Southmead Hospital, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK.
Southmead Hospital, North Bristol NHS Trust, Southmead Road, Bristol BS10 5NB, UK.
Injury. 2019 Jul;50(7):1376-1381. doi: 10.1016/j.injury.2019.05.001. Epub 2019 May 2.
Open lower limb fractures can be devastating with outcomes determined by tissue damage and adherence to strictly defined care pathways. Managing such injuries in paediatric and elderly populations presents logistical and technical challenges to achieve best outcomes. Orthoplastic principles were developed mainly in the young adult population whereas requirements for paediatric and elderly patients need further understanding.
A retrospective analysis was performed on two groups of patients at the extremes of age, with type IIIb (severe) open lower limb fractures, presenting to a Major Trauma Centre (MTC) with orthoplastic services over a six-year period - the first group being under 16 years; the second group being over 65. The timelines of combined surgery to both fix the fracture and flap the soft-tissue defect were strictly observed. Each group were followed-up for a minimum of nine months. Data were analysed according to patient demographics, mechanism of trauma, time to wound excision, time to definitive surgery, fixation technique, soft-tissue reconstruction type, deep infection rate, flap survival, bony union, secondary amputation and functional outcome (Enneking score).
33 paediatric patients and 99 elderly patients were identified. Paediatric: The median age was 12 years. All the children were ASA Grade I. Open tibial fractures were most common (76%) followed by ankle fracture dislocation (12%). The majority were high-energy injuries and were commonly managed with external fixators (or frames) and free flap coverage. Median hospital stay was 12 days, and time to union 114 days, with median Enneking scores of 85%. There was one flap failure and no deep infections. Elderly: The median age was 76 years. ASA grades varied and reflected multiple comorbidities. High-energy injuries required free flaps, while more common, low-energy fragility fractures were covered with loco-regional flaps. Internal fixation with intramedullary nails was most commonly used. Median hospital stay was 13 days, and time to union was 150 days, with median Enneking scores of 70%. There was one flap failure, one deep infection, and one delayed amputation.
These results reflect both similarities and important differences in managing open fractures in the extremes of age. The specific challenges of each group of patients are discussed, including surgical aspects, but also the importance of orthoplastics infrastructure within the MTC and input from allied professionals to facilitate patient pathways.
开放性下肢骨折可能是毁灭性的，其结果取决于组织损伤和严格定义的护理路径的遵守情况。在儿科和老年人群中管理此类损伤存在后勤和技术挑战，以实现最佳结果。矫形原则主要是在年轻成年人中发展的，而儿科和老年患者的需求需要进一步了解。
对在六年期间在一家主要创伤中心（MTC）接受矫形服务的两组极端年龄的 IIIb 型（严重）开放性下肢骨折患者进行回顾性分析 - 第一组年龄在 16 岁以下；第二组年龄在 65 岁以上。严格遵守同时固定骨折和皮瓣软组织缺陷的联合手术时间线。每组患者的随访时间均至少为九个月。根据患者的人口统计学、创伤机制、伤口切除时间、确定性手术时间、固定技术、软组织重建类型、深部感染率、皮瓣存活率、骨愈合、二次截肢和功能结果（Enneking 评分）对数据进行分析。
确定了 33 名儿科患者和 99 名老年患者。儿科：中位年龄为 12 岁。所有儿童的 ASA 分级均为 I 级。开放性胫骨骨折最为常见（76%），其次是踝关节骨折脱位（12%）。大多数是高能损伤，通常采用外固定器（或框架）和游离皮瓣覆盖。中位住院时间为 12 天，愈合时间为 114 天，中位 Enneking 评分为 85%。有一例皮瓣失败，无深部感染。老年：中位年龄为 76 岁。ASA 分级各不相同，反映了多种合并症。高能损伤需要游离皮瓣，而更常见的低能脆性骨折则用局部皮瓣覆盖。最常使用髓内钉内固定。中位住院时间为 13 天，愈合时间为 150 天，中位 Enneking 评分为 70%。有一例皮瓣失败，一例深部感染，一例延迟截肢。
这些结果反映了在极端年龄管理开放性骨折时的相似性和重要差异。讨论了每组患者的具体挑战，包括手术方面，但也讨论了 MTC 内矫形基础设施的重要性以及相关专业人员的投入，以促进患者的治疗途径。
