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Treatment of Fractures Complicated by Burn or Head Injuries in Children*

R. DALE BLASIER, M.D., F.R.C.S.(C), LITTLE ROCK, ARKANSAS

An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

	Introduction

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The treatment of fractures in children who have multiple injuries is often complex. Fractures that are complicated by burn or head injuries may be especially challenging because such injuries may be extremely severe and the prognosis may be poor. These children may be in extremis or in a very unstable condition at the time of presentation and thus may be poor candidates for anesthesia. Other injuries may be deemed to take precedence, and orthopaedic procedures tend to be postponed. However, because of the unique problems that occur in these patients both immediately after the injury and in the long term, operative stabilization of fractures often can provide great benefits.

	Treatment of Fractures in Children Who Have Burn Injuries

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The coexistence of burn injuries and fractures is not unusual in children because of the association between fire and traumatic injury. Kaplan and Pruitt noted orthopaedic injuries in 197 (6.1 percent) of 3221 patients who had burn injuries¹¹. Because burns and fractures complicate the treatment of each other, there must be some coordination between the trauma surgeon, the general surgeon, or the plastic surgeon who treats burns and the orthopaedic surgeon who treats fractures.

Initial Evaluation and Resuscitation
In the initial management of a patient who has both a burn and a fracture, priority must be given to the airway, breathing, and circulation. Injury to the airway, tissue oxygenation, and replacement of fluids and electrolytes are always concerns in the management of a patient who has a burn. Evaluation of musculoskeletal injury should be deferred until life-threatening conditions are assessed.

The history is helpful in guiding the examiner. Children who have been injured in a motor-vehicle accident with a resulting fire and those who have jumped from a burning building are likely to have multiple injuries. The identification of deformity and crepitus is helpful in diagnosing a fracture. Tenderness that is due to a fracture must be differentiated from that due to a burn. Radiographs will confirm the presence of a suspected fracture. In burnt areas, anti-infective dressings with use of silver-sulfadiazine or polymyxin-bacitracin cream must be applied before splinting is done.

Special Problems in Children Who Have Burn Injuries
Both burns and fractures can cause severe soft-tissue swelling. The constrictive effect of soft-tissue swelling and burnt skin may preclude effective circulation or, in the case of a chest burn, effective breathing. When there are circumferential burns of the trunk or limbs, escharotomy may be required immediately and is usually done in the emergency room. In a patient who has a full-thickness burn, this procedure may be done without an anesthetic as bleeding and pain are not problems. Fasciotomy with the patient under anesthesia may be required if the muscle swells from within and skin sensation and superficial perfusion are intact.

The depth of the burn is a very important factor in the management of these patients. Deeper involvement is associated with a poorer prognosis. Superficial burns are characterized by redness and tenderness, and prompt healing is expected regardless of the care. Partial-thickness burns result in destruction of the superficial layers with maintenance of the germinal layers and the sensory fibers. Sensation to pain is intact. Infection is possible. Topical care varies according to region, local custom, and standard of care, but it typically involves the application of silver-sulfadiazine or polymyxin-bacitracin cream, secured with circumferential gauze, directly to the area. Alternatively, the gauze may be impregnated with aqueous Sulfamylon (mafenide acetate) and wrapped around the burnt area. The dressing usually is changed twice a day. If possible, the patient can be immersed in a Hubbard tank or a whirlpool to clean and gently debride the skin before the dressing is changed.

Full-thickness burns involve superficial and deep skin elements, including the sensory-nerve fibers. The skin is discolored, has a leathery feel, and is insensate. Large full-thickness burns (those that are more than a few centimeters) will not heal spontaneously; excision and grafting is required. The term fourth-degree burn implies destruction of deep structures such as muscle, neurovascular bundles, periosteum, and even bone. Such injuries are likely to require an amputation.

Definitive Treatment
Bacterial contamination of deep burn wounds is inevitable, and infection is likely if the burn is not treated topically as described earlier. Treatment is aimed at prevention of infection while healing takes place. Topical antimicrobial agents, such as silver-sulfadiazine and polymyxin-bacitracin cream, and frequent changes of the dressing are appropriate for partial-thickness burns. Intravenous administration of antibiotics, excision, and grafting are usually required for full-thickness burns.

