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Debridement of Open Tibial Fractures and Infected Tibial Fractures

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p>- See: a href="/bones/tibia-fibula/open-fractures-of-the-tibia/">tibial fracture menu/a> / general a href="/ortho/12696">principles of debridement/a>br/>
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strong>- Debridement of Acute Fractures:/strong> br/>
    - goal is to avoid a href="/bones/tibia-fibula/tibia-fracture-infections/">tibial infection/a>; br/>
    - strong>timing:/strong> (is emergent debridement necessary?) br/>
           - references: br/>
                - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/15634809">The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children./a> br/>
                - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/14608171">Outcomes in open tibia fractures: relationship between delay in treatment and infection./a> br/>
                - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/12771843">Treatment of isolated type I open fractures: is emergent operative debridement necessary?/a> br/>
                - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/16054148">Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis./a> br/>
                - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/12172278">The effect of time to definitive treatment on the rate of nonunion and infection in open fractures./a> br/>
                - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/15005929">The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital./a> br/>
                - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/7776031">Osteomyelitis in grade II and III open tibia fractures with late debridement. br/>
/a>br/>
    - strong>radiographs:/strong> br/>
           - may give an indication of the missile tract or zone of injury in comparison to the wound; br/>
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    - strong>initial washout:/strong> (a href="/bones/hand/pressure-irrigation/">strong>pressure irrigation/strong>/a>) br/>
           - sufficient debridment & irrigation & preservation of periosteum are essential; br/>
           - debridement of all devascularized bone & soft tissues and appropriate a href="/bones/hand/pressure-irrigation/">pressure irrigation/a> br/>
    - strong>management of devascularized cortical fragments:/strong> br/>
           - some recommend replacing large free contaminated cortical fragments in order to add to mechanical integrity of internal fixation; br/>
                  - deep-wound infection occurrs in 7-25% of patients in whom devascularized cortical fragments are saved; br/>
           - some recommed removal of all devitalized tissue including bone; br/>
                  - infection rates can be reduced from 21% to 9% when all devitalized tissue is removed; br/>
           - others remove cortical bone until bleeding from its edges are seen; br/>
                  - there appears to be lower infection rate w/ aggressive debridement and removal of all loose bone fragments; br/>
                  - expect infection rates of  9-20 % in Grade III open tibial fractures when large free fragments are removed; br/>
           - references: br/>
                  - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/3652587">Management of open fractures with sterilization of large, contaminated, extruded cortical fragments/a>. br/>
                  - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/3365903">Severe open tibial fractures. Results treating 202 injuries with external fixation/a>.   br/>
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    - strong>a href="/trauma-fractures/debridement-of-muscle/">debridement of muscle/a>:/strong> br/>
           - debridement was originally described by Napoleon's surgeon Baron Dominique Jean Larrey; br/>
           - non-viable muscle can be identified by the 4 c's (color, consistency, contraction, and circulation); br/>
           - the best indicator of viability is bleeding during debridement; br/>
           - non viable muscle is identified by its dark color, mushy consistency, failure to contract when pinched w/ forceps (or cautery), and absence of bleeding from a cut surface; br/>
           - the fascia should be incised parallel parallel to the muscle fibers in both directions; br/>
           - strong>need to identify the missile tract:/strong> br/>
                  - underlying muscle surrounding the missle tract should be opened in the direction of its fibers to the degree necessary to achieve exposure adequate to inspect br/>
                         the tract, remove foriegn bodies, and excise non viable muscle; br/>
           - consider IV fluorescein dye to identify dead tissue; br/>
           - staged surgical debridment may be necessary q24-48 hrs; br/>
           - references: br/>
                  - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/6637310">Regional blood flow in skeletal muscle after high-energy trauma. An experimental study in pigs, using a new laser Doppler technique and radioactive microspheres./a> br/>
                  - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/13372037">An evaluation of the surgeon's criteria for determining the viability of muscle during debridement./a> br/>
                  - a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/6952686">Microcirculatory and biochemical studies of skeletal muscle tissue after high energy missile trauma./a> br/>
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- a href="/ortho/12543">strong>Wound Closure and Wound Care/strong>/a>:/p>
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    - a href="/bones/tibia-fibula/contaminated-wound-care/">Contaiminated Wound Care/a>: br/>
          - a href="/bones/tibia-fibula/soft-tissue-coverage-for-the-leg/">soft tissue coverage/a> may be necessary for large defects;
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p>br/>
strong>- Debridement of Chronic Osteomyelitis:/strong> br/>
    - see: a href="/bones/tibia-fibula/osteomyelitis/_debridement_of_sequestra">debridement of sequestra/a> / a href="/bones/tibia-fibula/osteomyelitis/">osteomyelitis/a>br/>
    - debridement is methodical until viable bleed tissue is seen at the resection margins; br/>
    - it is essential to ensure that all foci of infection are removed; br/>
    - strong>paprika sign/strong>: punctuate osseous bleeding; br/>
    - strong>deep cultures:/strong> br/>
           - following debridement multiple culutures are taken; br/>
           - w/ immunocomprimised patient consider checking for mycobacteria and fungi; br/>
br/>
    - a href="/bones/tibia-fibula/treatment-methods-for-tibial-fracture-defects/">management of tibial bone defects/a> br/>
           - posteromedial or a href="/bones/posterolateral-bone-grafting/">posterolateral bone grafting/a> can be done w/o disrupting non unions if alignment is satisfactory/p>
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a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/3298664">Pedestrian Tibial Injuries/a> br/>
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a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/8118980">An aggressive surgical approach to the management of chronic osteomyelitis/a>. br/>
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Cases Out of the Past: The First Antiseptic Operations.  br/>
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a onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/808870">Wound cleansing by high pressure irrigation/a>. br/>
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a ref="ordinalpos=1&ncbi_uid=6360485&link_uid=6360485&linksrc=docsum_title" onclick="window.open(this.href,'','resizable=no,location=no,menubar=no,scrollbars=yes,status=no,toolbar=no,fullscreen=no,dependent=no,status'); return false" href="http://www.ncbi.nlm.nih.gov/pubmed/6360485">Wound management advice in antebellum America. From The Transylvania Journal of Medicine and the Associated Sciences, 1828-1853./a>/p>/div>br/>hr/>br/>br/>br/>Last updated by Clifford R. Wheeless, III, MD on Tuesday, April 2, 2013 6:43 ambr/>

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