Practice Essentials
Because the tibia is a subcutaneous bone, tibial fractures are frequently open fractures (see the image below). Open fractures are commonly categorized according to the Gustilo-Anderson classification, which was first proposed in 1976 and subsequently modified in 1984 (see Presentation). The Tscherne classification is used for soft-tissue injuries.
Open tibial fracture.
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. (See Treatment.) 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.
Etiology
Motor vehicle accidents, skiing accidents, and high-energy falls are the common causes of open tibial fractures. 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.
Epidemiology
Behrens et al reported an incidence of two 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. [1] The incidence and severity may be even higher in the developing world.
Prognosis
The Gustilo-Anderson classification system (see Presentation) is a good prognostic indicator. The higher grades of injury (eg, type III fractures) are commonly associated with infection and nonunion.
Gougoulias et al reviewed 14 studies for data on management of open tibial fractures in children. [2] 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.
In a study of open tibial fractures in children, Baldwin et al reviewed the literature to help determine the risk of infection and time to union with various fractures and current treatment. [3] They found that over the preceding three decades, management of type I and III fractures did not change significantly, but type II fractures were increasingly likely to be treated by closed procedures. Type III fractures were associated with a 3.5-fold and a 2.3-fold higher infection risk than types I and II, respectively, but infection risk did not differ significantly between types I and II. Mean time to union increased with increasing severity of injury.
Giannoudis et al measured long-term functional outcome and health-related quality of life in 130 patients treated for tibial injury, including compartment syndrome (no underlying fracture; n = 33), closed diaphyseal tibial fracture (n = 30), grade IIIB/IIIC open fracture (n = 45), and below-knee amputation (n = 22). [4] Those with reconstructed IIIB fractures had problems with pain and carrying out normal activities more often than amputees and had problems with mobility as frequently as amputees. Those with open fractures and amputees were more likely to report anxiety, depression, and problems with self-care. Injury type was significantly predictive of all measured outcomes except self-care.
Giannoudis et al also systematically reviewed the literature on the efficacy and safety of plating for open fractures of the tibial diaphysis, which, as they noted, had been considered controversial. [5] They found that overall union rate ranged from 62% to 95%; time to union ranged from 13 to 42 weeks; reoperation rate ranged from 8% to 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.
In a study that used the Hamlyn Mobility Score to assess return of functional mobility after open tibial fracture, Kwasnicki et al found that most of patients' recovery was completed within 3 months in cases of grade I Gustilo-Anderson fracture, within 6 months in cases of grade II fracture, and within 9 months in cases of grade III fracture. [6] Whereas the quality of walking improved up to 12 months after operation, the capacity to walk reached a plateau after 6 months.
The Gustilo classification of open tibia fractures does not incorporate the presence of arterial injury when limb perfusion is intact. In the authors' experience, however, the presence of arterial injury appears to negatively impact microsurgical outcomes.
In a retrospective review of 361 soft-tissue flap procedures performed in patients with type IIIB (n = 332) or IIIC (n = 29) open tibia fractures, Stranix et al found that nonischemic arterial injury was common in the IIIB group and appeared to have a negative impact on reconstructive outcomes. [7] As compared with three-vessel runoff, one-vessel runoff was associated with higher rates of complications, take-backs, and total flap failures.
A randomized clinical trial by Haonga et al (N = 221) compared the outcomes of initial treatment with intramedullary nailing (n = 111) or external fixation (n = 110) in adults with open tibial fractures. [8] The primary outcome was death or reoperation for the treatment of deep infection, nonunion, or malalignment. Secondary outcomes included quality of life as measured with the EuroQol-5 Dimensions (EQ-5D) questionnaire, radiographic alignment, and healing as measured with the modified Radiographic Union Scale for Tibial fractures (mRUST).
In this study, there were 44 primary outcome events (occurring in 18.0% of the intramedullary nailing group and 21.9% of the external fixation group). [8] There was no significant difference between the groups with regard to the rate of deep infection. Intramedullary nailing was associated with a lower risk of coronal malalignment and sagittal malalignment at 1 year. The EQ-5D index favored intramedullary nailing at 6 weeks, but the difference dissipated by 1 year. The mRUST score favored intramedullary nailing at 6 weeks.
In a study of Gustilo III open tibia fractures in patients older than 75 years, Steele et al found that functional outcomes were particularly poor in this group, suggesting that these patients could benefit from a greater emphasis on intensive rehabilitation. [9]
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Open tibial fracture.
Tables
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 |
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 |
