Management of a Complex Lower Limb Open Fracture in a Teenage Patient: A Case Report

The challenges of managing Gustilo IIIB tibial fractures (ie, high energy trauma with a contaminated wound >10 cm in length, severe comminution [“crumbling”] or segmental fractures, and periosteal stripping) in children are unique in part because no clear guidelines exist and the injuries may cause short-term and long-term complications. Repeated wound debridement and secondary reconstruction are required in approximately 20% of these cases in both adults and children. A 13-year-old girl presented with severe polytrauma including an open Gustilo type IIIB fracture of the left lower leg.The patient declined limb amputation; a multidisciplinary team (plastic, pediatric, orthopedic-trauma surgeons, pediatrician, psychiatrist, clinical pharmacologist, anesthesiologist, physiotherapist, nurses) was assembled in order to give the patient the best chance of a successful outcome. Multiple limb salvage and reconstructive procedures including wound debridements, necrectomies, long-term negative pressure wound therapy, soft tissue reconstructions, external bone fixation, bone osteosynthesis, multiple skin grafts, and free-flap reconstruction were provided over a period of 6 months with great success. The patient is doing well 3 years after initial injury and is walking without complications. A multidisciplinary approach and structured treatment plan are important to minimize complications, avoid unnecessary delays in treatment, decrease morbidity, and provide the patient with the best result possible. Studies examining optimal treatment strategies for children and adolescents with these complicated fractures are needed. 

Managing Gustilo IIIB tibial fractures in children and adolescents presents unique challenges. In children, these fractures are associated with a 4.5% incidence of neurovascular compromise requiring intervention, 1.5% primary amputation, and 1.2% mortality rates; repeated wound debridement and secondary plastic surgery are required in approximately 20% of fractures.¹ In the pediatric population, open fractures account for approximately 5% of all tibia fractures,^2,3 which should raise awareness regarding the severity of these injuries. 

A trend toward better results has been noted in younger children and those with a low Gustilo-Anderson fracture grade. Higher fracture grades according to the Gustilo classification (see Table) are associated with a higher complication rate and longer union times (ie, time needed for the fracture reduction to stabilize without any gap formation).¹ According to a review of the literature,⁴ these injuries should be treated with delayed wound closure and may require a skin graft or a flap. According to a systematic review of literature by Baldwin et al,⁵ surgical fracture stabilization usually is required and the option of external fixation seems appropriate for the management of grade III open fractures. 

Open tibial fractures in adults have been studied extensively, and detailed treatment strategies have been developed by the AO Trauma Foundation⁶; wound irrigation and debridement, fracture stabilization, and delayed primary wound closure or early flap coverage are basic principles of management. However, no clear guidelines or protocols exist regarding the management of open tibial fractures in children, which makes these cases challenging for physicians. It is unclear whether open fractures of the tibia in children should be managed according to the same principles followed in adults, because the literature does not facilitate scientifically based conclusions of management strategy or identification of possible risk factors in children. In a combined retrospective and prospective review, Bartlett et al⁷ studied 23 fractures in children ages 3.5 years to 14.5 years (18 boys and 5 girls) that included 6 type II, 8 type IIIA, and 9 type IIIB fractures. The authors concluded open tibia fractures in children differ from similar fractures in adults in that soft tissues have excellent healing capacity, devitalized bone that is not contaminated or exposed can be saved and will become incorporated, and external fixation can be maintained until the fracture has healed. The authors also noted periosteum in young children can form new bone even when there is bone loss. A review by Gougoulias et al¹ suggested a lack of long-term follow-up examinations, despite the fact these injuries in the pediatric population can lead to angular deformity and leg length discrepancy. With no clear guidelines in the treatment of such injuries in children, the purpose of this paper is to document the outcome of the authors’ approach and describe the methods used to successfully treat and rehabilitate a child with a complicated Gustilo IIIB open fracture. 

