles from the more studied open tibia fractures. What the available evidence does show is that with lower infection rates and a more forgiving soft tissue envelope it may be safe to diverge from the current BOAST guidelines in certain cases. This has relevance in complex fracture patterns requiring specialist input where it is not possible to achieve definitive fixation in 72 h and when there are other life threatening injuries to manage. Despite this early antibiotic administration and debridement within 24 h remains a key component of the early management.

Comparison of nonoperative versus operative management in pediatric gustilo-anderson type I open tibia fractures

BACKGROUND

Recent studies suggest pediatric Gustilo-Anderson type I fractures, especially of the upper extremity, may be adequately treated without formal operative debridement, though few tibial fractures have been included in these studies. The purpose of this study is to provide initial data suggesting whether Gustilo-Anderson type I tibia fractures may be safely treated nonoperatively.

METHODS

Institutional retrospective review was performed for children with type I tibial fractures managed with and without operative debridement from 1999 through 2020. Incomplete follow-up, polytrauma, and delayed diagnosis of greater than 12 h since the time of injury were criteria for exclusion. Data including age, sex, mechanism of injury, management, time-to-antibiotic administration, and complications were recorded.

RESULTS

Thirty-three patients met inclusion criteria and were followed to union. Average age was 9.9 ± 3.7 years. All patients were evaluated in the emergency department and received intravenous antibiotics within 8 h of presentation. Median time-to-antibiotics was 2 h. All patients received cefazolin except one who received clindamycin at an outside hospital and subsequent cephalexin. Three patients (8.8%) received augmentation with gentamicin. Twenty-one patients (63.6%) underwent operative irrigation and debridement (I&D), and of those, sixteen underwent surgical fixation of their fracture. Twelve (36.4%) patients had bedside I&D with saline under conscious sedation, with one requiring subsequent operative I&D and intramedullary nailing. Three infections (14.3%) occurred in the operative group and none in the nonoperative group. Complications among the nonoperative patients include delayed union (8.3%), angulation (8.3%), and refracture (8.3%). Complications among the operative patients include delayed union (9.5%), angulation (14.3%), and one patient experienced both (4.8%). Other operative group complications include leg-length discrepancy (4.8%), heterotopic ossification (4.8%), and symptomatic hardware (4.8%).

CONCLUSION

No infections were observed in a small group of children with type I tibia fractures treated with bedside debridement and antibiotics, and similar non-infectious complication rates were observed relative to operative debridement. This study provides initial data that suggests nonoperative management of type I tibial fractures may be safe and supports the development of larger studies.

Pediatric Open Long-Bone Fracture and Subsequent Deep Infection Risk: The Importance of Early Hospital Care

The purpose of the current study was to identify risk factors for deep infection after an open long-bone fracture in pediatric patients. Systematic billing queries were utilized to identify pediatric patients who presented to a level I trauma center from 1998 to 2019 with open long-bone fractures. There were 303 open long-bone fractures, and 24 (7.9%) of these became infected. Fractures of the tibia/fibula (p = 0.022), higher revised Gustilo-Anderson type (p = 0.017), and a longer duration of time between the injury and hospital presentation (p = 0.008) were all associated with the presence of deep infection. Those who went on to have a deep infection also required more operative debridements (p = 0.022) and a total number of operative procedures (p = 0.026). The only factor that remained significant in multivariable regression was the duration between the injury and hospital presentation (OR 1.01 [95%CI 1.003-1.017]; p = 0.009), where the odds of deep infection increased by 1% for every minute of delayed presentation.

Outcomes After Operative Treatment of Pediatric Monteggia Fracture-Dislocations: Comparison Between Open and Closed Injuries

BACKGROUND

Open pediatric Monteggia fracture-dislocations are a relatively uncommon injury pattern, with limited numbers reported in previous series. Open fracture-dislocations frequently represent more severe injury patterns with potential for contamination. We aim to determine differences in long-term clinical and functional outcomes in the operative management of closed versus open pediatric Monteggia fracture-dislocations.

METHODS

A retrospective review of operatively treated pediatric Monteggia fracture-dislocations was performed. Closed versus open injuries were compared in both clinical outcomes, as well as patient-reported outcomes through Quick Disabilities of the Arm, Shoulder, and Hand (QuickDASH) questionnaire.

