The Treatment of Type I Open Fractures in Pediatrics
Open fractures are frequently encountered in orthopaedics. Treatment usually calls for a formal, operative procedure in which the bone is exposed, foreign tissue is debrided and the wound is irrigated. While this is the current standard of care, not all open fractures are equal. In retrospective studies, centers are reporting less aggressive operative management for open fractures may result in equal results without the time and expense of the operative theater. The investigators propose a prospective, randomized trial of children with type I open fractures to evaluate whether formal operative treatment is necessary. The investigators' hypothesis is that minor open fractures can be safely treated in the emergency room with irrigation, closed reduction and home antibiotics without an increased risk of infection or other complications. Children who meet the study criteria will be randomized into two treatment arms - formal operative management (OR) and emergency department (ED) management. Outcomes from each group will be evaluated and compared, including rate of infection, number of return visits to the operating room, time to union, and other complications.
Fractures in which bone has been exposed to the outside world through an associated skin injury, known as open fractures, are frequently encountered in orthopaedics. Traditionally, treatment calls for a formal, operative treatment in which the bone is exposed, foreign tissue is debrided and the wound is irrigated. The bone itself, depending on the age of the patient, fracture location and stability is then treated by the appropriate method of casting or internal fixation. However, while this is the current standard of care for all open fractures, not all open fractures are the same and can differ in terms of the bone involved, energy causing the injury and the skeletal maturity of the patient. Children, for example, have a thick periosteum which may diminish the rate of infection and decrease the time to healing. In addition, the protocol of operative debridement was introduced at the same time as widespread antibiotic use. It is not known whether the mechanical operative management or antibiotic use has resulted in improved outcomes. In retrospective studies, centers are reporting emergency department management alone may result in equal results without the time and expense of the operative theater.
We propose a prospective, randomized trial of children with type I open fractures to evaluate whether formal operative treatment is necessary. Our hypothesis is that minor open fractures in children can be safely treated in the emergency room with irrigation, closed reduction and home antibiotics without an increased risk of infection or other complications. If the inclusion criteria is met and informed consent is obtained, children will be randomized into two treatment arms - formal operative management (OR) and emergency department (ED) management. Children randomized to the OR arm will be taken to the OR within 24 hours for irrigation and debridement and appropriate bone management. Children in the ED arm will have a washout in the emergency room under conscious sedation, a closed reduction and home antibiotics. Both wounds will be examined at interval follow up periods for signs of infection. Outcomes evaluated will include the rate of infection, the number of return visits to the operating room, the time to bone healing, and other complications. This is a pilot study with the plan of eventually being a multicenter study evaluating open fracture care in children.
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
Formal Operative Treatment, Emergency Department Treatment
Children's Memorial Hospital
Not yet recruiting
Children's Memorial Hospital
Results (where available)
- Source: http://clinicaltrials.gov/show/NCT00870064
- Information obtained from ClinicalTrials.gov on July 15, 2010
Medical and Biotech [MESH] Definitions
Osteotomy, Le Fort
Transverse sectioning and repositioning of the maxilla. There are three types: Le Fort I osteotomy for maxillary advancement or the treatment of maxillary fractures; Le Fort II osteotomy for the treatment of maxillary fractures; Le Fort III osteotomy for the treatment of maxillary fractures with fracture of one or more facial bones. Le Fort III is often used also to correct craniofacial dysostosis and related facial abnormalities. (From Dorland, 28th ed, p1203 & p662)
First aid or other immediate intervention for accidents or medical conditions requiring immediate care and treatment before definitive medical and surgical management can be procured.
The specialty or practice of nursing in the care of patients admitted to the emergency department.
Emergency Service, Hospital
Hospital department responsible for the administration and provision of immediate medical or surgical care to the emergency patient.
Fractures in which there is an external wound communicating with the break of the bone.
The purpose of the study is to compare functional outcomes and recovery following surgical and non surgical treatment of potentially unstable , isolated fibula fractures. Secondary objecti...
This is a multicentre randomized clinical trial prospectively comparing operative treatment versus conservative (nonoperative) care in the management of displaced distal (Type II) clavicle...
An Emergency Department Targeted Ultrasound (EDTU) is an ultrasound examination performed by an emergency department physician, instead of a radiologist or ultrasound technician. EDTU is i...
A multi-site randomized controlled trial where patients are allocated to operative treatment or conservative treatment of fractures of the neck of the 5th metacarpal bone. The study goal i...
The purpose of this study is to compare the rate of non-urgent emergency department use between three groups of patients: those who were referred to the emergency department by Telehealth...
Fractures of the ankle are fairly common injuries. Open ankle fractures are much less common and associated with severe injuries to surrounding tissues. We have performed a systematic review of the li...
Acetabular both-column fractures are challenging articular injuries. They usually require operative treatment. We report on fundamental elements of pathoanatomy and radiology that are reviewed as far...
Standard treatment for most humeral shaft fractures is nonoperative functional bracing; however, certain clinical scenarios necessitate operative intervention. There have been few studies in the liter...
This paper outlines the history of advances made in the treatment of open fractures that have occurred during wartime.
Femoral head fractures may present in various patterns with or without associated fractures around the hip. As a result, the treating orthopaedic surgeon must understand not only the fracture pattern,...