History. Ms. A was admitted to the authors’ facility in January 2014 at age 14 years. When she was 11 years old, she was sold to a family and became the victim of human trafficking. At the age of 12 years, she experienced a spontaneous abortion, after which she managed to escape her captors and was placed into a government-run home where the case first was reported to authorities. Ms. A was hospitalized on 2 different occasions at the local county hospital due to psychological problems. She was diagnosed with anxiety disorder, reaction to severe stress, and adjustment disorder for which she was treated with counseling, oral antidepressives, and anxiolitics. 

After 1 year at the childcare facility, she allegedly heard she would be returned to her captors. This information and fear were the trigger for attempting suicide; she jumped off a 3-story building. Ms. A experienced severe polytrauma, including a closed fracture of the right tibia and fibula and an open tibial fracture on the left leg with an extremely contaminated large skin and soft tissue defect of about 50% of the total lower leg volume, severe fracture comminution (bone “crumbling”), and periosteal stripping. She suffered other injuries that further complicated her recovery, including fractures of her pelvic bones (acetabulum and right ischiopubic bone); basilar skull; left frontal, orbital, and zygomatic bones; and right sphenoid bone and nasal bones. Ms. A also had a diffuse cerebral contusion and bleeding into the maxillary, ethmoidal, frontal, and sphenoid sinuses. Due to thoracic contusion and bilateral contusion of the lungs, her condition was further complicated by respiratory failure. 

Treatment. Soon after Ms. A was admitted to the county hospital, surgery for the leg trauma was postponed due to head and thoracic injuries, and cast immobilization was placed. Three (3) days later, Ms. A developed compartment syndrome (a relatively uncommon complication in open fracture injuries in children¹) of the left lower leg and underwent a fasciectomy and placement of an external fixator. The primary fasciectomy (that resulted in a large tissue necrosis and local infection) was delayed because the cast immobilization covered the leg and during the next 3 days, the neurocirculatory status of the leg was not properly checked. 

Two (2) weeks after the initial injury, Ms. A was transferred to the authors’ Department of Plastic and Reconstructive Surgery where her lower leg was examined. Local findings included an open tibial fracture with external fixation, necrotic muscles of the anterior and lateral muscle compartments, purulent secretions, and a skin defect measuring 33 cm x 20 cm with necrotic edges, exposing the entire length of the lateral, posterior, and anterior aspects of the lower leg (see Figure 1). Additionally, Ms. A had a closed fracture of the right lower leg, also with external fixation. 

Upon her arrival, a surgeon performed a necrectomy and wound debridement of the necrotic skin and muscle tissue of the left lower leg and applied constant negative pressure wound therapy (NPWT) at -120 mm Hg that was changed every 4 to 5 days for the next 3 weeks (see Figure 2). 

After optimization of the wound bed, the external fixator was removed and osteosynthesis was performed using cortical screws. The residual soft tissue defect was filled using a free microvascular latissimus dorsi flap, anastomosing the thoracodorsal artery and vein to the popliteal artery and vein, respectively. To cover the skin defect, a split-thickness skin graft harvested from her left thigh region was placed (see Figure 3). Within 72 hours, the donor tissue developed dark discoloration and a loss of Doppler signal. It was surgically removed due to flap failure and tissue necrosis. To close the skin and soft-tissue defect, NPWT again was applied at the same setting (-120 mm Hg) and changed every 4 to 5 days for the next 5 months. During this period, several split-thickness skin grafts from the left thigh were harvested and placed to cover the residual skin defect, after which NPWT was reapplied as previously described (see Figures 4, 5). In the last month of her treatment, Ms. A also underwent a total of 22, 1-hour hyperbaric chamber treatments.

Two (2) months after the initial injury, the external fixator on the right lower leg was removed, the right tibia was manually repositioned, and osteosynthesis was achieved using an intramedullary nail. During the same surgical procedure, the screws previously placed in left lower leg were removed, necrectomy of necrotic bone of the proximal part of the left tibia was performed, and an external fixator again was positioned. Ms. A was hospitalized for a total of 6 consecutive months.