RESULTS

Of 30 operatively treated injuries, 12/30 (40%) were open fracture-dislocations. Patients were followed clinically for an average of 15.65 months in open injuries and an average of 4.61 months in closed injuries. A trend toward increased time to union was observed, however, significance was not achieved; open injuries averaged 8.0 versus 5.8 weeks for closed injuries ( P =0.07). Two patients (11%) in the closed fracture group experienced postoperative complications; both were minor. Five patients (42%) in the open fracture-dislocation group experienced a total of 6 postoperative complications; 5 of the 6 complications were major. QuickDASH scores were obtained at an average of 5 years postoperatively; mean QuickDASH scores were higher in the open fracture group, 13.1, compared with the closed fracture group, 5.9 ( P =0.038). Increased QuickDASH scores were independently associated with presence of postoperative complications. QuickDASH score could be expected to increase by 12.5 points in those with major complications ( P =0.044).

CONCLUSION

We present the largest single cohort of pediatric open Monteggia fracture-dislocation injuries to date. These injuries are predictive of poorer outcomes including trend toward increased time to union, increased risk of major complication, and can independently predict worse long-term patient-reported functional outcomes.

LEVEL OF EVIDENCE

Level III-these data represent a retrospective comparative study of clinical and functional outcomes.

The evidence base for 2017 BOAST-4 guidance on open fracture management: Are we due an update?

INTRODUCTION

Open fracture management in the United Kingdom and several other countries is guided by the British Orthopaedic Association's Standards for Trauma Number 4 (BOAST-4). This is updated periodically and is based on the best available evidence at the time. The aim of this study is to evaluate the evidence base forming this guidance and to highlight new developments since the last version in 2017.

METHODS

Searches have been performed using the PubMed, Embase and Medline databases for time periods a) before December 31, 2017 and from 01/01/2018-01/02/2021. Results have been summarized and discussed.

DISCUSSION

Several contentious issues remain within the 2017 guideline. Antibiotic guidance, the use of antibiotic impregnated PMMA beads and intramedullary devices, irrigation in the emergency department, time to theatre and the use of negative pressure dressings and guidance regarding the management of paediatric injuries have all demonstrated no clear consensus.

CONCLUSION

The advent of the BOAST-4 guideline has been of huge benefit, however the refinement and improvement of this work remains ongoing. There remains a need for further study into these contentious issues previously listed.

The Vacuum-Assisted Closure Device Increases Value in the Treatment of Gustilo Grade IIIb Open Tibia Fractures in Children

Background

Wound management associated with Gustilo grade IIIb open tibia fractures in children often requires muscle flaps, skin grafts, and amputations. The purpose of this study is to report the outcomes and complications of vacuum-assisted closure (VAC) treatment, as well as discuss its role in optimizing value when treating these injuries.

Methods

A retrospective review of medical records and imaging studies was performed from 2008-2015. Six pediatric patients with Gustilo grade IIIb fractures managed with the VAC were identified. The time to treatment, frequency of VAC changes, VAC size, and closure attempts, including muscle flaps and skin grafts, were documented. Fracture fixation methods, the incidence of delayed union or nonunion, as well as the occurrence of deep tissue infection and compartment syndrome were detailed.

Results

Five patients were male and one was female with an average age of 12 years (range 8-15 years). All patients sustained a Gustilo IIIb open tibia fracture and were treated with irrigation, debridement, intravenous (IV) antibiotics, fixation, and a VAC as a wound care adjunct. Three patients required both a muscle flap and a skin graft. One patient required a skin graft. There was one case of deep tissue infection. Three patients were treated successfully with the VAC alone and did not require any flap procedures.

Conclusions

Wound care for Gustilo grade IIIb open tibia fractures in children traditionally involved potentially painful twice-daily dressing changes with solutions such as dilute bleach or iodine. The implementation of VAC markedly reduced the frequency of dressing changes every three days. In the current study, the open wound gradually closed with only a VAC in 50% of Gustilo grade IIIb open pediatric tibia fractures. In summary, the VAC is an adjunct that increases value in the care of pediatric patients with Gustilo grade IIIb open tibia fractures (Value = Outcomes/Cost).

