Open Tibia Fracture Case File

Open Tibia Fracture Case File

Eugene C. Toy, MD, Andrew J. Rosenbaum, MD, Timothy T. Roberts, MD, Joshua S. Dines, MD

CASE 9

A 34-year-old man presents to the emergency department (ED) with a grossly deformed left leg after crashing his motorcycle into a fast-moving pickup truck on the freeway. He is writhing in pain. There are no other apparent injuries; he was helmeted and denies losing consciousness. There is a 15-cm soft tissue defect with protruding bone involving his anteromedial leg. Debris from the road is noted in the wound. On exam, he can flex and extend his great toe and appreciate sensation to light touch throughout his foot and has palpable dorsalis pedis and posterior tibial pulses. The patient has no past medical or surgical history, has no known drug allergies, and last ate approximately 10 hours ago. Vital signs are heart rate 125 beats/min, blood pressure 110/65 mmHg, respiratory rate 20 breaths/min, and temperature 98.1°F. Radiographs are shown ( Figure 9–1 ).

► What is your most likely diagnosis?

► What are your next steps in management?

► What is the general operative approach to open fractures?

A

B

Figure 9–1. (A) AP and (B) lateral radiographs of the tibia and fibula.

ANSWER TO CASE 9:

Open Tibia Fracture                              

Summary: A 34-year-old man presents to the ED with a grossly deformed left leg status post a motorcycle accident in which he crashed into a pickup truck. There is an open and grossly contaminated tibia fracture, as road debris was initially found in the wound. His left lower extremity is neurovascularly intact. Although tachycardic, his other vital signs are within normal limits and he appears hemodynamically stable. No other injuries are noted.

• Most likely diagnosis: Open tibia and fibula fracture
• Next steps in management: Emergency room management including tetanus prophylaxis, administration of intravenous antibiotics, provisional irrigation, wound dressing, fracture splinting, and operative planning
• General operative approach: Wound debridement and fracture stabilization with an understanding of the potential need for secondary operations for skin, soft tissue, and bone reconstruction

ANALYSIS

Objectives

1. Understand the stages of care for open tibia fractures.
2. Know how to classify open fractures ( Table 9–1 ).
3. Understand the role of emergency room management, antibiotics ( Table 9–2 ), and operative intervention.
4. Be familiar with the potential risks and complications of open fractures.

Considerations

This 34-year-old man presented with an open left tibia and fibula fracture after a motorcycle accident. The first priority should be for evaluation and treatment of life-threatening injuries by the ED and trauma physicians, as dictated by advanced trauma life support (ATLS) protocol. After identification and treatment of such injuries, orthopaedic assessment of the limb should ensue and includes evaluation of the soft tissue damage and neurovascular status. History, dimensions, and location of the open wounds must be documented. Obtaining a photograph may also be helpful during the initial exam.

In the ED, tetanus prophylaxis and intravenous antibiotics should be administered immediately ( Table 9–2 ). Provisional lavage of the wound with an adequate quantity of sterile saline should be performed. Any contaminants such as dirt and grass should be removed from the wound before it is covered with a sterile dressing. Fracture reduction should occur with placement in a well-padded splint. The limb’s neurovascular status should be documented before and after alignment. Pending stable labs and clearance by the trauma team, this patient should ideally be taken to the operating room within 6 to 8 hours from the time of injury for wound debridement and fracture stabilization.

APPROACH TO:

Open Tibia Fracture                                             

DEFINITIONS

OPEN FRACTURES: Fractures that communicate with the outside environment. These complex injuries involve both the bone and surrounding soft tissues and mandate management strategies focused on prevention of infection, fracture union, and restoration of function.

GUSTILO AND ANDERSON OPEN FRACTURE CLASSIFICATION: Classification system incorporating the amount of energy, severity of soft tissue injury, and degree of contamination for determination of fracture severity.

ZONE OF INJURY: A concept describing the true dimensions of the wound, as opposed to simply the skin wound, which may only be a small opening through which the true wound communicates with the exterior. This is often seen in fractures that have significant muscle coverage, such as femoral and humeral shaft fractures.

VACUUM-ASSISTED WOUND CLOSURE (VAC): The gold standard for temporary management of open fracture wounds. It exposes the wound bed to a mechanically induced negative pressure in a closed system that facilitates granulation tissue formation while removing fluid from the extravascular space, reducing edema and improving microcirculation.

CLINICAL APPROACH

Initial Assessment

Open tibia fractures are high-energy injuries. As such, identification of other lifethreatening injuries is vital. Once these injuries have been identified and adequately treated, attention must be directed toward the traumatized extremity. History and physical exam should focus on mechanism of injury, neurovascular status of the extremity, compartment syndrome, size of the soft tissue defect, periosteal stripping, fracture pattern, bone loss, and contamination. This knowledge will help to classify the fracture, determine treatment, and establish prognosis. Of note, the degree of soft-tissue damage and contamination is important in classifying open fractures (Table 9–1 ).

    It is important to recognize that the diagnosis of open fractures can be missed, as seen when a small puncture wound is the only defect or when a wound is located posteriorly and the examining physician fails to inspect the limb circumferentially. Plain radiographs can also be used to aid in this diagnosis and may depict fracture comminution, displacement, bone loss, and/or subcutaneous air.

    Emergency room management of an open tibia fracture requires a team-oriented approach between orthopaedic, ED, and trauma staff. Gross contaminants such as leaves and grass must be removed from the wound, and irrigation with sterile saline solution should be performed. There is no consensus regarding optimal volume, delivery method, and irrigation solution. After provisional lavage, a dry sterile dressing should be applied and not be removed until the operating room. The tibia should be reduced and placed in a splint. Tetanus prophylaxis, if necessary, must be administered and intravenous antibiotics given ( Table 9–2 ).

