- Discussion:
- these fractures by definition are associated w/
vascular trauma, and have a high prevalence of
infection:
- its important to assess viability of the limb, both w/ common sense, as well as w/ objective criteria such as the
MESS;
-
main controversy is whether tp procede on with vascular repair, frx fixation, (and subsequent
soft tissue reconstruction /
tibial defect reconstruction)
vs consideration of
BKA amputation;
- considerations:
-
mangled extremity severity score:
- relative indications for amputation:
- high velocity
open tibia frx, w/ concomitant nerve, artery, &/or massive soft tissue disruption;
- types
IIIB and
IIIC tibial frx w/ assoc w/ insensate foot or major bony injuries;
- open tibia fractures w/ severe comorbidity (elderly pt, renal failure ect);
- Initial Management:
-
prevent infection:
- irrigation (w/ > 9 lit) and repeated debridment;
-
debridement of open tibia fractures
- consider leaving the wound open,
wound vac, w/ delayed closure at 3-5 days post-injury;
-
antibiotics
-
type II and III open frx repeat debridment is required to evaluate amount of devitalized & potentially necrotic soft tissue;
- Fracture Considerations:
-
tibial fracture menu: (
Gustilo Classification):
-
external fixators (type c fractures are generally treated w/ an external fixator);
- most advocate that orthopedic stabilization of frx or dislocation be done prior to definitive vascular repair so that arterial repair
will not be disrupted during fracture manipulation;
- this is reasonable if it will not interfere with the exposure required for adequate arterial reconstruction;
- Vascular Considerations:
- compartment syndrome menu
-
fasciotomy of the leg:
-
reperfusion injury
-
vascular injuries associated w/ tibial fractures
- arterial trauma -
artery menu
-
intimal injuries:
-
pharmocological agents in vascular surgery:
-
prosthetic grafts:
-
arterial microanastomosis /
venous repair
- once
arteriography confirms arterial injury, pt should be taken to the operating room;
- patient should have the affected extremity and at least one other extremity prepped in case a vein graft is required;
- use of a temporary
vascular shunts has been advocated in pts w/ long ischemia times being treated with initial orthopedic
stabilization prior to vascular repair;
- initial vascular repair is also preferable in an extremity where prolonged ischemia (more than 6 hours) threatens the success of revascularization;
- if definitive vascular repair is done first, vascular surgeon should be present during initial fracture manipulation and should reexamine
patient at end of the case to ensure integrity of vascular repair;
- Soft tissue coverage as soon as the wound is clean;
- skin grafting & free flaps are often required;
- STSG over bone is rarely successful;
References for Arterial Trauma
To Reconstruct or Not to Reconstruct?
Open tibial fractures with associated vascular injuries: prognosis for limb salvage.
Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures.
- references:
-
Classification of type III (severe) open fractures relative to treatment and results.
-
Severe open fractures of the tibia
-
Severe open tibial fractures: a study protocol.
-
Complicated open fractures of the distal tibia treated by secondary interlocking nailing.
-
Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming.
-
Locked intramedullary nailing of open tibial fractures.
-
Treatment of open fractures of the tibial shaft with the use of interlocking nailing without reaming.
-
Locked intramedullary nailing of open tibial fractures.
-
Open tibial fractures: faster union after unreamed nailing than external fixation.
-
Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures.
-
Local or free muscle flaps and unreamed interlocked nails for open tibial fractures.
-
Treatment of type II, IIIA, and IIIB open frx of the tibial shaft. A prospective comparison of unreamed interlocking IM nails and half-pin ex fixators.
-
Nonreamed locking intramedullary nailing for open fractures of the tibia.
-
Reamed interlocking intramedullary nailing of open fractures of the tibia.
-
Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study.
-
Contaminated fractures of the tibia: a comparison of treatment modalities in an animal model.
-
The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming.
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