Wound infections are usually acquired during hospitalization; therefore, empirical treatment with antibiotics is tailored to the local flora, which may differ among institutions. Before a specific organism has been identified on the basis of cultures, one of the following antibiotics may be given intravenously: ceftazidime (fifty milligrams per kilogram of body weight every eight hours), cefazolin (fifty to 100 milligrams per kilogram of body weight per day, in divided doses every eight hours), or vancomycin (forty milligrams per kilogram of body weight per day, in divided doses every six hours). After a definite causative organism has grown on culture of blood or of specimens from the wound, the most effective antibiotic for that type of organism should be used.

During treatment, positioning of joints and limbs is needed to prevent contracture. Physical therapy, performed twice daily, is helpful in maintaining mobility.

Nonoperative treatment is appropriate for many fractures with adjacent burns. More severe burns or fractures should not be treated with a circumferential cast as it does not allow easy access to the skin for examination or changes of the dressing. A splint allows intermittent access to the skin, but changing the splint may be painful or may lead to loss of reduction in patients who have an unstable fracture pattern. Traction is useful for suspending limbs, aligning fractures of the long bones, and preventing contractures, but it makes treatments outside the bed more difficult.

There are obviously patients in whom treatment of the fracture and the burn will be facilitated by operative stabilization of the fracture, including those who have an unstable fracture pattern with overlying burns that preclude use of a cast, those who have a fracture of a long bone that precludes mobility of the patient or the limb, and those who have a displaced periarticular or intra-articular fracture. Major factors that may contraindicate operative treatment include the risk of an extensive operation in a patient whose condition is unstable, poor skin quality, wound infection, and sepsis. The risks and benefits must be weighed for each patient.

It has been suspected for years that operative stabilization of fractures in patients who have burn injuries is not only possible but beneficial. Studies of animals have provided evidence that internal fixation may be performed through burnt skin. Fitts et al. found that, compared with use of gauze and plaster, intramedullary nailing in dogs with burns did not increase the prevalence of infection but did increase the rate of healing⁶. Grisolia et al. performed intramedullary nailing in dogs that had third-degree burns⁸. Immediate nailing resulted in healing in nine of nine dogs, whereas only four of fifteen dogs had healing when nailing had been delayed for forty-eight hours. In a subsequent study, those authors found that fracture-healing improved greatly if excision of burnt skin and grafting was performed forty-eight hours before open reduction and internal fixation⁹.

Operative treatment for humans has evolved slowly. In 1944, Warthen suggested that closed reduction and encasement in plaster was appropriate for burnt limbs and that traction was appropriate for fractures of the long bones²⁰. In 1968, Dowling et al. recommended topical treatment of burns and delayed treatment of fractures⁵. Those authors believed that an incision through burnt skin was risky. In 1977, Novak et al. advocated the use of primary internal fixation combined with excision and grafting of skin¹⁵. In 1983, Saffle et al. recommended early open reduction and internal fixation of fractures even through burnt skin, as this did not appear to cause infection¹⁸. In 1989, Curtis and Clarke reported that the benefits of early skeletal stabilization outweighed the risk of infection in patients who had burn injuries³. In 1991, Dossett et al. recommended that, if resuscitation and treatment of other immediate operative priorities have been successful, an early operative approach should be used even through burnt skin for major fractures that would require internal fixation in an unburned patient or for those that would interfere with treatment of the burn if the limb was salvageable⁴. In 1994, Brandt et al. noted that early stabilization of fractures in patients with burn injuries improved mobility and wound care and minimized late complications¹.

Fracture-Related Factors for Consideration
Time from the injury: The time from the injury to the operation is important. Incisions through burnt skin should be performed within forty-eight hours after the injury or the skin must be presumed to be colonized by bacteria. If fixation of the fracture is delayed for more than forty-eight hours, the skin must be allowed to heal before the operation or fixation can be performed after excision and grafting. External fixation is an option at any time.

Open injury: Open fractures must be irrigated and debrided as soon as possible. A wound with gross contamination (for example, from dirt or grass), extensive contamination by particles, or high-risk contamination (for example, from barnyard dirt) is a contraindication to internal fixation, and external fixation should be considered.

Location of the fracture: It is recommended that periarticular fractures be reduced and fixed internally as soon as possible to allow positioning and motion. If there is a choice, the operation should be performed through good-quality skin.

