Open Tibia Fractures Treatment & Management


Background

Because the tibia is a subcutaneous bone, tibial fractures are frequently open fractures (see the image below). 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.

Open tibial fracture. Open tibial fracture.

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. [1The 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. [2They 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. [3They 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). [4Those 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 has been considered controversial. [5They 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. [6Whereas the quality of walking improved up to 12 months after operation, the capacity to walk reached a plateau after 6 months.

Open tibia fractures are commonly stratified by the Gustilo classification, an orthopedic grading system that 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.



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. [89]

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.

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). [101112 The Tscherne classification is used for soft-tissue injuries (see Table 2 below). Both of these classifications have poor interobserver agreement [13; 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. [14]

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. [15]

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. [161718 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.


Approach Considerations

Routine preoperative blood tests are ordered.

Routine limb, chest, and cervical spine radiographs are ordered.



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 for limb salvage include the following:

  • Completely mangled limb
  • Presence of warm ischemia for longer than 6 hours
  • Poor facilities for salvage

Absolute contraindications for nailing an open fracture include the following:

  • Untreated compartment syndrome
  • Gustilo-Anderson types IIIB and IIIC open fractures

Antibiotic Therapy, Irrigation, and Debridement

Intravenous (IV) antibiotics are administered promptly. First-generation cephalosporins providing gram-positive coverage (eg, cephalothin 1-2 g q6-8hr) suffice for type I fractures. An aminoglycoside providing gram-negative coverage (eg, gentamicin 120 mg q12hr; 240 mg/day) is added for type II or III injuries. Metronidazole 500 mg q12hr or penicillin 1.2 g q6hr can also be added for coverage against anaerobes. Tetanus prophylaxis should be instituted. Antibiotics generally are continued for 72 hours after 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 (ED). [21A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room (OR) as soon as is feasible. Debridement within 6 hours is necessary to keep the rate of infection low. [22A key factor in infection prevention is early rigid stabilization of the fracture.

The aims of antibiotic therapy and debridement are to sterilize the wound to a negligible bacterial load and to 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 to be followed. 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 applicable to this setting. 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 found that high-pressure pulsatile lavage also resulted in bacterial seeding into the intramedullary canal and significant damage to the architecture of the bone. [23However, 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 effectively removed 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. [24]

The bone ends should be debrided thoroughly. Aggressive bone debridement has been demonstrated to lower infection rates in high-grade open fractures. [1125]

Soft-tissue coverage can be achieved primarily in all cases except those with extensive contamination and risk of anaerobic infection. [26A delayed primary closure or coverage is provided for wounds with extensive contamination and a significant 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. [27Gustilo-Anderson types I and II injuries can also be allowed to granulate and close spontaneously by secondary intention.

Surgical Repair and Amputation

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. [282930Type IIIB fractures can also be treated with unreamed nails. Solid-core nails are associated with the lowest rate of infection. [31 In a study comparing suprapatellar and infrapatellar approaches to medullary nailing of the tibia in patients with open tibia fractures, Marecek et al found the two approaches to be essentially similar with respect to the risk of knee sepsis. [32]

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. [33]

External fixation is used for types IIIA and IIIB fractures. Thakur and Patankar demonstrated excellent results using a protocol of early bone grafting and fixator dynamization with monolateral fixators. [3435]

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. [3637Alternately, the fixator can be removed and the limb immobilized in a cast until the pin sites have healed; the tibia can then be nailed.

A meta-analysis by Bhandari et al found that in comparison with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in open tibial fractures. [3839It also showed that the risk of reoperation was lower with reamed nails than with unreamed nails. This finding 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.

In this meta-analysis, plate fixation was found to be uniformly the worst of all methods of internal fixation. [39Although plating a fracture that is exposed may be tempting (because of the open nature of the injury), the risk of nonunion, malunion, and deep infection [40is too high to justify it.

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. [3441]

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.

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. [28The 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. [4243]

Complications

Open tibial fractures have higher rates of nonunion, infection, and chronic pain syndrome (CPS). [44 The Gustilo-Anderson classification of the fracture is a good predictor of the likelihood of nonunion and infection. [45]

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.

Long-Term Monitoring

Given the higher rates of nonunion, infection, and CPS seen with open tibial fractures, close follow-up is required until union. CPS should be anticipated and treated early, rather than after the pain patterns are entrenched. Follow-up should also watch for possible acute, subacute, or chronic osteomyelitis surfacing months or even years after the injury. Pin-site infections arising after external fixation should be aggressively treated with oral or parenteral antibiotics and debridement or even pin exchange. Pin-site chroni