Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Open Tibia Fractures Treatment & Management

  • Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
 
Updated: Dec 21, 2015
 

Approach Considerations

The various limb salvage scoring systems, such as the Mangled Extremity Severity Score (MESS), 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.

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.

Next

Medical Therapy

Intravenous (IV) antibiotics are administered promptly. First-generation cephalosporins (gram-positive coverage) such as cephalothin (1-2 g q6-8hr) suffice for Gustilo-Anderson type I fractures. An aminoglycoside (gram-negative coverage) such as gentamycin (120 mg q12hr; 240 mg/day) is added for types II and III injuries. Additionally, metronidazole (500 mg q12hr) or penicillin (1.2 g q6hr) can be added for coverage against anaerobes. Tetanus prophylaxis should be instituted. Antibiotics generally are continued for 72 hours following wound closure. Short courses of prophylactic antibiotics appear to be as effective as longer ones in this setting.[20]

After initial assessment, the wound is irrigated in the emergency department.[21] A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room as soon as feasible.[21] Debridement within 6 hours is necessary to keep the rate of infection low.[22] A key factor in infection prevention is early, rigid stabilization of the fracture.

The aim of antibiotic therapy and debridement is to sterilize the wound to a negligible bacterial load and render the wound similar to a typical surgical wound. The first debridement is the best chance for infection prevention.

A tourniquet should not be used. This helps in identifying the devitalized tissue. The skin is sharply cut back to bleeding edges. Radical debridement is performed with sharp dissection until bleeding tissue is visualized. "Red is good, and gray is bad" is the general dictum. Devitalized muscle can also be identified by its lack of response to electrical stimulus.

All extrinsic debris is meticulously removed. Copious irrigation is employed. "The solution to pollution is dilution" is another dictum. Irrigation works predominantly by mechanical means. A pulsatile lavage system works by creating local eddy currents and dislodging the debris from the soft tissues.

High-pressure pulsatile lavage should be avoided because it can cause soft-tissue damage. Bhandari et al also found that high-pressure pulsatile lavage resulted in bacterial seeding into the intramedullary canal and significant damage to the architecture of the bone.[23] However, both high- and low-pressure lavage were associated with similar degrees of periosteal separation from the cortical bone surface.[23] Both high- and low-pressure lavage were effective in removing adherent bacteria from bone after a delay of 3 hours before irrigation, but only high-pressure lavage removed adherent bacteria from bone at a delay of 6 hours before irrigation.[24]

The bone ends should be debrided thoroughly. Aggressive bone debridement has been demonstrated to lower infection rates in high-grade open fractures.[11, 25]

Soft-tissue coverage can be achieved primarily in all cases except those with extensive contamination and risk of anaerobic infection.[26] A delayed primary closure or coverage is provided for wounds with extensive contamination and risk of anaerobic infection. If the wound cannot be closed primarily, skin grafting or flap coverage can be provided, though muscle flaps provide better coverage and results.[27] Gustilo-Anderson types I and II injuries can also be allowed to granulate and close spontaneously by secondary intention.

Previous
Next

Surgical Therapy

After primary debridement, the surgical setup should be changed and the limb redraped without losing sterility.

Fracture repair

Intramedullary nailing is the best option for Gustilo-Anderson types I, II, and III fractures.[28, 29, 30] Type IIIB fractures can also be treated with unreamed nails. Solid-core nails are associated with the lowest rate of infection.[31]

One randomized trial studied the addition of an absorbable collagen sponge containing recombinant human bone morphogenetic protein-2 (rhBMP-2) to reamed intramedullary nail fixation in patients with open tibial fractures compared with patients treated with intramedullary nail fixation and the standard of care. A healed fracture was the primary endpoint as depicted by radiography and clinical examination at 13 and 20 weeks after wound closure. The addition of rhBMP-2 did not significantly increase healing compared with those in the standard of care group.[32]

External fixation is used for Gustilo-Anderson types IIIA and IIIB fractures. Thakur and Patankar demonstrated excellent results using a protocol of early bone grafting and fixator dynamisation with monolateral fixators.[33, 34]

Alternatively, an exchange nailing can be performed after removal of the fixator. This procedure is associated with a high risk of infection. Infection risk can be minimized by avoiding and treating pin-site infection and by exchanging to a nail after less than 15 days of external fixation.[35, 36] Alternately, the fixator can be removed and the limb immobilized in a cast until the pin sites have healed; the tibia can then be nailed.

