Open Fractures of the Tibia

- 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.
                  - PRS study comparing single-agent antibiotic therapy, cipro, 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 fractures. 
                  - Type III open tibia fractures: immediate antibiotic prophylaxis minimizes infection.  
                  - Substantial improvement in prophylactic antibiotics for open frx patients: results of a performance improvement program.
     - bacterial cultures
          - wound cx obtained before debridement have minimal value in predicting infectious organism if a wound infection develops;
          - cultures obtained after irrigation improve the ability to determine the particular organism causing a subsequent deep infection;
          - 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 Wound Closure in Open Fractures Based on Cultures Obtained After Debridement

    - 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 vs delayed treatment of open tibial frx: rates of infection and secondary 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 frxs: 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 fractures: a 9-year 
                  - Open tibia fractures: timely debridement leaves injury severity as the only determinant of poor outcome

    - wound closure and nitial wound care of open tibia fractures:
           - pressure irrigation 
           - debridement of open tibia fractures 
                  - Orthoplastic reconstruction of type IIIB open tibial fractures retaining debrided devitalized cortical segments
           - 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 frx during the past 2 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."         
- references:
                - Rbmp for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. 
                - Treatment of open fractures of the shaft of the tibia.
                - Open fractures of the tibia treated by immediate intramedullary tibial nail insertion without reaming: a prospective study
                - Staged Protocol in Treatment of Open Distal Tibia Fracture: Using Lateral MIPO
                - Staged external and internal locked plating for open distal tibial fractures.
    - grade I Frx:
            - references:
                  - Closed intramedullary tibial nailing. Its use in closed and type I open fractures.  
                  - 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 (e.g., a
                      medially placed external fixator might interfere w/ a medial gastrocnemius flap);
            - wound vac
            - 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
            - Open tibial fractures: faster union after unreamed nailing than external fixation.
            - Clinical results of primary IM osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft frx.
            - 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: comparison of unreamed interlocking IM nails vs ex fix. 
            - Nonreamed locking intramedullary nailing for open fractures of the tibia.
            - Reamed interlocking intramedullary nailing of open fractures of the tibia.
            - Locking IM 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
          - wound vac
          - 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 flaps, bone-grafting/ IM nailing in patients who have a frx of tibial shaft with extensive soft-tissue injury. 
                 - 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 dressing to salvage a IIIB fracture with concomitant osteomyelitis to avert a free flap. 
                 - Negative pressure wound therapy after severe open fractures: a prospective randomized study. 
                 - Does the zone of injury in combat-related Type III open tibia fractures preclude the use of local soft tissue coverage?
                 - Negative pressure wound therapy in grade IIIB tibial fractures: fewer infections and fewer flap procedures?  
                 - Delay in Flap Coverage Past 7 Days Increases Complications for Open Tibia Fractures: A Cohort of 140 Trauma Centers.

- 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 BMP for treatment of open tibial frx: a prospective, controlled, randomized study of 450 patients. 
          - Recombinant Human Bone Morphogenetic Protein-2 in Open Tibial Fractures. A Subgroup Analysis of Data Combined from
          - Temporary intentional leg shortening and deformation to facilitate wound closure using the Ilizarov/Taylor spatial frame.
          - Recombinant Human BMP-2 for the Treatment of Open Tibial Fractures

- Complications: Osteomyelitis
          - What is the rate of methicillin-resistant Staphylococcus aureus and Gram-negative infections in open fractures?

- Misc References:

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

Management of open tibial fractures

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.  

Update on the management of open fractures of the tibial shaft. 

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

Open fractures of the tibia in children.

Immediate Intramedullary Flexible Nailing of Open Pediatric Tibial Shaft Fractures

Original Text by Clifford R. Wheeless, III, MD.

Last updated by Clifford R. Wheeless, III, MD on Sunday, October 20, 2019 11:11 pm