- Discussion:
- main controversy is whether tp procede on with vascular repair, frx fixation, (and subsequent
soft tissue reconstruction /
tibial defect reconstruction) vs and
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
- 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.
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