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Current Concepts in Open Tibial Fracture Management PDF Print E-mail

Don Weber, M.D., FRCSC
Associate Clinical Professor
University of Alberta
Edmonton, AB

Open tibial fractures are the most common open fracture in orthopaedics and are still associated with significant complications. At one time, open fractures were a death sentence. Today, we deal mostly with infection, nonunions, and functional deficits. Over the past 10 to 15 years, there have been improvements in patient outcomes as a result of both laboratory and clinical work. Dr. Olson and Dr. Schemitsch have provided an excellent review of the most recent literature1.  

The principles remain the same, but some of the details of treatment can reduce the rate of common complications. Because a large portion of the tibia is subcutaneous, and the soft tissue envelope is unforgiving, special care must be taken in all stages of the management of these frequent high-energy injuries.

The treatment protocol begins as soon as allied health care providers reach the patient. ATLS protocol is initiated, the patient is stabilized, and the limb is reduced and splinted to prevent further soft tissue injury. A photograph of the open injury prior to application of a sterile dressing can reduce repeated exposures and contamination. Rapid transportation to the nearest appropriate trauma center is arranged and antibiotics are administered. As soon as feasible, tetanus status is determined and addressed.

Figure 1: Bone transport over a nail for a large segmental tibial defect. Figure 2: Regenerate bone and distal bone grafting of docking site.
An orthopaedic assessment is carried out at the trauma center and quality radiographs are obtained. Once life-threatening injuries are stabilized, the patient is moved to the operating theatre on an emergent basis. Under anesthetic the extremity is carefully exposed. Maintaining control of both sides of the fracture is imperative throughout the process. A vascular and neurologic assessment should have been performed at all prior stages. The skin edges are shaved and the wound and limb undergo a scrub and lavage prior to preparation and draping. A tourniquet is applied but used only if absolutely necessary. After evaluating the limb and the radiographs, both an immediate and long-term plan of action should be established. An extensile exposure is used for debridement, taking care to minimize further soft tissue injury. Skin resection should be minimized, knowing questionable integument can be resected at the secondary debridement. Fat and fascia are generally expendable and poorly vascular. Muscle viability is evaluated along the lines of contractility, consistency, color, and capillary perfusion (the 4 C's). Bone ends are delivered into the wound and all non-viable bone is resected. Retained devascularized bone in the wound, even as a structural support, can lead to a 50% increase in infection2.

Remember to consider therapeutic or prophylactic fasciotomies in all open fractures.

Only after the debridement can the true extent of injury be determined and grade assigned. Generally, the modified Gustillo classification system is utilized although it can be somewhat unreliable3. The grade can be utilized to determine treatment options and antibiotic choice. Use of a broad-spectrum antibiotic such as cefazolin has been proven to reduce infection rates seven-fold in open fractures4. Single daily dose gentamicin (6 mg/kg) is as effective as divided doses and should be added for Grade III fractures. If there is potential anaerobic contamination, add penicillin or metronidazole. Antibiotics should be continued for 48 to 72 hours after each debridement.

After and during the debridement, copious irrigation (6 to 10L) with warm isotonic solution is essential. Low pressure pulsed lavage or cystoscopy tubing open to free flow are both acceptable delivery methods. High-pressure lavage causes damage to bone5.

Figure 3: Final clinical result (Flap and Bone Transport).
Stabilization of the tibia is the next important step in preventing complications. Intramedullary nailing with minimal reamed or non-reamed technique have both been proven safe in Grade I, II and III fractures6. Plate fixation is associated with unacceptable infections rates unless used in a periarticular application as a staged procedure. External fixation is generally reserved for Grade III fractures or as a temporary measure, especially with vascular injuries. It is a quicker procedure than nailing but generally has a higher complication rate and makes soft tissue coverage more difficult.

With the first debridement and stabilization completed, placement of an antibiotic bead pouch has proven to reduce infection rates. 1.2 g of powdered tobramycin are added to each package of cement and formed into round beads of 5 to 15mm strung on a wire7. The wound is then covered with an adhesive impermeable film such as Opsite or Ioban until the second debridement in 48 to 72 hours. Some Grade I injuries may be closed primarily. Absorbable antibiotic beads show some promise but are as yet unproven in the literature.

Definitive soft tissue coverage with local tissue, wound vacuums, grafts, or flaps should be completed within 7 to 10 days to significantly reduce overall infection rates8.

Reconstruction of bony defects can take place as a planned bone grafting at six weeks post injury or using a bone transport type system such as Ilizarov early on. Bone grafting prior to six weeks leads to resorption of the graft in the inflammatory wound bed, or an increased infection rate.

In summary, optimal outcome in open tibia fractures requires early antibiotics, bony stabilization, and aggressive, repeated debridement. This is followed by expeditious soft tissue coverage and planned bony reconstruction.

References

  1. Olson S.A., Schemitsch E.H. Open Fractures of the Tibial Shaft: An Update. Instructional Course Lectures 2003;52:623-631.

  2. Edward C.C., Simmons S.C., Browner B.D., Weigel M.C. Severe Open Tibial Fractures: Results treating 202 injuries with external fixation. Clin Orthop 1988;230:98-115.

  3. Brumback R.J., Jones A.L. Interobserver agreement in classification of open fractures of the tibia. J Bone Joint Surg Am 1994;76:1162-1166.

  4. Patzakis M.J., Harvey J.P. Jr., Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am 1974; 56:532-541.

  5. Bhandari M., Schemitsch E.H., Adili A., Lachowski R., Shaughnessy G.H. High and low pressure lavage of contaminated tibial fractures: An in vitro study of bacterial adherence and bone damage. J Ortho Trauma 1999;13:526-533.

  6. Henley M.B., Chapman J.R., Agel J., Harvey E.J., Whorton A.M., Swionntkowski M.F. Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: A prospective comparison of unreamed interlocking intramedullary nails and half-pin external fixators. J Orthop Trauma 1998;128:12:1-7.

  7. Ostermann P.A., Seligson D., Henry S.L. Local antibiotic therapy for severe open fractures: A review of 1085 consecutive cases. J Bone Joint Surg Br 1995;77:93-97.

  8. Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconst Surg 1986;78:285-292.

 

 
 
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