Acute Intentional Deformation of Open Tibial Fractures for Complex Soft Tissue Closure in the Pediatric Patient

A 15-year-old male sustained a left tibia Gustillo 3B injury after he was struck by a motor vehicle while riding his bicycle. No other major injuries necessitating operative intervention were sustained, and his lower extremity was determined to be neurovascularly intact without sensory/motor deficit. The patient was taken to the operating room on the day of admission by orthopedic surgery who placed an external fixator on the left tibia and performed a washout and debridement with placement of a wound vacuum-assisted closure (VAC, KCI) over the large soft tissue defect. The lower extremity major vessels were examined at that time and were determined to be intact without injury. The patient was returned to the operating room 3 days later for repeat debridement; at that time, plastic surgery was consulted for evaluation of the soft tissues. There was a 17 x 15 x 2-cm soft tissue defect over the open left tibia fracture with denuded periosteum. There was also concern about the viability of the surrounding skin in the zone of injury.

This patient would require a very large flap for reconstruction to cover the soft tissue defect over the open fracture. Due to the family’s cultural heritage, they had concerns about the possibility of losing a functional muscle as a result of the free tissue transfer. After discussion with the patient, his family, and the pediatric orthopedic surgeon, the decision was made to instead intentionally deform the patient’s leg to allow for a substantial decrease in the size of the wound, which would facilitate soft tissue closure with locoregional tissue and skin grafting.

In accordance with previously described techniques in the orthopedic literature,^1-5 the tibial fracture was fixated at an angular deformity of 45° and shortened by 4.5 cm to allow for the wound size to be closed using local musculature from the anterior compartment of the lower leg along with adjacent tissue transfer and a split-thickness skin graft.

The postoperative appearance of his left lower extremity can be observed in Figure 1. After 1 month of healing time, the external fixator was gradually adjusted to correct the intentional deformity and bring the fracture back into alignment. The soft tissue reconstruction remained stable throughout this time. Radiographic images of his tibia during the preoperative, deformation, and postoperative stages can be observed in Figure 2. The patient is now status post external fixator removal with an excellent functional and aesthetic outcome (Figure 3). The patient and his family consented for both clinical information and photographs to be used in this case report.

Lower extremity reconstruction in the pediatric patient has been described extensively in the plastic surgery and wound care literature, which has reinforced the safety and efficacy of free tissue transfer as needed in pediatric patients.^6-9 Both muscle and fasciocutaneous free flaps have been described for use in the pediatric patient with excellent outcomes. However, free tissue transfer procedures are not appropriate or indicated in all settings; their use can be precluded by the nature of the injury, concomitant patient conditions, vascular injury or disease, or patient noncompliance or lack of desire for the surgery.¹ In these patients, selecting an alternative method of soft tissue coverage can be difficult.

The use of temporary bone malpositioning to allow for soft tissue coverage in large open fractures was first described in the orthopedic literature in 2006.² This technique has subsequently been published in several articles that validate its efficacy and utility in patients with complex soft tissue wounds.^3-4 Temporary bone shortening has also been described where the bone is acutely shortened over an intramedullary nail, also allowing for a decrease in the size of the soft tissue defect. However, in these cases the limb remains permanently shortened, and this type of closure requires good bony apposition, which is not always possible for Gustillo Type III injuries.⁵ Rather than shortening, the external fixator can fix the bones into an intentionally deformed position that is then gradually adjusted to correct the deformity over time. Vascular perfusion to the extremity should be closely monitored throughout this process because arterial kinking can occur following changes to the external fixator. If concerns for perfusion occur during limb manipulation, the fixator should be modified as needed. This may necessitate operative exploration or intervention if the patient becomes neurovascularly compromised. The gradual manipulation of the bony position over time allows for the soft tissue coverage to stretch and maintain compliance without significant wound breakdown and dehiscence. Ultimately, the bone maintains its length and the soft tissue coverage remains adequate without requiring a free flap. The patient should remain with the external fixator in place for at least 6-8 weeks following correction of the limb restoration to allow for complete bony and soft tissue healing prior to removing the distractor devices.

This procedure does have some limitations. Not all wounds are conducive to limb deformation; very proximal or distal lower leg injuries would not be ideal, as it is easier to perform limb deformation along the mid-shaft of a long bone. Candidates with nerve/vascular injury necessitating repair may also not be ideal candidates for this procedure because gradual limb deformation and repositioning could place tension on the repair. Additionally, candidates with wound healing issues related to the bone (osteogenesis imperfecta) or soft tissues (Ehlers-Danlos syndrome, cutis laxa) would not have an optimal outcome using this technique. Moreover, although free tissue transfer procedures would require additional operative time initially, this procedure does require compliance with external fixator modifications and multiple operating room procedures, which may not be ideal in certain patients.

In summary, we present an alternative treatment option for pediatric patients with open lower extremity fractures and significant soft tissue defects. Intentional limb deformation can be considered a safe alternative to free tissue transfer when it is either contraindicated or not desirable.

Affiliations: ¹Division of Pediatric Plastic Surgery, Nationwide Children’s Hospital, Columbus, OH; ²Department of Orthopedic Surgery, Nationwide Children's Hospital, Columbus, OH; ³Department of Plastic Surgery, The Ohio State University College of Medicine, Columbus, OH

Correspondence: Gregory D Pearson, MD; gregory.pearson@osumc.edu

Disclosures: The authors have no relevant financial or nonfinancial interests to disclose.