Open Fractures of the Tibia - Wheeless' Textbook of Orthopaedics

- Discussion:
- see open frx menu, tibia fracture menu and infections of the tibia:

- Initial Treatment and Timing of Surgery:
- preoperative antibiotics;
- therapeutic doses of ancef and tobramycin for 3 days are appropriate;
- w/ contamination consider anaerobic antibiotics (penicillins, clindamycin, flaggyl);
- tetanus prophylaxis if appropriate;
- references:
- Once daily high-dose gentamicin to prevent infection in open fractures of the tibial shaft: a preliminary investigation.
- Prospective, randomized, double-blind study comparing single-agent antibiotic therapy, ciprofloxacin, to combination antibiotic therapy in open fracture wounds.
- Ciprofloxacin Inhibition of Experimental Fracture-Healing.
- Clostridial myonecrosis.
- The use of antibiotics in open fractures.
- Duration of preventive antibiotic administration for open extremity frx;
- bacterial cultures:
- initial bacterial cultures are probably not helpful;
- references:
- Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?
- Epidemiology of bacterial infection during management of open leg fractures.
- Efficacy of cultures in the management of open fractures.

- timing of surgery:
           - compartment syndrome mandates immediate management;
                  - Compartment syndrome in open tibial fractures.
            - references:
- Outcomes in open tibia fractures: relationship between delay in treatment and infection.
- Early versus delayed surgical treatment of open tibial fractures: effect on the rates of infection and need of secondary surgical procedures to promote bone union.
- Evaluation of orthopaedic injuries in Operation Enduring Freedom.
- Osteomyelitis in grade II and III open tibia fractures with late debridement.
- Delayed presentation is no barrier to satisfactory outcome in the management of open tibial fractures.
- The effect of time to definitive treatment on the rate of nonunion and infection in open fractures.
- The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.
- The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital.
- Treatment of isolated type I open fractures: is emergent operative debridement necessary?
                  - The effect of the timing of antibiotics and surgical treatment on infection rates in open long-bone frx: A 9-yr prospective study from a district general hospital.
    - initial wound care of open tibia fractures:
- pressure irrigation:
- debridement of open tibia fractures:
- contaminated wound care:
- wound vac;
- antibiotic bead pouch:

- Frx Stabilization Based on Gustilo Classification:
- " There have been major improvements in the surgical treatment of open tibial fractures during the past
two decades. These improvements include aggressive treatment of soft tissue injury by means of immediate
debridement and early coverage as well as the preferred use of IM nails instead of external fixation to
stabilize the bony injury. These changes in the standard of care have been widely adopted with the
justified expectation of a lower rate of healing problems."
- BESTT study group. JBJS 84: 2123-2134
- grade I Frx:
- references:
- Closed intramedullary tibial nailing: its use in closed and type I open fractures. CM Court-Brown et al. JBJS Vol 73-B. 1991. p 959-964.
- Treatment of Isolated Type I Open Fractures: Is Emergent Operative Debridement Necessary?
- Factors affecting fracture healing after intramedullary nailing of the tibial diaphysis for closed and grade I open fractures.
- grade II frx:
- generally treated w/ intramedullary nail or an external fixator (see references of IM nailing of open tiba fractures)
- grade IIIb frx:
- generally treated w/ intramedullary nail or an external fixator: (see references of IM nailing of open tiba fractures)
- note that if a external fixator is being considered, it should be placed in a way so as not to interfere w/
flap application (eg a medially placed external fixator might interfere w/ a medial gastrocnemius flap);
- references:
- Reamed nailing of Gustilo grade-IIIB tibial fractures.
- Emergency management of type IIIB open tibial 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.
- grade IIIc frx:

- Soft Tissue Coverage for Tibial Defects
- note that if a external fixator is being considered, it should be placed in a way so as not to interfere w/ flap application (eg a medially placed
external fixator might interfere w/ a medial gastrocnemius flap);
- references:
- The Timing of Flap Coverage, Bone-Grafting, and IM Nailing in Patients Who Have a Frx of the Tibial Shaft With Extensive Soft-Tissue Injury.
MD Fischer et al. JBJS 73-A. 1991. p 1316-1322.
- Early microsurgical reconstruction of complex trauma of the extremities.
- Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results.
- The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap.
- Negative pressure wound therapy after severe open fractures: a prospective randomized study.

- Management of Tibial Bone Defects:
     - BMP - osteogenic proteins
     - tibial lengthening (distraction histiogenesis)
- bone grafting of tibial frx: (posterolateral bone grafting)
- references:
- Early prophylactic autogenous bone grafting in type III open tibial fractures.
- Recombinant Human BMP-2 for Treatment of Open Tibial Fractures. A Prospective, Controlled, Randomized Study of Four Hundred and Fifty Patients.
- Recombinant Human Bone Morphogenetic Protein-2 in Open Tibial Fractures. A Subgroup Analysis of Data Combined from Two Prospective Randomized Studies.
          - Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame.

- Misc References:

Plates versus external fixation in severe open tibial shaft fractures. A randomized trial.

Management of open tibial fractures

Plates versus external fixation in severe open tibial shaft fractures. A randomized trial.

Medial external fixation with lateral plate internal fixation in metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury.

Team approach to tibial fracture. 37 consecutive type III cases reviewed after 2-10 years.

Flexible Medullary Nailing of Acute Tibial Shaft Fractures. Wiss. Clinical Orthopaedics; 212: 122-132, 1986;

Flexible Medullary Nailing of Tibial Shaft Fractures. Wiss. et. al. J. Trauma, 26: 1106-1112, 1986;

Update on the management of open fractures of the tibial shaft. DC Templeman MD et al. CORR. No 350. p 18-25. May 1998.

Treatment of type II and type III open tibia fractures in children.

Open fractures of the tibia in children.