Timing of the Operation
Fractures that are amenable to operative treatment should be fixed as soon as possible. The benefits of fixation, including ease of nursing care, pain control, access to the limb for the treatment of burns, and patient mobility, can be realized immediately. If the operation is delayed for more than forty-eight hours after the injury, the risks of bacterial colonization of the wound, operative infection, and respiratory complications will increase. Resolution of these problems may be protracted.

Recommendations for the Operative Treatment of Fractures
When a patient has a fourth-degree burn with severe damage to deep structures, early amputation must be considered in order to prevent life-threatening sepsis.

Open fractures must be irrigated and debrided as soon as the patient can tolerate anesthesia in order to prevent deep infection.

Patients who have a fracture with an adjacent burn and are seen within forty-eight hours after the injury can be operated on immediately in order to stabilize the fracture. If the quality of the soft tissues is poor or the patient cannot tolerate a long period of anesthesia, external fixation or minimum internal fixation should be considered.

When a patient is seen more than forty-eight hours after the time of the injury, colonization of the skin by bacteria must be assumed, along with the risk of deep infection after fixation. External or minimum internal fixation should be considered. Otherwise, operative treatment must be delayed until the skin has healed, or formal open reduction and internal fixation can be performed in association with skin excision and grafting. Provisions to replace severe blood loss must be made.

In summary, the orthopaedist is often hesitant to operate on children who have burns because the injuries can be mutilating, the patient is often in an unstable condition, the skin is damaged, and there is an increased risk of infection. However, operative fixation of associated fractures may be the most humane course of action because it allows painless movement of the limb for physical therapy and facilitates frequent changes of the dressing, bathing, and skin-grafting. With use of these guidelines, the benefits of fixation clearly outweigh the risks.

	Treatment of Fractures in Children Who Have a Head Injury

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It is estimated that, in the United States, 125,000 children who are less than fifteen years old sustain a head injury each year¹⁶. These injuries usually occur as a result of high-energy trauma, such as a motor-vehicle accident, a sports-related accident, or a severe fall. Although children have a relatively high rate of mortality due to head injury (estimated¹⁶ at ten per 100,000), those who survive have an excellent prognosis for recovery. Most patients who are in a coma for six weeks or less will become independent with regard to the ability to walk and self-care. Furthermore, children can continue to recover for as long as five years after the injury¹⁶. Head injury is often associated with multiple injuries, including fractures of the extremities. The coexistence of a head injury and fractures of the extremities complicates the treatment of each.

Initial Evaluation and Resuscitation
Initially, the airway, breathing, and circulation take priority over injuries of both the head and the extremities. After the initial assessment, a neurological examination is performed. If life-threatening injuries are ruled out, the limbs are examined for deformity, swelling, crepitus, and ecchymosis, which would suggest a fracture.

The history is important because specific mechanisms of injury can suggest specific fracture patterns, as in a patient who has been struck by an automobile or one who has been ejected from a vehicle. Whether or not a seat belt had been used and an air bag had deployed must be ascertained.

If the initial assessment suggests a fracture, it is appropriate to apply a splint to the injured part in order to protect the soft tissue from additional damage, especially if the patient is agitated or combative. The use of radiolucent materials for splinting will make it easier to visualize a fracture.

The search for injuries must be diligent and repeated. Patients who are unable to verbalize their symptoms must be assessed repeatedly in order to identify injuries that may have been missed initially. A bone scan may be appropriate for patients who have multiple injuries in order to identify occult fractures¹⁰. Compartment syndrome must always be considered.

While the type and severity of the injuries may vary, the ability of the patient to survive after the head injury dictates the extent of early treatment of the fracture. A few severe injuries, such as an open fracture of the skull with severe loss of the substance of the brain or an injury complicated by massive, irreversible anoxic changes, may not be survivable. Fixation of a fracture or application of an extensive cast should not be undertaken for these patients; however, splinting is appropriate in order to minimize discomfort during expected treatment. If there is any possibility that the child will survive and will awaken from a coma, efforts must be made to prevent musculoskeletal deformity and disability. Many children with very severe head injuries eventually have recovered, much to the surprise of the treating physician. Early, intensive treatment of fractures may prevent difficult or irreversible problems from developing later.

