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Open Tibia Fractures: Type C – (Arterial Injuries)

- Discussion:
     - these fractures by definition are associated w/ vascular trauma, and have a high prevalence of infection
     - its important to assess viability of the limb, both w/ common sense, as well as w/ objective criteria such as the MESS
     - main controversy is whether tp procede on with vascular repair, frx fixation, (and subsequent soft tissue reconstruction /tibial defect reconstruction)
             vs 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 (type c fractures are generally treated w/ an external fixator); 
           - 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 microanastomosisvenous 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; 

- Neurologic Considerations:
  - 55% of patients that have an insensate foot will regain normal sensation 2 years after injury;
  - references:
        - The insensate foot following severe lower extremity trauma: An indication for amputation? 
        - Factors influencing the decision to amputate or reconstruct after high-energy lower extremity trauma.

- 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

Early fasciotomy in patients with extremity vascular injury is associated with decreased risk of adverse limb outcomes: A review of the National Trauma Data Bank

Gustilo IIIC fractures in the lower limb: Our 15-year experience

Combined orthopedic and vascular lower extremity injuries: sequence of care and outcomes.

Effect of temporary shunting on extremity vascular injury: an outcome analysis from the Global War on Terror vascular injury initiative.

Open tibial fractures grade IIIC treated successfully with external fixation, negative-pressure wound therapy and recombinant human bone morphogenetic protein 7