Debridement of Open Tibial Fractures and Infected Tibial Fractures

(see also tibial fracture menu / general principles of debridement)

Debridement of Acute Fractures

• goal is to avoid tibial infection;
• timing: (is emergent debridement necessary?)
• references:
  • The Effect of Surgical Delay on Acute Infection Following 554 Open Fractures in Children.
  • Outcomes in open tibia fractures: relationship between delay in treatment and infection.
  • Treatment of isolated type I open fractures: is emergent operative debridement necessary?
  • Intramedullary nailing for open fractures of the femoral shaft: evaluation of contributing factors on deep infection and nonunion using multivariate analysis.
  • The effect of time to definitive treatment on the rate of nonunion and infection in open fractures.
  • The effect of time delay on infection in open long-bone fractures: a 5-year prospective audit from a district general hospital.
  • Osteomyelitis in grade II and III open tibia fractures with late debridement.
• radiographs:
  • may give an indication of the missile tract or zone of injury in comparison to the wound;
• initial washout: (pressure irrigation)
  • sufficient debridment & irrigation & preservation of periosteum are essential;
  • debridement of all devascularized bone & soft tissues and appropriate pressure irrigation
• management of devascularized cortical fragments:
  • some recommend replacing large free contaminated cortical fragments in order to add to mechanical integrity of internal fixation;
    • deep-wound infection occurrs in 7-25% of patients in whom devascularized cortical fragments are saved;
  • some recommed removal of all devitalized tissue including bone;
    • infection rates can be reduced from 21% to 9% when all devitalized tissue is removed;
  • others remove cortical bone until bleeding from its edges are seen
    • there appears to be lower infection rate w/ aggressive debridement and removal of all loose bone fragments;
    • expect infection rates of  9-20 % in Grade III open tibial fractures when large free fragments are removed;
  • references:
    • Management of open fractures with sterilization of large, contaminated, extruded cortical fragments.
    • Severe open tibial fractures. Results treating 202 injuries with external fixation.

Debridement of Muscle »

• debridement was originally described by Napoleon's surgeon Baron Dominique Jean Larrey;
• non-viable muscle can be identified by the 4 c's (color, consistency, contraction, and circulation);
• the best indicator of viability is bleeding during debridement;
• 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;
• the fascia should be incised parallel parallel to the muscle fibers in both directions;
• need to identify the missile tract:
  • 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
    the tract, remove foriegn bodies, and excise non viable muscle;
• consider IV fluorescein dye to identify dead tissue;
• staged surgical debridment may be necessary q24-48 hrs;
• references:
  • Regional blood flow in skeletal muscle after high-energy trauma. An experimental study in pigs, using a new laser Doppler technique and radioactive microspheres.
  • An evaluation of the surgeon's criteria for determining the viability of muscle during debridement.
  • Microcirculatory and biochemical studies of skeletal muscle tissue after high energy missile trauma.

Wound Closure and Wound Care

• Contaiminated Wound Care:
• soft tissue coverage may be necessary for large defects;

Debridement of Chronic Osteomyelitis:

• see: debridement of sequestra / osteomyelitis
• debridement is methodical until viable bleed tissue is seen at the resection margins;
• it is essential to ensure that all foci of infection are removed;
• paprika sign: punctuate osseous bleeding;
• deep cultures:
  • following debridement multiple culutures are taken;
  • w/ immunocomprimised patient consider checking for mycobacteria and fungi;
• management of tibial bone defects
• posteromedial or posterolateral bone grafting can be done w/o disrupting non unions if alignment is satisfactory

References

• Pedestrian Tibial Injuries
• An aggressive surgical approach to the management of chronic osteomyelitis.
• Cases Out of the Past: The First Antiseptic Operations.
• Wound cleansing by high pressure irrigation.
• Wound management advice in antebellum America. From The Transylvania Journal of Medicine and the Associated Sciences, 1828-1853.