Open Tibia Fractures Treatment & Management
- Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD more...
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.
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.
After initial assessment, the wound is irrigated in the emergency department. A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room as soon as feasible. Debridement within 6 hours is necessary to keep the rate of infection low. 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. However, both high- and low-pressure lavage were associated with similar degrees of periosteal separation from the cortical bone surface. 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.
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. 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. Gustilo-Anderson types I and II injuries can also be allowed to granulate and close spontaneously by secondary intention.
After primary debridement, the surgical setup should be changed and the limb redraped without losing sterility.
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.
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.
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.
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.
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.
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. 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. 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]
Open tibial fractures have higher rates of nonunion, infection, and chronic pain syndrome (CPS).
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.
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.
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|Type||Wound Description||Other Criteria|
|I||< 1 cm (so-called puncture wounds)|
|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|
|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|