Special Problems in Children Who Have a Head Injury
Early management of patients who have a head injury and fractures is often complicated by an associated injury of the abdomen or chest. These patients may display agitation, posturing, and increased tone. Many require mechanical ventilation and induced pharmacological coma. Supine positioning is generally chosen to allow access to the face, chest, and abdomen. From the start, attention must be paid to pressure points on the skin in order to prevent breakdown of the skin over the scapulae, sacrum, buttocks, heels, and occiput. Open wounds and visceral injuries should be treated in an urgent manner, according to the patient's ability to tolerate anesthesia.

Soon after the injury, it is likely that the patient will need to be placed in and taken out of a magnetic resonance imaging or computerized tomographic scanner, so the presence of a bulky cast or traction device will be a hindrance.

Later on, increased tone is likely in these children, and special measures must be taken in order to prevent contracture. These include physical therapy, splinting, and tone-reducing medications. Baclofen is used to reduce tone. Children between the ages of two and seven years old are given ten to fifteen milligrams orally per day, with each of three doses given every eight hours. The dose is titrated upward in five-milligram increments, every three days, to a maximum of forty milligrams per day in order to obtain the desired effect. For children who are eight years old or more, the dose may be increased to a maximum of sixty milligrams per day.

In the late stages of recovery, the patient may have fixed contractures, abnormal tone, weakness, muscle imbalance and ataxia, and heterotopic ossification. Behavioral abnormalities and cognitive loss may complicate rehabilitation.

Definitive Treatment
Early treatment of a head injury may include supportive care, such as induced coma, fluid management, mechanical ventilation, and monitoring of intracranial pressures, until the patient's condition has stabilized. Operative decompression may be appropriate in some patients.

Treatment of the fracture should be initiated as soon as possible. Nonoperative treatment is appropriate for most fractures of the hand, forearm, tibia, ankle, foot, and humerus. Articular fractures, which may lead to an incongruent joint or to growth disturbance, should be treated operatively as soon as the patient can tolerate anesthesia.

Noncircumferential splinting should be considered if there are underlying skin problems or if access to the compartments is required in order to diagnose compartment syndrome. This diagnosis is suggested if the findings on physical examination include tense swelling and tenderness, and it is confirmed by measurement of compartment pressures. Both physical examination and measurement of pressures necessitate access to the compartments. Placing the patient in traction and slings is a good temporary measure but is difficult to maintain if the patient is agitated, posturing, or combative^7,17. This apparatus also hinders magnetic resonance imaging and computerized tomographic scanning.

Operative fixation should be considered for major fractures that interfere with nursing care, including fractures of the femur and, occasionally, those of the humerus, tibia, or pelvis. A spica cast may hinder free positioning of the patient and access to the vital organs of the trunk and should be avoided if possible.

Several clinical studies have suggested that operative treatment of fractures is appropriate in children who have a head injury, especially those who have a fracture of the femur. Ziv and Rang, in 1983, reported that open reduction and internal fixation of femoral fractures in children who had a head injury was effective when anesthesia could be tolerated²². Intramedullary nailing was safe and provided satisfactory treatment for sixteen fractures, but infection complicated an additional three of five fractures that had been treated with insertion of a plate. In 1986, Porat et al. described the use of external fixation for the treatment of seven femoral fractures in children who had a head injury with associated spasticity, decerebrate posturing, and seizures¹⁷. The fractures healed in good alignment with maintenance of the length of the limb. Those authors recommended this technique for its simplicity and lack of complications.

In 1990, Kirschenbaum et al. described the use of external fixation for the treatment of complex femoral fractures in children, including those who had associated head injury, cerebral palsy, or skin problems and those for whom use of a cast had failed¹². Those authors believed that external fixation effectively controlled unacceptable femoral shortening and angulation in children who had multiple injuries. In 1992, Ward et al. described the use of compression plates in children and adolescents who had a femoral fracture¹⁹. Those authors thought that a good reason for plate fixation was simplification of nursing care and rehabilitation of children who had an associated head injury or polytrauma. In 1993, Kregor et al. reported the results of plate fixation for the treatment of twelve fractures of the femoral shaft¹³. Those authors thought that plate fixation was a good treatment option for children who had a fracture of the femoral shaft and a major head injury or multiple injuries, or both.

In 1976, Fry et al. reported the results of various methods of treatment in thirty-nine children with a head injury who had a total of forty-four fractures of the femoral shaft⁷. Those authors believed that tibial traction and skin traction were ineffective, and they recommended internal fixation or distal femoral traction. Not all fractures of the long bones need fixation. In 1987, Wood and Hoffer reported good results with use of closed methods for the treatment of twenty-nine tibial fractures in children who had a head injury²¹. Those authors were unable to establish a need for operative treatment.

