Surgery Unnecessary for Open Fractures?

New work from researchers at Johns Hopkins Children’s Center is challenging the clinical status quo. In a study of 40 pediatric patients, the investigators found that many children with open fractures in the forearm or lower leg can heal safely without surgery.

The study, which involved children ages 4 to 16 treated nonsurgically at Johns Hopkins between 2000 and 2013, was published ahead of print in the Journal of Children’s Orthopaedics. As indicated in the December 10, 2014 news release, “The team found that when the wound is small—less than ½ inch in diameter—and the surrounding tissue is free of visible contamination with dirt or debris, children heal well on their own.”

“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, ” says study senior investigator Paul Sponseller, M.D., M.B.A., director of pediatric orthopaedics at the Johns Hopkins Children’s Center. “We believe our results set the stage for a larger study to settle the long-standing debate on this issue once and for all.”

As stated in the news release, “The nonsurgical option requires irrigating and cleaning the flesh wound without cutting any further around the break, setting the bone ends together, and casting the limb, all done with the use of local anesthesia in the emergency room.”

The researchers cautioned that each and every open fracture is not necessarily right for nonsurgical repair. “Those that include damage to surrounding nerves or blood vessels require a more elaborate surgical treatment, as do wounds that are visibly contaminated and in need of surgical removal of affected tissue, the team notes. Cases in which the realignment of the bone is tricky and cannot be achieved without surgery should also be treated operatively.”

“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. “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.”