Level of evidence

Therapeutic level IV

The Management of Pediatric Open Forearm Fractures

Open pediatric forearm fractures are common injuries that present to emergency departments across the United States. A total of 32% to 80% of all open pediatric fractures involve the forearm. Standard treatment for these injuries includes prompt intravenous antibiotic administration, tetanus prophylaxis, and usually bedside irrigation as a temporizing measure. Gustilo and Anderson type 2 and 3 open pediatric forearm fractures are generally managed with formal irrigation and debridement and fracture stabilization in the operating room. Management of Gustilo and Anderson type 1 open pediatric forearm fractures is not standardized, and level I evidence is currently lacking. Based on the existing data available, early antibiotic administration, bedside irrigation, and fracture stabilization in the emergency department may be a safe and effective initial treatment for these injuries, conferring a low risk for subsequent infection.

Management of Pediatric Type I Open Fractures in the Emergency Department or Operating Room: A Multicenter Perspective

BACKGROUND

The management of pediatric type I open fractures remains controversial. The aim of this study is to compare outcomes in type I open fractures managed with superficial wound debridement and antibiotics in the emergency department (ED) (nonoperative management) to patients managed with operative debridement and antibiotics (operative management).

METHODS

A multicenter retrospective review was performed of all pediatric type I open forearm, wrist, and tibia fractures treated at 4 high volume pediatric centers between 2000 and 2015. Patients with multiple traumatic injuries, immunocompromised patients, or those without final radiographs indicating healing were excluded.

RESULTS

In total, 219 patients met inclusion criteria. A total of 170 fractures were treated operatively (77.6%), 49 fractures were treated nonoperatively (22.4%). There was 1 infection in the nonoperative group (2.0% infection rate), and no infections in the operatively managed group (P=0.062). Cefazolin was the most commonly administered antibiotic (88.1% of patients). Duration of hospital-administered antibiotics was significantly different, with a mean of 10.9 hours in the nonoperative group and 41.6 hours in the operative group (P<0.001). Length of stay averaged 16.3 hours for nonoperative patients and 48.6 hours for the operatively treated patients (P<0.001). In the nonoperative group, 44/49 had documented superficial wound debridement in the ED utilizing, on an average, 1500 mL of irrigant. There were 10 other complications, 9 in the operative group (5.4%) and 2 in the nonoperative group (4.1%, P=0.107), including 2 compartment syndromes and 1 acute carpal tunnel syndrome all requiring immediate surgical release (1.8%) in the operative group.

CONCLUSIONS

There was no significant difference in infection rate or complication rate in those managed with antibiotics and operative debridement versus those managed with superficial wound debridement and antibiotics in the ED. Consideration should be given to the similar safety profiles for these 2 treatment modalities when managing pediatric patients with type I open fractures.

LEVEL OF EVIDENCE

Level III.

Evidence-based update on the surgical treatment of pediatric tibial shaft fractures

PURPOSE OF REVIEW

To describe surgical treatment options for pediatric tibial shaft fractures which are the third most common pediatric long bone fracture. Management of these injuries is dictated by fracture location, fracture pattern, associated injuries, skeletal maturity, and other patient-specific factors. Although most pediatric tibial shaft fractures can be treated nonoperatively, this review provides an update on surgical treatment options when operative intervention is indicated.

RECENT FINDINGS

Advances in surgical implants and techniques affords a wide range of options for the surgical treatment of pediatric tibial shaft fractures. Flexible intramedullary nailing is gaining wide adoption for acute surgical treatment. Recent studies support cross-sectional imaging for further evaluation and scrutiny of fracture patterns suspicious for intraphyseal or intra-articular extension. Grade I open tibial shaft fractures may be safely treated with irrigation and debridement in the emergency department; however, no high-level comparative studies have been performed to make any definitive conclusions regarding the effectiveness of this treatment strategy.