Bhandari et al, in a meta-analysis, found that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in open tibial fractures.[37, 38] They also found a reduced risk of reoperation with 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 plating a fracture that is exposed may be tempting (ie, because of the open nature of the injury), the risk of nonunion, malunion, and deep infection is too high to justify it.[38]

In a meta-analysis that compared unreamed nails with external fixation, Bhandari et al found that the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in persons with open tibial fractures.[37, 38] They also found a reduced risk of reoperation with using reamed nails as opposed to unreamed nails.

These findings appear 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.[38]

Cast treatment is avoided for many reasons. It does not provide rigid fracture stabilization, the wound is not open for inspection and regular dressing changes, and a circumferential cast increases the risk of circulatory compromise.

Delayed union or nonunion may be avoided with early prophylactic posterolateral bone grafting.[33, 39]

Monolateral external fixators generally are preferred for the tibia, though multiplanar and circular fixators provide greater stability. For periarticular plateau and plafond fractures, circular or hybrid frames yield the best results, with the lowest morbidity, especially related to infection and soft-tissue complications.

Newer devices such as the Taylor Spatial Frame can be applied quickly in an emergency situation. Using the so-called rings-first method, each ring is applied individually orthogonal to each fragment and the struts are connected. The fracture is then reduced gradually in a nonemergency fashion by bringing all the struts to equal length and all the rings parallel. The reduction can then be fine-tuned by using the residual correction program. This is especially useful when rapid stabilization is required before a vascular repair, though the device may impede surgical access.

Amputation

Not every severely injured limb can be salvaged. Several scoring methods have been developed to predict the chances of limb salvage. The MESS is the best known. Many authors have found these scoring systems to be unreliable.[28] The presence of warm ischemia for longer than 6 hours, infrapopliteal vascular injury, and posterior tibial and/or common peroneal nerve neurotmesis are the strongest indications for amputation.[28] With a good MESS, a limb should be considered salvageable; however, a poor MESS should not automatically prompt amputation. Clinical judgment and availability of limb reconstruction facilities should be the ultimate factors in decision-making.[40, 41]

Previous
Next

Complications

Open tibial fractures have higher rates of nonunion, infection, and chronic pain syndrome (CPS).[42]

Osteomyelitis may occur and can be acute, subacute, or chronic. It may surface many months or years after injury.

Pin-site infections are common with external fixator treatment. Chronic osteomyelitis in the pin sites is relatively common.

Previous
Next

Long-Term Monitoring

Open tibial fractures have higher rates of nonunion, infection, and CPS. Close follow-up is required until union. CPS should be anticipated and treated early, rather than after the pain patterns are entrenched. Osteomyelitis can be acute, subacute, or chronic and may surface many months or years after injury. Pin-site infections are common with external fixation and should be dealt with aggressively with oral or parenteral antibiotics and debridement or even pin exchange. Pin-site chronic osteomyelitis is also relatively common.

Previous
 
Contributor Information and Disclosures
Author

Minoo Patel, MBBS, PhD, MS, FRACS Senior Lecturer, Monash University; Director, Centre for Limb Reconstruction and Deformities, Epworth Centre; Chairman, Cabrini Hospital Orthopaedic Surgery Specialty Group; Orthopaedic Adult/Pediatric Surgeon, Epworth Hospital; Fellowship Director, Epworth Kleos Upper Limb and Limb Reconstruction Fellowship; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia

Minoo Patel, MBBS, PhD, MS, FRACS is a member of the following medical societies: American Academy of Orthopaedic Surgeons, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Royal Australasian College of Surgeons, Orthopaedic Research Society, AO Foundation, Orthopaedics Overseas, Indian Orthopedic Association, Bombay Orthopedic Society, Shoulder and Elbow Society of Australia, Australian Paediatric Orthopaedic Society, Australian Limb Lengthening and Reconstruction Society, Victorian Hand Surgery Society, Victorian Shoulder and Elbow Society

Disclosure: Nothing to disclose.