    Systemic antibiotics must be started as soon as possible, as a delay of >3 hours increases the risk of infection. Although duration of antibiotic therapy is controversial, most physicians who treat open fractures believe that it should be limited to 3 days. At wound closure, or after any major surgical procedure, an additional 3-day course of antibiotics should be given. Local therapy, in the form of antibioticimpregnated polymethylmethacrylate beads, can be inserted into the fracture wound or inside the bone defect. This is often reserved for select grade II and III injuries.

Operative Intervention

Primary surgery ideally occurs within 6 to 8 hours from the time of injury. However, there are little data to support this timeline. In the operating room, a more thorough examination of the wound occurs, with a determination of the true zone of injury. Irrigation and debridement is performed, as the presence of nonviable tissue and foreign objects promotes bacterial growth. The ultimate goal is a clean wound with viable tissue and no infection. In significantly contaminated wounds, additional debridement may be necessary after 24 to 48 hours.

    After wound care, the fracture reduction and fixation occurs. The decision to temporarily versus definitively stabilize the fracture depends on the general condition of the patient, extent of injury and fracture pattern. In the setting of an open tibia fracture, fixation options include temporary external fixation and intramedullary nailing. Regardless of whether temporary or definitive fixation is chosen, the goals are to restore the tibia to its normal length and alignment, as this reduces dead space and hematoma volume. The stabilization provided will also prevent additional damage from mobile bone fragments and promote healing. With the exception of cases with heavy bacterial contamination, significant soft tissue damage, or vascular injury (grades IIIb and IIIc), intramedullary nailing is preferable.

Secondary Surgery

Definitive fracture management may occur at a later date if only temporary fixation was performed with an external fixator. This is done when swelling has subsided and the condition of the soft tissues has improved. Soft tissue and skin coverage should occur within 7 days. Infection risk increases in wounds left open for longer periods of time.

Risks and Complications

The major risk associated with open fractures is infection, which can lead to amputation, loss of function, delayed union, malunion, or nonunion. Delayed union and nonunion are more common in open than closed fractures. The frequency of all of the preceding risk factors increases with the severity of the initial injury. Prolonged immobilization may also occur, not only because of the open fracture, but also because of other associated injuries that may have been incurred. The patient must understand these risks and that multiple surgeries may be necessary. Appropriate rehabilitation is crucial in regard to optimizing outcomes of open fractures.

COMPREHENSION QUESTIONS

9.1 A 42-year-old man is brought to the trauma center after a 6-foot fall off a ladder. Physical exam shows a slightly deformed left lower extremity with a 0.5-cm soft tissue defect over the anterolateral aspect of his leg. The wound appears

relatively clean with no gross contaminants present. Radiographs depict a short

oblique proximal one-third diaphyseal tibia fracture. What is his Gustilo open

fracture classification grade?

A. I

B. II

C. IIIa

D. IIIb

E. V

9.2 What antibiotic should the patient in question 9.1 receive?

A. Vancomycin

B. Penicillin

C. Levaquin

D. Cefazolin

E. Cephalexin

9.3 A 70-year-old woman is brought to the trauma center with a significantly deformed right lower extremity with a 4-cm wound over the posteromedial portion of her leg. She is found to have a Gustilo and Anderson type 3A fracture. Which of the following interventions has been shown to decrease the risk of infection at the fracture site?

A. Irrigating with high-pressure pulsatile lavage

B. Immediate prophylactic antibiotic administration

C. Application of a wound VAC of the soft tissue defect in the ED

D. Operative debridement within 6 to 8 hours of injury

ANSWERS

9.1 A. This is a Gustilo and Anderson type I fracture. There is a simple fracture pattern in the setting of clean, <1-cm wound.

9.2 D. Type I fractures should receive an intravenous first-generation cephalosporin such as cefazolin ( Table 9–2 ). Vancomycin, penicillin, and Levaquin are not cephalosporins. Cephalexin, although a cephalosporin, is an oral antibiotic and thus is not indicated for an open fracture.

9.3 B. The duration to beginning of antibiotic administration and adequate surgical debridement of the wound are the only factors definitively shown to reduce infection and improve outcome in open fractures. Although traditional recommendations include surgical irrigation and debridement within 6 to 8 hours of injury, there is no literature to support this time window. There is also no evidence to support pulsatile lavage over gravity flow. Finally, in this setting there is also no role for wound VAC application in the ED.

    CLINICAL PEARLS    

► Open tibia fractures are high-energy injuries, and as such, evaluation and treatment of life-threatening injuries per ATLS protocol is the first priority. ► Systemic antibiotics must be started as soon as possible; a delay of >3 hours increases the risk of infection. ► It is recommended that operative irrigation and debridement be performed within 6 to 8 hours from the time of injury, although there is little evidence to support this. ► Initial stabilization of open tibia fractures includes external fixation and intramedullary nailing. ► The predominant risk associated with open fractures is infection, which can lead to amputation, loss of function, delayed union, malunion, or nonunion.

REFERENCES

Melvin JS, Dombroski DG, Torbert JT, Kovach SJ, Esterhai JL, Mehta S. Open tibial shaft fractures: I. Evaluation and initial wound management. J Am Acad Orthopaed Surg. 2010;18:10-19. 

O’Brien PJ, Mosheiff R. Open fractures: stages of care. AO Principles of Fracture Management . AO Foundation. Available at: https://www2.aofoundation.org. Accessed November 12, 2011. 

Zalavras CG, Patzakis MJ. Open fractures: evaluation and management. J Am Acad Orthopaed Surg. 2003;11:212-219.

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