- 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;
- 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.
Gustilo IIIC fractures in the lower limb: Our 15-year experience
Combined orthopedic and vascular lower extremity injuries: sequence of care and outcomes.