Fracture-Related Factors for Consideration
Open injury: Open injuries must be treated early and intensively. The only contraindication to operative irrigation and débridement of an open fracture is impending death or an inability to tolerate anesthesia. If it is not possible to proceed with débridement, documentation of the reasoning must appear in the chart. If the procedure must be delayed, it still should be done as soon as possible to decrease the risks of invasive contamination, infection, and sepsis.

Concomitant injury: The benefits of an orthopaedic procedure always must be weighed against any possible deleterious effects on head or visceral injuries. Communication between subspecialists is essential to the safety of the patient. Life-saving operations must take precedence over limb-saving procedures. A head injury with resultant lability of vital signs may preclude the use of anesthesia for any reason.

Location of the fracture: The location of the fracture is important. There is agreement that fractures of the femoral shaft must be stabilized. There are relative indications for the fixation of fractures of the humerus, pelvis, and tibia, including the need to facilitate nursing care, increase mobility, decrease pain, and minimize deformity associated with spasticity. Fixation of a periarticular fracture will not facilitate nursing care but will help to prevent complications. An early operation may prevent a child from having, as a result of a delay in treatment, a fixed joint derangement, growth arrest, or a contracture after recovery from a head injury.

Timing of the Operation
A fracture that is best treated operatively should be fixed internally as soon as possible. Clearance to operate must be obtained from the neurosurgeon. There may be an early window of opportunity for fixation that may disappear with the onset of sepsis, problems related to the central nervous system, or pulmonary complications. The second window of opportunity may not appear for several days or weeks, making later treatment difficult as the fracture may have begun to heal and may be difficult to reduce at that time. Therefore, early treatment is the best option. Children with multiple injuries who have had early stabilization of a femoral fracture have been found to have less frequent complications and shorter stays in intensive-care units compared with those who have not had early stabilization^2,14.

Indications for Operative Treatment
Operative fixation of fractures in children who have a head injury should be considered in several types of situations: (1) a fracture of the femur, except in infants and toddlers, in order to minimize the effects of spasticity on the fracture, to minimize pain and damage from movement of the limb and agitation, to obviate the need for a cast or traction, and to allow early mobilization of the joint; (2) a fracture of the tibia, pelvis, or humerus if alignment cannot be maintained with simple immobilization, if the cast interferes with the treatment of other problems or if it is causing pressure sores, or if spasticity and agitation interfere with closed treatment; (3) a fracture in an area where the requirements for wound and skin care or compartment syndrome preclude use of a cast or a splint; and (4) an articular or periarticular fracture that would necessitate open reduction and internal fixation in a normal child if the child with a head injury may recover from that injury.

Choice of Fixation
The type of operative stabilization that is selected depends on the age of the child, the bone that is involved, and the condition of the soft tissues. For long bones, choices include plates, nails inserted after reaming, flexible nails, and external fixation. Plates are generally not used in children because of the large amount of dissection that is required for insertion and removal. Nails inserted after reaming, while generally quite useful for fixation of fractures of the femur, tibia, and humerus in adults, are not useful in children because insertion might damage a growth plate or jeopardize the blood supply to the capital femoral epiphysis. Small-diameter flexible nails are quite useful as they can be placed through small incisions away from the fracture site without violating a growth plate. External fixation has its own set of problems, such as care of the pin tracks, delayed healing, and refracture, but it can be used for basically any fracture of a long bone, even if the quality of the soft tissues is poor.

For fractures of the humeral shaft, the best choice is external fixation placed from a lateral direction or flexible nails inserted either retrograde from the olecranon fossa or antegrade from the proximal humeral metaphysis. Both devices allow access to skin or wounds and do not expose the fracture site.

Flexible nails inserted antegrade or retrograde are useful for transverse or short oblique fractures of the femoral shaft, which do not tend to shorten. Intramedullary nails inserted after reaming prevent shortening of comminuted or long oblique fractures, but because of the risk of osteonecrosis they should be used only in patients in whom the proximal femoral physis has closed.

Younger children who need stabilization of a fracture that is at risk of shortening should have external fixation. A plate is rarely recommended.

