Open Tibia Fractures: Type C - (Arterial Injuries) : Wheeless' Textbook of Orthopaedics

- 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 microanastomosis / venous 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;