1. 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

2. 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

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

4. 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

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

6. Priorities ABC’S Assoc Injuries Tetanus Antibiotics Fracture reduction
Splinting

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

8. 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

9. 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

10. 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

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

12. 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

13. 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

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

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

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

17. 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

18. 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

19. 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

20. 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

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

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

23. 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

24. 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

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

26. 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

27. 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

28. 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

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

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

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

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

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

34. 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

35. 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

36. 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

37. 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

38. 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

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

40. 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

41. 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

42. 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

43. 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

44. 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

45. 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

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

47. 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

48. 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

49. 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.

50. 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
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