SUMMARY

Tibial shaft fractures are common injuries in pediatric patients. Management is dictated by fracture location, fracture pattern, associated injuries, patient age, and other patient-specific factors. Surgical intervention is indicated for fractures that are open, irreducible, have failed nonoperative management, are associated with compartment syndrome, or in the multiply injured patient. Surgical treatment options include flexible intramedullary nailing, plate osteosynthesis, external fixation, and rigid intramedullary nailing. Recent literature has shown increased rates of flexible intramedullary nailing. All operative and nonoperative management options can result in complications including compartment syndrome, infection, delayed union, nonunion, malunion, limb length discrepancy, and symptomatic hardware. Most pediatric patients go on to uneventful union with excellent final outcomes and return to full activities.

Pediatric Orthopedic Trauma: An Evidence-Based Approach

The management of pediatric fractures has evolved over the past several decades, and many injuries that were previously being managed nonoperatively are now being treated surgically. The American Academy of Orthopaedic Surgeons has developed clinical guidelines to help guide decision making and streamline patient care for certain injuries, but many topics remain controversial. This article analyzes the evidence regarding management of 5 of the most common and controversial injuries in pediatric orthopedics today.

Management of Orthopaedic Injuries in Multiply Injured Child

Multiply injured child is a unique challenge to the medical communities worldwide. It is a leading cause of preventable mortality and morbidity in children. Common skeletal injuries include closed or open fractures of tibia and femur and pelvic injuries. Initial management focuses on saving life and then saving limb as per pediatric advanced life support and advanced trauma life support. Orthopedic management of open fracture includes splinting the limb, administration of prophylactic antibiotic, and surgical debridement of the wound when safe. However, gross contamination, compartment syndrome, and vascular injuries demand urgent attention.

Optimizing Management of Open Fractures in Children

Open fractures in children differ from adults owing to their better healing potential. Management strategies for open fracture in children are changing with improvement in our understanding of soft-tissue reconstruction and fracture fixation. A literature review was performed for articles covering management of open fractures in children. The cornerstones of management include prevention of infection, debridement, and skeletal stabilization with soft-tissue coverage. The injury should be categorized according to the established trauma classification systems. Timely administration of appropriate antibiotics is important for preventing infections. Soft-tissue management includes copious irrigation and debridement of the wound. Fractures can be stabilized by a variety of nonoperative and operative means, taking into consideration the special needs of the growing skeleton and the role of a thick and active periosteum in the healing of fractures. The soft-tissue coverage required depends on the grade of injury.

The emerging trend of non-operative treatment in paediatric type I open forearm fractures

PURPOSE

Open fractures are considered an orthopaedic emergency and are generally an indication for operative debridement. Recent studies have questioned this approach for the management of Gustilo-Anderson Type I open fractures in the paediatric population. This meta-analysis studies the non-operative management of Type I open paediatric forearm fractures.

METHODS

An Ovid MEDLINE and PubMed database literature search was performed for studies that involved a quantified number of Gustilo-Anderson Type I open forearm fractures in the paediatric population, which were treated without operative intervention. A fixed-effect meta-analysis, weighting each study based on the number of patients, and a pooled estimate of infection risk (with 95% confidence interval (CI)) was performed.

RESULTS

The search results yielded five studies that were eligible for inclusion. No included patients had operative debridement and all were treated with antibiotics. The number of patients in each study ranged from 3 to 45, with a total of 127 paediatric patients in the meta-analysis. The infection rate was 0% for all patients included. The meta-analysis estimated a pooled infection risk of 0% (95% CI 0 to 2.9).

CONCLUSIONS

The five included studies had a total of 127 patients with no cases of infection after non-operative management of Type I open paediatric forearm fractures. The infection rate of Type I fractures among operatively managed patients is 1.9%. The trend in literature towards non-operative treatment of paediatric Type I open fractures holds true in this meta-analysis.

The management of open tibial fractures in children

Aims

Following the introduction of national standards in 2009, most major paediatric trauma is now triaged to specialist units offering combined orthopaedic and plastic surgical expertise. We investigated the management of open tibia fractures at a paediatric trauma centre, primarily reporting the risk of infection and rate of union.

Patients and Methods

A retrospective review was performed on 61 children who between 2007 and 2015 presented with an open tibia fracture. Their mean age was nine years (2 to 16) and the median follow-up was ten months (interquartile range 5 to 18). Management involved IV antibiotics, early debridement and combined treatment of the skeletal and soft-tissue injuries in line with standards proposed by the British Orthopaedic Association.

