Open Fractures of the Tibial Diaphysis David Templeman, MD Darin Friess, MD Original Authors: Robert V. Cantu, MD and David Templeman, MD; March 2004 New Authors: David Templeman and Darin Friess, MD; Revised June 2006

Incidence Open fractures of the tibia are more common than in any other long bone Roughly 25% of tibial shaft fractures are open -Court-Brown, McBirnie JBJS 1995

Mechanism of Injury Can occur in lower energy, torsional type injury (eg, skiing) More common with higher energy direct force (eg car bumper)

Associated Injuries Approximately 30% of patients have multiple injuries Associated fibula fracture Proximal or distal tib-fib joints may be disrupted Ligamentous knee injury and/or ipsilateral femur (‘floating knee’) more common in high energy fractures

Associated Injuries Neurovascular structures require repeated assessment Foot fractures also common Compartment syndrome

Priorities ABC’S Assoc Injuries Tetanus Antibiotics Fracture reduction Splinting

Physical Examination Given subcutaneous nature of tibia, deformity and open wound usually readily apparent Circumferential inspection Lacerations Ecchymosis Swelling Tissue turgidity

Physical Exam Neurologic and vascular exam Ankle-Brachial Index if needed Grading of wound done at time of surgical debridement Cover wound, avoid multiple exams -Mills, J. Trauma 2004

Initial Treatment ER superficial evaluation Tetanus prophylaxis Sterile dressing Reduction & splint Tetanus prophylaxis Antibiotics I cefazolin II, III Add Aminoglycoside Soil contaminant add PCN Antibiotic spectrum changing based on local bacterial spectrum

Radiographic Evaluation Full length AP and lateral views from knee to ankle Ankle or knee films for fracture extension Arteriography indicated if vascular compromise present after reduction

Fracture Classification Descriptive OTA Classification Number 42 simple(A) butterfly(B) comminuted(C)

Gustilo and Anderson Classification Type I - skin opening of 1cm or less, minimal muscle contusion, usually inside out mechanism Type II - skin laceration 1-10cm, extensive soft tissue damage Type IIIA - extensive soft tissue laceration(10cm) but adequate bone coverage Type IIIB - extensive soft tissue injury with requiring flap advancement or free flap Type IIIC - vascular injury requiring repair Gustilo, JBJS 1976

Tscherne Classification of Soft Tissue Injury Grade 0- negligible soft tissue injury Grade 1- superficial abrasion or contusion Grade 2- deep contusion from direct trauma Grade 3- Extensive contusion and crush injury with possible severe muscle injury, compartment syndrome

Open Fracture Classification Interobserver agreement only 60% Grading of open injury likely best done in the OR Brumback, JBJS 1995

Compartment Sydrome Diagnosis same as in closed tibial fractures Common with high energy tibia fractures Treatment is 4 compartment fasciotomies

Objectives Prevent Infection Soft tissue coverage Union Function Often requires staged treatment over several months

Timing of Surgical Debridement Controversial issue Classically <6hrs Currently urgent, not emergent Early antibiotics may be more critical More wound contamination requires more urgency and more frequency -Bosse, JAAOS, 2002 -Skaggs, JBJS 2005

Treatment of Soft Tissue Injury Meticulous debridement Explore/Extend wound Deliver bone ends for full exposure Excise all foreign material, necrotic muscle, unattached bone fragments, exposed fat and fascia Infection 21% vs 9% w/ improved debridement Fasciotomy as indicated -Edwards, CORR 1988 -Patzakis, JAAOS 2003

Role of Irrigation D & I “Debridement & Irrigation” No consensus on volume required Pulse lavage May remove debris vs. harmful to osteoblasts Antibiotics vs. Soap -Anglen, JBJS 2005

Bead Pouches Tobra 1.2g per packet of PMMA Seal wound to create antibiotic-laden seroma Reduced risk of infection 12% vs 4% Reduced aminoglycoside toxicity -Ostermann, JBJS-B 1995

Fracture Stabilization Reduces risk of infection External Fixation uniplane vs. multiplane provisional vs. definitive tx Intramedullary nail Plate fixation

Advantages of External Fixator Can be applied quickly in polytrauma patient Allows easy monitoring of soft tissues and compartments

Technique of External Fixation Unilateral frame with half pins 5mm half pins (‘near-near and far-far’) Pre-drilling of pins recommended Fracture held reduced while clamps and connecting bar applied

Outcomes of External Fixation 95% union rate for group of closed and open tibia fractures 20% malunion rate Loss of reduction associated with removing frame prior to union Risk of pin track infection Anderson et al. Clin Orthop 1974 Edge and Denham JBJS[Br] 1981

Advantages of IM Nail Less malunion and shortening Earlier weight bearing Early ankle and knee motion Reduced time to union -Shannon, J. Trauma 2002

Reamed vs. Nonreamed Nails Reamings (osteogenic) Larger Nails (& locking bolts) Hardware failure rare w/ newer nail designs Damage to endosteal blood supply? Clinically proven safe even in open fx Finkemeier, et.al. JOT 2000 Forster, et.al. Injury Mar 2005 Bhandari, et.al., JOT 2000

