Children may recover from open fractures without surgery


December 22, 2014

Topic: orthopaedic surgery

Good news for young, active children everywhere: Kids may not necessarily need to have orthopaedic surgery on open fractures.

Good news for young, active children everywhere: Kids may not necessarily need to have orthopaedic surgery on open fractures.

"Not all pediatric fractures are created equal and our findings indicate that when it comes to simple, clean open breaks, which are very common in kids, a minimalistic 'clean, set the bone and watch' approach could be just as effective as more aggressive surgical treatment," lead study author Paul Sponseller, M.D., M.B.A., said in a statement. The findings were published in the Journal of Children's Orthopaedics.

Learning about open fractures
An open fracture is when a bone breaks off and ends up puncturing tissue near the injury site, causing a cut. However, people may not be able to see the bone. The American Academy of Orthopaedic Surgeons noted that is only one type of fracture. Other common types include oblique fractures, which is when the bone is broken at an angle, transverse fractures, which is a horizontal break, stable fractures, when the bones do not move, and comminuted fractures, which is when the bone breaks into three or more pieces.

The study authors found that when the fracture is less than 1/2 inch in diameter and the wound tissue is not infected, children can recover without surgery. The study examined 40 patients between the ages of 4 and 16 who all had open fractures and healed normally without surgery. Of the children examined, many of the fractures occurred to the shin and forearm.

In the past, clinicians have believed that all pediatric bone breaks should be surgically repaired, as the bones are still growing. However, this new development sheds light on the concept that as long as the fracture is clean, it will heal successfully without complications. The researchers hope their findings challenge the current beliefs in the orthopaedic world.

Standard orthopaedic treatment
The AAOS noted that there are a few different types of treatment methods for open fractures, depending on the severity of the injury. Regardless of the type of injury, the fracture needs to be debrided. That means that all contaminated tissue, loose pieces of bone, dirt and debris are completely removed from the wound. Not taking away these items may put people at risk for an infection. Once those small pieces are removed, the fracture area is irrigated with a salt solution to fully cleanse it. Physicians then need to stabilize the fracture to prevent any loose bone from damaging the muscle around the fracture. Depending on the type of open fracture, it will either be stabilized from the outside or inside, both of which require surgery.

The study authors suggested that children who choose to opt out of surgery may have a faster recovery and less scarring around the surgical site. It also makes the orthopaedic physician's job easier, as patients are in the hospital for less time, there is less action involved and less time spent in physical therapy.

However, not all children can heal without surgery, the researchers warned. If the area around the fracture is contaminated or nerve damage has occurred, surgery may be necessary to allow the child to fully heal. If the bone cannot be realigned without a stabilization technique, then it should be surgically treated.

Looking forward
The study authors concluded that every open fracture is different, depending on a variety of factors. 

"The take-home lesson here is that when it comes to pediatric open fractures, a one-size treatment doesn't fit all, and each fracture requires careful clinical evaluation," Sponseller said in a statement. "But it is clear to us that surgery is not always the best choice. Nonsurgical approaches should be considered for all kids with simple open bone breaks and no evidence of infection, serious damage or major debris."

However, they suggested that the perceptions surrounding open fractures in children may need to be altered, though they did not call for a formal change.


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