Coauthor(s)

John Herzenberg, MD, FRCSC Head of Pediatric Orthopedics, Director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore

John Herzenberg, MD, FRCSC is a member of the following medical societies: American Academy for Cerebral Palsy and Developmental Medicine, Pediatric Orthopaedic Society of North America, Limb Lengthening and Reconstruction Society, American Academy of Orthopaedic Surgeons

Disclosure: Received educational grant from Smith and Nephew, EBI, Orthofix for none.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Thomas M DeBerardino, MD Associate Professor, Department of Orthopedic Surgery, Consulting Surgeon, Sports Medicine, Arthroscopy and Reconstruction of the Knee, Hip and Shoulder, Team Physician, Orthopedic Consultant to UConn Department of Athletics, University of Connecticut Health Center

Thomas M DeBerardino, MD is a member of the following medical societies: American Academy of Orthopaedic Surgeons, American Orthopaedic Association, American Orthopaedic Society for Sports Medicine

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Arthrex, Inc.; Ivy Sports Medicine; MTF; Aesculap; The Foundry, Cotera; ABMT<br/>Received research grant from: Histogenics; Cotera; Arthrex.

Additional Contributors

Dennis P Grogan, MD Clinical Professor (Retired), Department of Orthopedic Surgery, University of South Florida College of Medicine; Orthopedic Surgeon, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa

Dennis P Grogan, MD is a member of the following medical societies: American Medical Association, American Orthopaedic Association, Scoliosis Research Society, Irish American Orthopaedic Society, Pediatric Orthopaedic Society of North America, American Academy of Orthopaedic Surgeons, American Orthopaedic Foot and Ankle Society, Eastern Orthopaedic Association

Disclosure: Nothing to disclose.

References
  1. Behrens F. Current concepts of external fixation of fractures. Berlin:. Springer-Verlag. 1982.

  2. Behrens F, Searls K. External fixation of the tibia. Basic concepts and prospective evaluation. J Bone Joint Surg Br. 1986 Mar. 68(2):246-54. [Medline].

  3. Gougoulias N, Khanna A, Maffulli N. Open tibial fractures in the paediatric population: a systematic review of the literature. Br Med Bull. 2009. 91:75-85. [Medline].

  4. Baldwin KD, Babatunde OM, Russell Huffman G, Hosalkar HS. Open fractures of the tibia in the pediatric population: a systematic review. J Child Orthop. 2009 Jun. 3(3):199-208. [Medline]. [Full Text].

  5. Giannoudis PV, Harwood PJ, Kontakis G, Allami M, Macdonald D, Kay SP, et al. Long-term quality of life in trauma patients following the full spectrum of tibial injury (fasciotomy, closed fracture, grade IIIB/IIIC open fracture and amputation). Injury. 2009 Feb. 40(2):213-9. [Medline].

  6. Giannoudis PV, Papakostidis C, Kouvidis G, Kanakaris NK. The role of plating in the operative treatment of severe open tibial fractures: a systematic review. Int Orthop. 2009 Feb. 33(1):19-26. [Medline].

  7. Kwasnicki RM, Hettiaratchy S, Okogbaa J, Lo B, Yang GZ, Darzi A. Return of functional mobility after an open tibial fracture: a sensor-based longitudinal cohort study using the Hamlyn Mobility Score. Bone Joint J. 2015 Aug. 97-B (8):1118-25. [Medline].

  8. Geller E. Emergency treatment of the trauma patient. In: Dee R, Hurst LC, Gruber MA, Kottmeier SA, eds. Principles of Orthopedic Practice. NY:. McGraw-Hill. 1997:379-388.

  9. Shuler TE. Adult trauma. In: Miller MD, ed. Review of Orthopedics. Philadelphia:. WB Saunders Co. 1996:350-393.

  10. Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty- five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun. 58(4):453-8. [Medline].

  11. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984 Aug. 24(8):742-6. [Medline].

