Open Tibia Fractures Clinical Presentation

Updated: Mar 17, 2020
  • Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
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Presentation

Physical Examination

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. [10, 11]

The primary survey includes the ABCs (ie, airway, breathing, circulation). A Glasgow Coma Scale (GCS) 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 s), 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, a pedestrian hit by a car). These injuries may exhibit few external signs.

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Classification

Open fractures are commonly categorized according to the Gustilo-Anderson classification, which was first proposed in 1976 and subsequently modified in 1984 (see Table 1 below). [12, 13, 14]  The Tscherne classification is used for soft-tissue injuries (see Table 2 below). Both of these classifications have poor interobserver agreement [15] ; however, they serve as good general guides for management and for comparison in studies.

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

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 (Open Table in a new window)

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

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. [16]

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Complications

Compartment syndrome

Persons who sustain high-energy tibial fractures have a high frequency of compartment syndrome. It is important to be aware that even open fractures can be associated with a compartment syndrome; thus, it is a mistake automatically to assume that the open wound will necessarily have decompressed the compartment. Blood clots can impede effective decompression. The muscle or fascial layers can close the trap door with similar effects. Blick et al reported a 9% rate of compartment syndrome in persons with open tibial fractures. [17]

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. [18, 19, 20]  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. [21]

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