Immediately upon arrival and throughout hospitalization, a pediatric psychiatrist monitored Ms. A on a daily basis. Ms. A was treated with anxiolitic and antidepressive medications — diazepam, 10 mg per day, and sertraline, 25 mg per day. She also underwent weekly psychotherapy consultations. During her stay, multiple wound, urine, blood, and central venous catheter cultures were taken, and appropriate antibiotics were prescribed according to the antibiogram results. Bacterial isolates from wound cultures included Enterococcus faecalis, Pseudomonas aeruginosa, Staphylococcus species, and Acinetobacter baumannii. 

Prognosis. Six (6) months after admission, Ms. A was discharged from the Department of Plastic and Reconstructive Surgery and transferred to the Department of Orthopedics, afebrile with all wounds closed. She underwent 5 separate additional surgical procedures at the Department of Orthopaedic Surgery. 

The first surgical procedure involved elongation of the left Achilles tendon, tenotomy of the left posterior tibial muscle, and capsulotomy of the left posterior talocrural and subtalar joints. The second and third surgical procedures were tenotomies of the left digital flexor muscles and the abductor muscle of the left thumb. The fourth procedure was to correct the patient’s pes cavus using the Steindler technique (ie, muscle and fascia stripping from the plantar surface of the calcaneus). The last procedure was performed to correct pseudoarthrosis of the left lower leg using an Ilizarov apparatus that was removed 3 months later.

Ms. A’s early postoperative status at the Department of Orthopedic Surgery was satisfactory. She was independently mobile with the aid of crutches and orthotics. 

Follow-up. Ms. A’s follow-up was performed based on common clinical practice in the authors’ department. At her 18-month follow-up, Ms. A was afebrile, all wounds were closed, and she experienced no discomfort. No edema was noted on her lower limbs, her left knee was flexed to about 75˚ with the aid of orthotics, and she was mobile (see Figures 6, 7). She continued to receive regular psychiatric counselling and remains on her psychiatric medications.

Open tibial fractures have been studied extensively in adults, and detailed treatment strategies have been developed that include wound irrigation and debridement, fracture stabilization, and delayed primary wound closure or early flap coverage as basic principles of management. No clear guidelines exist regarding the management of open tibial fractures in children.¹

 Glass et al⁴ performed a systematic review of the literature and evaluated Gustilo grade IIIB tibial shaft fractures in preadolescent and adolescent children with regard to both the skeletal and soft tissue management and patients’ outcome. The authors found that in 54 children with grade IIIB tibial fractures, mean union (complete fracture closure) time was 31 weeks and included 33 weeks for 42 adolescents and 23 weeks for 12 preadolescents. This difference tended toward statistical significance. Delayed union (a failure to reach bony union by 6 months post-injury) occurred in 22% and nonunion (an arrest in the fracture repair process or progressive evidence of nonhealing of a fracture of a bone) in 13% of patients, mostly in adolescents. Of the 45 fractures, 2 covered by vascularised flaps and 3 of 9 treated without flaps developed deep infection (P = .028). The authors also found no correlation between method of skeletal fixation and union time. They concluded that Gustilo IIIB tibial shaft fractures in preadolescents tended toward faster healing with fewer complications, irrespective of the method of skeletal fixation, and adolescent healing times were similar to adults. Soft tissue closure without flaps was associated with deep infection in one third of patients, requiring debridement and flap cover. Adequate debridement and flap cover was suggested in all cases, irrespective of age.

As noted earlier from their combined retrospective and prospective review, Bartlett et al⁷ evaluated treatment protocol for type II and type III open tibial fractures in children over a 10-year period (1984 to 1993). They sought to determine whether severe open tibial fractures in children behave like similar fractures in adults. The authors found open tibial fractures in children differ from similar fractures in adults in that soft tissues have excellent healing capacity, devitalized bone that is not contaminated or exposed can be saved and will become incorporated, and external fixation can be maintained until the fracture has healed. Periosteum in young children can form bone even in the face of bone loss. 