  12. Gustilo RB, Gruninger RP, Davis T. Classification of type III (severe) open fractures relative to treatment and results. Orthopedics. 1987 Dec. 10(12):1781-8. [Medline].

  13. Brumback RJ, Jones AL. Interobserver agreement in the classification of open fractures of the tibia. The results of a survey of two hundred and forty-five orthopaedic surgeons. J Bone Joint Surg Am. 1994 Aug. 76(8):1162-6. [Medline].

  14. Sterett WI, Ertl JP, Chapman MW, Moehring HD. Open tibia fractures in the splenectomized trauma patient: results of treatment with locking, intramedullary fixation. J Trauma. 1995 Apr. 38(4):639-41. [Medline].

  15. Blick SS, Brumback RJ, Poka A, et al. Compartment syndrome in open tibial fractures. J Bone Joint Surg Am. 1986 Dec. 68(9):1348-53. [Medline].

  16. McQueen MM, Christie J, Court-Brown CM. Acute compartment syndrome in tibial diaphyseal fractures. J Bone Joint Surg Br. 1996 Jan. 78(1):95-8. [Medline].

  17. McQueen MM, Court-Brown CM. Compartment monitoring in tibial fractures. The pressure threshold for decompression. J Bone Joint Surg Br. 1996 Jan. 78(1):99-104. [Medline].

  18. McQueen MM, Gaston P, Court-Brown CM. Acute compartment syndrome. Who is at risk?. J Bone Joint Surg Br. 2000 Mar. 82(2):200-3. [Medline].

  19. McQueen MM, Christie J, Court-Brown CM. Compartment pressures after intramedullary nailing of the tibia. J Bone Joint Surg Br. 1990 May. 72(3):395-7. [Medline].

  20. Isaac SM, Woods A, Danial IN, Mourkus H. Antibiotic Prophylaxis in Adults With Open Tibial Fractures: What Is the Evidence for Duration of Administration? A Systematic Review. J Foot Ankle Surg. 2015 Sep 10. [Medline].

  21. Tripuraneni K, Ganga S, Quinn R, Gehlert R. The effect of time delay to surgical debridement of open tibia shaft fractures on infection rate. Orthopedics. 2008 Dec. 31(12):[Medline].

  22. Kindsfater K, Jonassen EA. Osteomyelitis in grade II and III open tibia fractures with late debridement. J Orthop Trauma. 1995 Apr. 9(2):121-7. [Medline].

  23. Bhandari M, Adili A, Lachowski RJ. High pressure pulsatile lavage of contaminated human tibiae: an in vitro study. J Orthop Trauma. 1998 Sep-Oct. 12(7):479-84. [Medline].

  24. Bhandari M, Schemitsch EH, Adili A, et al. High and low pressure pulsatile lavage of contaminated tibial fractures: an in vitro study of bacterial adherence and bone damage. J Orthop Trauma. 1999 Nov. 13(8):526-33. [Medline].

  25. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am. 1990 Feb. 72(2):299-304. [Medline].

  26. Choudry U, Moran S, Karacor Z. Soft-tissue coverage and outcome of Gustilo grade IIIB midshaft tibia fractures: a 15-year experience. Plast Reconstr Surg. 2008 Aug. 122(2):479-85. [Medline].

  27. Richards RR, McKee MD, Paitich CB, et al. A comparison of the effects of skin coverage and muscle flap coverage on the early strength of union at the site of osteotomy after devascularization of a segment of canine tibia. J Bone Joint Surg Am. 1991 Oct. 73(9):1323-30. [Medline].

  28. Tornetta P. Tibial fractures. In: Dee R, Hurst LC, Gruber MA, Kottmeier SA, eds. Principles of Orthopedic Practice. NY:. McGraw-Hill. 1997:519-530.

  29. Lefaivre KA, Guy P, Chan H, Blachut PA. Long-term follow-up of tibial shaft fractures treated with intramedullary nailing. J Orthop Trauma. 2008 Sep. 22(8):525-9. [Medline].

  30. Agrawal A, Chauhan VD, Maheshwari RK, Juyal AK. Primary Nailing in the Open Fractures of the Tibia-Is it worth?. J Clin Diagn Res. 2013 Jun. 7(6):1125-30. [Medline]. [Full Text].

