Open Tibia Fractures 

Because the tibia is a subcutaneous bone, tibial fractures are frequently open fractures.

When an individual presents with an open tibial fracture, the physician strives to save the life of the patient and the limb, to unite the fracture, and to prevent infection. Maintaining a functional limb is the goal; when that is not possible, the physician must consider amputation.

Recent studies

Gougoulias et al reviewed 14 studies for data on management of open tibial fractures in children. They found that patients older than 10 years and those with grade II, or severe, open fractures had complications and outcomes similar to those that occur in adult patients. They found no clear effect of any particular fracture fixation method on time to union. They suggested based on the evidence that adolescents may best be managed as adults.^[1]

In another study of open tibial fractures in the pediatric population, Baldwin et al performed a review of the literature to help determine the risk of infection and time to union with various fractures and current treatment. They found no significant changes having occurred in management of type I and III fractures in the past 3 decades, but in more recent years, type II fractures have been more likely to be treated by closed procedures. Type III fractures were associated with a 3.5-fold and 2.3-fold greater risk of infection than type I and II fractures, respectively, but there was no significant difference in infection risk between types I and II. As might be expected, the mean time to union increased with increasing severity of injury, from type I to II to III.^[2]

Giannoudis et al performed a questionnaire study with 130 patients treated for different types of tibial injury (33 patients with compartment syndrome (no underlying fracture), 30 with closed diaphyseal tibial fractures, 45 with grade IIIB/IIIC open fractures, and 22 requiring below-the-knee amputation) to measure long-term functional outcome and health-related quality of life. Patients who had reconstructed IIIB fractures reported problems with pain and carrying out normal activities at a higher rate than amputees and problems with mobility as frequently as amputees. In the patients with open fractures and amputees, anxiety and depression were more common, as were problems with self-care. Injury type, in general, was significantly predictive of all measured outcomes except self-care.^[3]

In addition, Giannoudis et al performed a systematic review of the literature concerning the efficacy and safety of plating for open fractures of the tibial diaphysis, which is currently considered controversial. They found that overall union rate ranged from 62-95%; time to union ranged from 13-42 weeks; reoperation rate ranged from 8-69%; and a pooled estimate of deep infection rate was calculated at 11%. The authors suggested that plate fixation for open tibial fractures may be considered under specific conditions but that well-designed clinical trials still need to be conducted.^[4]

Frequency

Behrens et al reported an incidence of 2 open tibia fractures per 1000 injuries per year in a defined population group in an industrialized western society; this is 0.2% of all injuries.^{[5, 6]} The incidence and severity may be even higher in the developing world.

Motor vehicle accidents, skiing accidents, and high-energy falls are the common causes. The mechanism of injury determines the fracture configuration (eg, skiing injuries typically cause spiral fractures). Most fractures are comminuted. Pedestrians who are hit in the upper and middle one third of the tibia sustain bumper injuries. Distal tibial and plafond fractures are commonly a result of a fall from a significant height.

All persons who have undergone high-energy trauma should be examined in accordance with the principles defined by the Road Trauma Committee of the Royal Australasian College of Surgeons/Emergency Management of Severe Trauma.^{[7, 8]} The primary survey includes the ABCs (ie, airway, breathing, circulation). A Glasgow Coma Scale score indicates the severity of any head injury component. The secondary survey should include the chest, abdomen, and pelvis for associated injuries, as well as the upper limbs and the contralateral lower limb. The ipsilateral limb also may have other fractures, such as a femur fracture, leading to a floating knee, or joint injuries such as knee dislocations.

The dictum is to save the patient first and the limb next.

Limb examination should consist of a detailed examination of the vascularity of the limb, including limb color, warmth and perfusion, palpable pulses, capillary return (normal < 3 seconds), and transcutaneous oxygenation and pulse wave forms using pulse oximetry. A detailed neurologic examination should document the sensory and motor function.

The skin over the fracture should be examined carefully. Any break in the skin at the level of the fracture should be considered indicative of a possible open fracture. Remember that wounds away from the fracture can communicate with the fracture. Periarticular open fractures almost always contaminate the associated joints.

Signs of crush injury should be sought if indicated by the mechanism of injury (eg, pedestrian hit by a car). These injuries may exhibit few external signs.

Compartment syndrome

Persons who sustain high-energy tibial fractures have a high frequency of compartment syndrome. Importantly, note that even open fractures can be associated with a compartment syndrome. Assuming that the open wound has decompressed the compartment is wrong. Blood clots can impede effective decompression. The muscle or fascial layers can close the trap door with similar effects. Blick et al from the Adam Cowley Shock Trauma Centre reported a 9% rate of compartment syndrome in persons with open tibial fractures.^[9]

The earliest signs of compartment syndrome are stretch pain and loss of the sensations (eg, fine touch, proprioception) carried by the fast conducting, and therefore more hypoxia-susceptible, fibers. Because these patients require surgical debridement and stabilization, performing a fasciotomy and compartment release is imperative. With delayed presentations or a diagnosis of compartment syndrome, performing an early fasciotomy may be preferable to merely monitoring it with a wick catheter.^{[10, 11, 12]} The traumatized soft tissues and bone are susceptible to hypoxia, and delaying a compartment release decreases oxygen delivery and impedes healing.

In fractures treated with intramedullary nailing, McQueen et al found no difference in the pressures recorded between the different Tscherne soft-tissue grades, between open and closed fractures, between low- and high-energy injuries, or between fractures treated early and those not treated until more than 24 hours after injury.^[13]

Classification

Open fractures are typed using the Gustilo-Anderson classification, which was first proposed in 1976 and subsequently modified in 1984.^{[14, 15, 16]}

Table 1. Gustilo-Anderson Classification of Open Fractures (Open Table in a new window)

Table 2. Tscherne Classification of Soft Tissue Injuries (Open Table in a new window)

Note that both of these classifications have poor interobserver agreement.^[17] However, they serve as good general guides for management and for comparison in studies.

Patients who are polytraumatized and immunocompromised develop infections more frequently, and their fractures take longer to unite. Sterett et al found that patients with splenectomies had a significantly higher prevalence of chronic osteomyelitis (25% vs 4.6%), their fractures took almost twice as long to unite, and they required additional tibial surgeries to achieve union (75% vs 16%) following open tibial fractures.^[18]

The various limb salvage scoring systems, such as the MESS (Mangled Extremity Severity Score), are good indicators for salvage but poor indicators for amputation; thus, a limb with a good MESS usually should be salvaged, but a limb with a poor MESS does not necessarily require amputation.

Regarding nailing versus external fixation, Bhandari et al reported from a meta-analysis that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in persons with open tibial fractures.^{[19, 20]} They also found a reduced risk of reoperation with using reamed nails compared with unreamed nails. This appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail. Plate fixation was found to be uniformly the worst of all methods of internal fixation. Although it may be tempting to use plate fixation for a fracture that is exposed (ie, because of the open nature of injury), the risk of nonunion, malunion, and deep infection is too high to justify the action.^[20]

See Surgical therapy.

Absolute contraindications to limb salvage are a completely mangled limb, the presence of warm ischemia for longer than 6 hours, and poor facilities for salvage.

Absolute contraindications to nailing an open fracture are untreated compartment syndrome and types IIIB and IIIC open fractures.