Treatment of Gustilo-Anderson type III open fractures with segmental long bone loss secondary to gunshot and war ınjurıes in paediatric patients with bone segment transport by the limb reconstructıon system (LRS)

Published:January 23, 2023DOI:



      : The information on firearm- or explosive-related extremity injuries in children is very limited. Reports of segmental bone loss due to these types of fractures are even rarer and the treatment remains a problem. There has been no report of distraction osteogenesis with limb reconstruction system (LRS) specifically in children. We evaluated the treatment results of Gustilo–Anderson type 3 open fractures with segmental bone loss due to firearm injuries by distraction osteogenesis performed with LRS in skeletally immature patients.


      : Nine patients with Gustilo–Anderson (GA) type 3 open fractures with segmental bone loss due to firearm injuries who had not completed their skeletal development were included. Two of the patients had GA type 3a, four had type 3b, and the remaining three had type 3c. Bony and functional assessment was conducted using Association for the Study and Application of the Methods of Illizarov (ASAMI) criteria.


      : Mean follow-up period was 20.1 months (range 5.5–35 months). The mean bone loss was 45.5 mm (range 15-80mm) before the treatment started. The mean time of external fixation (day) was 180.6. The mean distraction index (distraction period per cm) was 11.3 day/cm. The mean time for bone union index (duration of bony union per cm) was 33.7 days/cm. Bony union was achieved in all patients at the end of the treatment. Bony results as per ASAMI score were excellent in seven fractures and good in three. Functional results were excellent in five patients, good in two, and fair in two. We had no fair or poor results with respect to bony results but had two fair functional results.


      : LRS provides a good treatment choice for children with fractures with segmental bone loss due to firearm injuries. It also provides easy access to the wound with its monolateral construction.

      Graphical Abstract


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        • Bertani A
        • Mathieu L
        • Dahan JL
        • et al.
        War-related extremity injuries in children: 89 cases managed in a combat support hospital in Afghanistan.
        Orthop Traumatol Surg Res. 2015; 101: 365-368
        • Creamer KM
        • Edwards MJ
        • Shields CH
        • et al.
        Pediatric wartime admissions to US military combat support hospitals in Afghanistan and Iraq: learning from the first 2,000 admissions.
        J Trauma. 2009; 67: 762-768
        • Washington ER
        • Lee WA
        • Jr Ross WA
        Gunshot wounds to the extremities in children and adolescents.
        Orthop Clin North Am. 1995; 26: 19-28
        • Arslan H
        • Subasi M
        • Kesemenli C
        • et al.
        Problem fractures associated with gunshot wounds in children.
        Injury. 2002; 33: 743-749
        • Mathieu L
        • Bertani A
        • Rongiéras F
        • et al.
        Wartime paediatric extremity injuries: experience from the Kabul International Airport Combat support hospital.
        J Pediatr Orthop B. 2015; 24: 238-245
        • Mauffrey C
        • Barlow BT
        • Smith W.
        Management of segmental bone defects.
        J Am Acad Orthop Surg. 2015; 23: 143-153
        • Arslan H
        • Özkul E
        • Gem M
        • et al.
        Segmental bone loss in pediatric lower extremity fractures: indications and results of bone transport.
        J Pediatr Orthop. 2015; 35: e8-12
        • Salcedo Cánovas C.
        Bone elongation using monolateral external fixation: a practical guide.
        Strategies Trauma Limb Reconstr. 2015; 10: 175-188
        • Stucky W
        • Loder RT
        Extremity gunshot wounds in children.
        J Pediatr Orthop. 1991; 11: 64-71
        • Barlow B
        • Niemirska M
        • Gandhi RP.
        Ten years' experience with pediatric gunshot wounds.
        J Pediatr Surg. 1982; 17: 927-932
        • Trionfo A
        • Cavanaugh PK
        • Herman MJ.
        Pediatric Open Fractures.
        Orthop Clin North Am. 2016; 47: 565-578
        • Bartlett 3rd, CS
        • Weiner LS
        • Yang EC
        Treatment of type II and type III open tibia fractures in children.
        J Orthop Trauma. 1997; 11: 357-362
        • Naranje SM
        • Gilbert SR
        • Stewart MG
        • et al.
        Gunshot-associated Fractures in Children and Adolescents Treated at Two Level 1 Pediatric Trauma Centers.
        J Pediatr Orthop. 2016; 36: 1-5
        • Papakostidis C
        • Bhandari M
        • Giannoudis PV.
        Distraction osteogenesis in the treatment of long bone defects of the lower limbs: effectiveness, complications and clinical results; a systematic review and meta-analysis.
        Bone Joint J. 2013; 95-B: 1673-1680
        • Patil MY
        • Gupta SM
        • Kurupati SK
        • et al.
        Definitive management of open tibia fractures using limb reconstruction system.
        J Clin Diagn Res. 2016; 10: RC01-RC04
        • Ajmera A
        • Verma A
        • Agrawal M
        • et al.
        Outcome of limb reconstruction system in open tibial diaphyseal fractures.
        Indian J Orthop. 2015; 49: 429-435
        • Green SA
        • Harris NL
        • Wall D
        • et al.
        The Rancho Mounting Technique for the Ilizarov Method.
        Clin Orthop Relat Res. 1992; 280: 104-116