Current Practice in the Management of Type I Open Fractures in Children: A Survey of POSNA Membership

Abstract

Background: Treatment of pediatric type I open fractures is controversial. Centers have reported good success with emergency room (ER) treatment of low-energy (type I) open pediatric fractures. The purpose of this study was to ascertain the treatment preferences of pediatric orthopaedic surgeons for type I open fractures. We hypothesize that surgeons will have different treatment protocols and preferred location for these injuries.

Methods: A questionnaire was given to Pediatric Orthopaedic Society of North America (POSNA) members at the 2012 annual meeting. Demographic questions inquired about surgeon's practice environment and experience, whereas clinical questions queried opinions regarding the typical treatments and past experiences with open fractures. Clinical scenarios questioned preferred management of open fractures.

Results: A total of 181 surveys were collected from the 503 POSNA members in attendance (36%). Years in practice were well represented with 34%: <10 years, 37%: 10 to 19 years, and 29%: >20 years. Most respondents' practices comprised over 80% pediatric patients (86%), were academic (68%), and worked with residents (77%). After initial treatment of an open fracture, 86% of respondents admitted patients for intravenous antibiotics and 57% gave oral antibiotics. There was no consensus regarding the amount or type of irrigation preferred, use of antibiotics in the irrigation, or whether the bone ends are delivered during irrigation and débridement. Soft-tissue infections and delayed union were noted by 13% and 8%, respectively, of respondents in type I open fractures treated in the ER and in 16% and 30% treated in the operating room (OR). ER treatment was preferred in 19% to 31% of respondents for type I open fractures. When queried if level 1 evidence existed that demonstrated equivalent results between ER and OR management, 92% of respondents would change their practice.

Conclusions: Treatment methods of type I open fractures are variable. Many surgeons prefer to treat type I open fractures in the ER as opposed to the traditional OR irrigation and débridement. On the basis of this survey, either children are going to the OR when ER treatment would be adequate or they may be receiving inadequate care when they avoid OR management. This survey establishes the equipoise necessary for a randomized, prospective trial comparing ER and OR management in the treatment of pediatric type I open fractures.