  31. Riemer BL, DiChristina DG, Cooper A, et al. Nonreamed nailing of tibial diaphyseal fractures in blunt polytrauma patients. J Orthop Trauma. 1995 Feb. 9(1):66-75. [Medline].

  32. Aro HT, Govender S, Patel AD, Hernigou P, Perera de Gregorio A, Popescu GI, et al. Recombinant human bone morphogenetic protein-2: a randomized trial in open tibial fractures treated with reamed nail fixation. J Bone Joint Surg Am. 2011 May. 93(9):801-8. [Medline].

  33. Thakur AJ, Patankar J. Open tibial fractures. Treatment by uniplanar external fixation and early bone grafting. J Bone Joint Surg Br. 1991 May. 73(3):448-51. [Medline].

  34. Roseiro LM, Neto MA, Amaro A, Leal RP, Samarra MC. External fixator configurations in tibia fractures: 1D optimization and 3D analysis comparison. Comput Methods Programs Biomed. 2014 Jan. 113(1):360-370. [Medline].

  35. Antich-Adrover P, Marti-Garin D, Murias-Alvarez J, Puente-Alonso C. External fixation and secondary intramedullary nailing of open tibial fractures. A randomised, prospective trial. J Bone Joint Surg Br. 1997 May. 79(3):433-7. [Medline].

  36. Blachut PA, Meek RN, O''Brien PJ. External fixation and delayed intramedullary nailing of open fractures of the tibial shaft. A sequential protocol. J Bone Joint Surg Am. 1990 Jun. 72(5):729-35. [Medline].

  37. Bhandari M, Guyatt GH, Tong D, et al. Reamed versus nonreamed intramedullary nailing of lower extremity long bone fractures: a systematic overview and meta-analysis. J Orthop Trauma. 2000 Jan. 14(1):2-9. [Medline].

  38. Bhandari M, Guyatt GH, Swiontkowski MF, et al. Treatment of open fractures of the shaft of the tibia. J Bone Joint Surg Br. 2001 Jan. 83(1):62-8. [Medline].

  39. Blick SS, Brumback RJ, Lakatos R, et al. Early prophylactic bone grafting of high-energy tibial fractures. Clin Orthop. 1989 Mar. (240):21-41. [Medline].

  40. Saddawi-Konefka D, Kim HM, Chung KC. A systematic review of outcomes and complications of reconstruction and amputation for type IIIB and IIIC fractures of the tibia. Plast Reconstr Surg. 2008 Dec. 122(6):1796-805. [Medline].

  41. Parmaksizoglu F, Cansü E, Unal MB, Yener Ince A. Acute emergency tibialization of the fibula: reconstruction of a massive tibial defect in a type IIIC open fracture. Strategies Trauma Limb Reconstr. 2013 Aug. 8(2):127-31. [Medline]. [Full Text].

  42. Cannada LK, Anglen JO, Archdeacon MT, Herscovici D Jr, Ostrum RF. Avoiding complications in the care of fractures of the tibia. J Bone Joint Surg Am. 2008 Aug. 90(8):1760-8. [Medline].

 
Previous
Next
 
Open tibial fracture.
Table 1. Gustilo-Anderson Classification of Open Fractures
Type Wound Description Other Criteria
I < 1 cm (so-called puncture wounds)  
II 1-10 cm  
IIIA >10 cm, coverage available Segmental fractures, farm injuries,



or any injury occurring in a highly contaminated environment



High-velocity gunshot injuries



IIIB 10 cm, requiring soft tissue coverage procedure Periosteal stripping
IIIC   With vascular injury requiring repair
Table 2. Tscherne Classification of Soft-Tissue Injuries
Grade Soft-Tissue Injury



(Superficial)



Soft-Tissue Injury



(Deep)



Compartments
0 Absent or negligible Absent or negligible Soft and/or normal
1 Superficial abrasion Contusion from within Soft and/or normal
2 Deep contaminated abrasion Significant contusion Impending compartment syndrome
3 Crushed skin, subcutaneous avulsions Crushed devitalized muscle Compartment syndrome
Previous
Next
 
 
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.