OPEN FRACTURE OF THE TIBIA IN CHILDREN

The records of eighty-three children who had had an open fracture of t he tibial metaphysis or diaphysis between January 1983 and July 1993 w ere studied retrospectively. The average duration of follow-up was fou rteen months (range, two to seventy-five months). There were twenty-fo ur grade-I, forty grade-II, thirteen grade-IIIA, six grade-IIIB, and n o grade-IIIC fractures, according to the classification scheme of Gust ilo et al. Sixty patients (72 per cent) had sustained the fracture whe n they were struck by an automobile, and forty-eight patients (58 per cent) had other associated major injuries. All fractures were treated with irrigation and debridement, and antibiotics were administered par enterally for a minimum of forty-eight hours. Thirty-two patients were managed with immobilization in a cast only; forty, with transcutaneou s fixation with an average of two Steinmann pins followed by immobiliz ation in a cast; nine, with external fixation; one, with open reductio n and internal fixation with two screws and two pins; and one, with de layed intramedullary nailing. Fifty-seven wounds were closed primarily (forty-four, over a Penrose drain, and thirteen, without a drain), te n were treated with delayed closure, four were allowed to heal by seco ndary intention, seven were covered with a soft-tissue flap, and five were treated with skin-grafting (a split-thickness skin graft was used for four, and a split-thickness and a full-thickness skin graft were used for one). The average time to union was fifteen weeks (range, fiv e to sixty-one weeks), with the fracture healing by sixteen weeks in s ixty-four patients (77 per cent). Eighteen patients (22 per cent) had delayed union, and only one patient (1 per cent) had non-union. Second ary procedures were necessary to achieve union in only two patients. T wo patients had a superficial wound infection, and no patient had oste omyelitis. One patient, who had been managed with external fixation, h ad a pin-track infection; none of the patients who had had transcutane ous fixation had a pin-track infection. Two patients had a compartment syndrome, and two patients had a transient stretch injury of a nerve (the peroneal nerve in one and the sciatic nerve in the other). Four f ractures healed with an angulatory deformity of more than 10 degrees i n any plane. Five patients had overgrowth of the limb of one centimete r or more. Physeal arrest did not occur in any patient. We concluded t hat treatment of unstable open fractures of the tibia in children with debridement and transcutaneous fixation followed by immobilization in a cast leads to good anatomical and functional results. We prefer thi s technique to external fixation, which is associated with several pot ential complications. Loose closure of a clean open wound over a Penro se drain is effective and can be safely utilized in selected children.