Flexible nails, placed to avoid the proximal and distal physes, are an excellent choice for fractures of the tibial shaft. Nails requiring reaming cannot be inserted in the tibia of a child without causing damage to the proximal physis. External fixation is the best choice for open fractures or for those that are at risk of shortening.

Fractures of the shaft of the forearm are best treated with a plate or, if it is desirable to avoid exposure of the fracture site, with flexible nails. External fixation is not well tolerated in the forearm.

Unstable fractures of the pelvis can be stabilized with external fixation if there is some posterior sacroiliac stability. If there is not, posterior sacroiliac screws and an anterior pubic or symphyseal plate are needed to obtain stability.

The treatment of periarticular fractures in children who have multiple injuries can be associated with problems. The use of screws and pins, which is traditional in children, may not provide enough stability in an unsplinted limb. The goal is an unsplinted limb that can be rapidly mobilized and can be accessible for the treatment of wounds or burns. Rigid fixation with screws and plates may be necessary.

	Overview

Top Introduction Treatment of Fractures in... Treatment of Fractures in... Overview References

 
In summary, the treatment of fractures in children who have associated burn or head injuries can be complicated. Fractures that do not interfere with overall care can be treated nonoperatively. Early stabilization of fractures of the long bones or the pelvis should be considered in order to facilitate early nursing care, mobility in and out of scanners, and pulmonary, wound, and burn care. The pain associated with movement of the fracture ends is clearly decreased with stabilization. Early operative treatment of periarticular fractures affords the best opportunity for a good result. A delay in treatment due to pulmonary, infectious, or intracranial complications may make eventual treatment difficult. Unless the patient is clearly going to die because of the injuries, early intensive treatment of fractures is always necessary in order to prevent late disability and impairment.

	Footnotes

 
*Printed with permission of the American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 49, American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 2000.

No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

Department of Orthopedic Surgery, Arkansas Children's Hospital, Sturgis 363, 800 Marshall Street, Little Rock, Arkansas 72202. E-mail address: blasierrobertd@exchange.uams.edu.

	References

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1. Brandt, C. P.; Fallon, W. F.; and Malangoni, M. A.: The burned and fractured extremity. Prob. Gen. Surg., 4: 621-631, 1994.
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3. Curtis, M. J., and Clarke, J. A.: Skeletal injury in thermal trauma: a review of management. Injury, 20: 333-336, 1989.[Medline]
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11. Kaplan, J. Z., and Pruitt, B. A.: Burns and fractures. In Fracture Treatment and Healing, pp. 992-1009. Edited by R. B. Heppenstall. Philadelphia, W. B. Saunders, 1980.
12. Kirschenbaum, D.; Albert, M. C.; Robertson, W. W., Jr.; and Davidson, R. S.: Complex femur fractures in children: treatment with external fixation. J. Pediat. Orthop., 10: 588-591, 1990.[Medline]
13. Kregor, P. J.; Song, K. M.; Routt, M. L. C., Jr.; Sangeorzan, B. J.; Liddell, R. M.; and Hansen, S. T., Jr.: Plate fixation of femoral shaft fractures in multiply injured children. J. Bone and Joint Surg., 75-A: 1774-1780, Dec. 1993.[Abstract/Free Full Text]
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15. Novak, J.; Papp, T.; and Zaborszky, A.: Burns associated with mechanical injuries. Burns, 4: 197-206, 1977.
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17. Porat, S.; Milgrom, C.; Nyska, M.; Whisler, J. H.; Zoltan, J. D.; and Mallin, B. A.: Femoral fracture treatment in head-injured children: use of external fixation. J. Trauma, 26: 81-84, 1986.[Medline]
18. Saffle, J. R.; Schnelby, A.; Hofmann, A.; and Warden, G. D.: The management of fractures in thermally injured patients. J. Trauma, 23: 902-910, 1983.[Medline]
19. Ward, W. T.; Levy, J.; and Kaye, A.: Compression plating for child and adolescent femur fractures. J. Pediat. Orthop., 12: 626-632, 1992.[Medline]
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21. Wood, D., and Hoffer, M. M.: Tibial fractures in head-injured children. J. Trauma, 27: 65-68, 1987.[Medline]
22. Ziv, I., and Rang, M.: Treatment of femoral fracture in the child with head injury. J. Bone and Joint Surg., 65-B(3): 276-278, 1983.

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