6 - Fractures with Soft Tissue Injuries

Abstract

Pediatric extremity fractures with substantial soft tissue injury (whether open fractures or closed fractures with degloving injuries) are usually caused by high-energy mechanisms such as motor vehicle accidents, lawn mowers, and farm machinery. Prognosis and treatment decisions in children can be guided by injury severity scores such as the Mangled Extremity Severity Score (MESS) and the Ganga Hospital Open Injury Severity Score (GHOISS). Initial care should focus on hemorrhage control in the field and Advanced Trauma Life Support (ATLS) protocols in the emergency department. Antibiotic and tetanus prophylaxis must be initiated at the time of initial evaluation in the emergency department, although the timing of formal irrigation and débridement for pediatric injuries is somewhat controversial. Wounds should generally be débrided in the operating room, although some centers are recommending the use of irrigation in the emergency department for grade 1 "inside-out" low-energy open-forearm fractures in children. Further evidence is needed before such recommendations can be universally adopted. Débridement should be meticulous while preserving the viable soft tissues, including the periosteum particularly in the case of bone defects, as the highly vascularized and biologically active periosteum of a child makes bony union possible even in the setting of segmental bone loss. Acute compartment syndrome develops with relative frequency in children and adolescents with open fractures, and is often difficult to diagnose in children, whose symptoms may differ compared with adults. Pediatric fractures with soft tissue injuries must be treated with consideration of future remodeling and growth potential, taking care to preserve the physis and chondroepiphysis if at all possible, and must be stabilized with implants appropriate for a growing skeleton.