For the patient in this report, after latissimus dorsi flap deterioration the main issue for discussion became further therapeutic possibilities: free flap, pedicle flap, “cross leg” fasciocutaneous flap, or amputation. It was necessary to compare the advantages and disadvantages of each approach and modality of treatment. The patient was not willing to lose her leg, and none of the above-mentioned reconstructive options was ideal because of the extent of bone and soft tissue defects. NPWT proved to be helpful even in this severe case, although it is not a reconstructive method and requires a considerable amount of time and patience. In this case, NPWT helped provide an acceptable healing result, even though the injuries were severe and contaminated. In their review of literature, Setter and Palomino³ found external fixation remains a successful treatment option for unstable tibial shaft fractures. However, the question remains whether Ms. A would have derived more benefit from leg amputation and a functional prosthesis than from all procedures performed when considering the long duration of hospitalization (a total of 10 months), the large amount of antibiotics and other medication she received, and many episodes of general anesthesia she endured. Amputation remains an option for Ms. A to decide for herself in the future. 

Tibial fractures must be managed by a multidisciplinary team (plastic, pediatric, orthopedic-trauma surgeon, pediatrician, psychiatrist, clinical pharmacologist, anesthesiologist, physiotherapist, nurses) due to their complexity in order to give the patient the best chance of a successful outcome.⁸ A multidisciplinary approach optimizes the patient’s treatment and may avoid delays by having multiple specialists simultaneously involved in the case; hence, minimizing confusion, delay in treatment, and contradictory treatment modalities; decreasing the chance for or spread of infection; monitoring the status of the wound and skin grafts and flaps; and providing constant patient care.  It remains unclear whether open tibial fractures in children should be managed according to the principles followed in adults. Carefully designed prospective cohort studies with a large number of children would be of value. Adequate follow-up is necessary to assess the long-term effects in the growing skeleton, and outcome studies based on general health measures are needed.

With no clear guidelines in the treatment of such injuries in children, a child with multiple injuries including a complicated Gustilo IIIB open fracture was managed with long-term antibiotic treatment, debridements, necrectomies, internal and external bone fixation, long-term NPWT, skin grafting, free flap reconstruction, multiple soft tissue reconstructions, physical therapy, and psychiatric care. A multidisciplinary approach and structured treatment plan are important to minimize complications, avoid unnecessary delays in treatment, and decrease morbidity, providing the patient with the best result possible. Further studies that include a larger patient population are needed to create clear and concise guidelines and optimal treatment strategies for children and adolescents with these complicated fractures.

Dr. Mijatović is a professor, Plastic, Reconstructive and Aesthetic Surgery, University of Zagreb, School of Medicine; and Chief of Staff, Plastic, Reconstructive and Aesthetic Surgery ward at the University Hospital Center, Zagreb, Croatia. Dr. Smuđ Orehovec is a plastic, reconstructive, aethetic surgery specialist, University Hospital Center, Zagreb. Prof. Đapić is a professor of orthopedic surgery, University of Zagreb, School of Medicine; and a pediatric surgeon, Department of Orthopaedic Surgery, University Hospital Center, Zagreb. Dr. Vrbanović Mijatović is a specialist in anesthesiology and reanamatology, Department of Anesthesiology, Clinical Hospital Centre, Zagreb. Dr. Mance is a fourth-year resident, Plastic, Reconstructive and Aesthetic Surgery, University Hospital Center, Zagreb.

Please address correspondence to: Sanda Smuđ Orehovec, MD, Clinical Hospital Centre, Zagreb, Department of Surgery, Division of Plastic, Reconstructive and Breast Surgery, Kišpatićeva 12, 10000 Zagreb, Croatia; email: sanda.smud@gmail.com.