Unreamed IM Nail Laboratory benefit of improved cortical perfusion Good results 9% delayed union 5% deep infection in Type III fractures -Schemitsch, J. Trauma 1998 -Gaebler, JOT 2001

Reamed Tibial Nailing Good results in Open Fx time to union 26wks deep infection rate 3.5% Complications increased with Type IIIB fractures time to union 50 weeks infection rate 23%* -Court-Brown JBJS 1991

Reamed vs. Nonreamed Nails Reamed Non-Reamed # pts. 73 63 Nonunion 4% 11% Malunion 4% 3% Broken Bolts 3% 16% Blachut JBJS 79A

Complications Infection 1-5% Union >90% Knee Pain 56% w/ kneeling 90% w/ running 56% at rest 33% Court-Brown, JOT 1996

Plating of Tibial Fractures Narrow 4.5mm DCP plate can be used for shaft fractures Periarticular plates available Plate through open wound

Subcutaneous Tibial Plating Newer alternative is use of limited incisions and subcutaneous plating- requires indirect reduction of fracture

Disadvantages of Plating Increased risk of infection 13% deep infection -Bach, CORR 1989

Wound Closure Primary closure controversial Surgical judgement gained with experience If in doubt, repeat debridement 24-72hrs Type I and some Type II wounds can be closed primarily or after repeat I+D Type II and Type IIIa can be closed after repeat debridement if clean -Bosse, JAAOS 2002

Soft Tissue Coverage Type IIIB fractures require local rotation flap, split-thickness skin graft, or free flap “reconstructive ladder” within 7 days <72 hrs may be better Reduced need for complex flaps with negative pressure wound therapy -Parrett, Plast & Recon Surg, 2006 -Gopal, JBJS-B, 2000

Soft Tissue Coverage Proximal third tibia fractures - gastrocnemius rotation flap Middle third tibia fractures - soleus rotation flap Distal third fractures - free flap or reverse sural rotation flap

Bone Grafting Typically no acute bone grafting due to risk of infection Bone graft substitutes BMP-2, OP-1 BESST trial w/ BMP-2 in open fxs Safe, fewer infections, faster fracture healing Unknown cost effectiveness -Govender, et.al. JBJS 2002

Gunshot Wounds Low energy missiles rarely require debridement and can often be treated like closed injuries Fractures due to high energy missiles (eg assault rifle or close range shot gun) treated as standard open injuries

Complications Nonunion Malunion Infection- deep and superficial Fatigue fractures Hardware failure

Nonunion Definition varies from 3 months to one year Rule out infection Treatment options: onlay bone grafts Bone graft substitutes free vascularized bone grafts reamed exchange nailing compression plating Ilizarov ring fixator

Malunion Varus malunion more of a problem than valgus May not be symptomatic For symptomatic patients with significant deformity treatment is osteotomy -Kristensen et al. Acta Orthop Scand 1989

Superficial Infection Ex-fix pin tracts Should respond to elevation and appropriate antibiotics (typically gram + cocci coverage) High index of suspicion for deep infection with repeat debridement required

Deep Infection Pain, erythema,wound drainage, or sinus formation Multiple staged treatment Radical Debridement Hardware removal Cultures Antibiotic beads/nail Soft tissue coverage IV antibiotics Delayed bone reconstruction -Patzakis, JAAOS 2005

Associated Fatigue Fractures Sometimes seen during rehab after prolonged non-weight bearing Can present with localized tenderness in metatarsal, calcaneus, or distal fibula Bone scan or MRI may be required to make diagnosis as plain radiographs often normal Treatment is temporary reduction in weight bearing

Hardware Failure Usually due to delayed union or nonunion Rule out infection Treatment depends on type of failure: plate or nail breakage often requires revision locking screw in nail may not require operative intervention

Limb Salvage vs. Amputation Saving a functional limb versus saving the patient

Mangled Extremity Severity Score An attempt to help guide between primary amputation vs. limb salvage Score of 7 or higher was predictive of amputation -Johansen et al. J Trauma 1991

Limb Salvage vs. Amputation Host factors Type A – healthy Type B – minimal comorbidities Type C – Multiple comorbidites, tobacco use, poor social support The four “D’s” Disabled Destitute Drunk Divorced

LEAP Study Multicenter observational prospective trial 569 patients MESS or other scores not predictive of amputation Insensate limb not predictive of outcome At 2 years & 7 years F/U no difference in outcome scores (SIP) or return to work Limb reconstruction more likely to require rehospitalization for revision procedures. -Bosse, et.al.

Outcomes Outcome most affected by severity of soft tissue and neurovascular injury Aggressive, staged treatment improves results Most studies show major change in results between Type IIIA and IIIB/C fractures Early soft tissue coverage improves results If you would like to volunteer as an author for the Resident Slide Project or recommend updates to any of the following slides, please send an e-mail to ota@aaos.org E-mail OTA about Questions/Comments Return to Lower Extremity Index