Results

There were 36 diaphyseal fractures and 25 distal tibial fractures. Of the distal fractures, eight involved the physis. Motor vehicle collisions accounted for two thirds of the injuries and 38 patients (62%) arrived outside of normal working hours. The initial method of stabilisation comprised: casting in nine cases (15%); elastic nailing in 19 (31%); Kirschner (K)-wiring in 13 (21%); intramedullary nailing in one (2%); open reduction and plate fixation in four (7%); and external fixation in 15 (25%). Wound management comprised: primary wound closure in 24 (39%), delayed primary closure in 11 (18%), split skin graft (SSG) in eight (13%), local flap with SSG in 17 (28%) and a free flap in one. A total of 43 fractures (70%) were Gustilo-Anderson grade III. There were four superficial (6.6%) and three (4.9%) deep infections. Two deep infections occurred following open reduction and plate fixation and the third after K-wire fixation of a distal fracture. No patient who underwent primary wound closure developed an infection. All the fractures united, although nine patients required revision of a mono-lateral to circular frame for delayed union (two) or for altered alignment or length (seven). The mean time to union was two weeks longer in diaphyseal fractures than in distal fractures (13 weeks versus 10.8 weeks, p = 0.016). Children aged > 12 years had a significantly longer time to union than those aged < 12 years (16.3 weeks versus 11.4 weeks, p = 0.045). The length of stay in hospital for patients with a Gustilo-Anderson grade IIIB fracture was twice as long as for less severe injuries.

Conclusion

Fractures in children heal better than those in adults. Based on our experience of deep infection we discourage the use of internal fixation with a plate for open tibial fractures in children. We advocate aggressive initial wound debridement in theatre with early definitive combined orthopaedic and plastic surgery in order to obtain skeletal stabilisation and soft-tissue cover. Cite this article: Bone Joint J 2017;99-B:544–53.

Hafnia alvei: A new pathogen in open fractures

Background

Deep infection following open both bone forearm fractures is a rare complication. Prophylactic antibiotic regimens are targeted at the most common pathogens, which include primarily Staph aureus followed by gram-negative bacteria. Hafnia alvei is an unusual pathogen that is rarely pathogenic in humans and has never been reported as a cause of infection following open fracture.

Methods

We present a 12-year-old male with an open forearm fracture who developed a late deep infection. Cultures grew only Hafnia alvei. The patient was treated with debridement, placement of antibiotic beads, and ciprofloxacin.

Results

At 6 months following the initial debridement, the patient had no clinical evidence of infection and regained full function of the affected forearm without any residual deficits.

Conclusions

This is the first report of deep infection following an open forearm fracture owing to Hafnia alvei, a pathogen rarely responsible for human infection.

Pediatric and Adolescent Forearm Fractures: Current Controversies and Treatment Recommendations

Pediatric and adolescent forearm fractures continue to present treatment challenges. Despite high-level evidence to the contrary, traditional guidelines for nonsurgical treatment have been challenged in favor of surgical intervention, but it is unclear if this results in improved outcomes. Recent evidence suggests that certain open fractures in children may be successfully treated nonsurgically. Good results have been achieved with closed reduction and appropriate casting and clinical follow-up. Further research investigating functional outcomes into adulthood is needed.

Type I Open Fractures Benefit From Immediate Antibiotic Administration But Not Necessarily Immediate Surgery

Pediatric open fractures are rare, occurring in approximately 2% to 9% of all pediatric fractures. Type I open fractures represent the most common type of open fractures seen in pediatrics and are commonly caused by low-energy mechanisms. The management of these injuries has been primarily dictated by the adult literature. Immediate antibiotic administration, specifically a first generation cephalosporin, has been shown to reduce infection rates. The duration of antibiotic treatment is less clear, but longer courses of antibiotics have not been significantly better than a shorter course. Retrospective case series have shown no difference in infection rates with nonoperative management of type I open fractures. However, concern regarding serious and even life-threatening infection continues to limit the universal adoption of nonoperative treatment protocols. A prospective randomized control trial is underway and will hopefully elucidate which open fractures can be safely managed with prompt antibiotic administration and nonoperative care.