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DR.RANAT VISHNOI
INTRODUCTION
 An open fracture is one in which a break in the skin
 allows for direct communication of the fracture site or
 fracture hematoma with the elements external to the
 usual protection of the skin.

The prognosis in open fractures is determined by :-
 the amount of devitalized soft tissue.
 the level and type of bacterial contamination.
 geometry of fracture.
Incidence
 Open fractures of the tibia
  are more common than in
  any other long bone

 Rate of tibial diaphysis
  fractures reported 2 per
  1000 population and of
  these approximately one
  fourth are open tibia
  fractures.
PRINCIPLES OF MANAGEMENT

             ABC’S
             Assoc  Injuries
             Tetanus
             Antibiotics
             Soft Tissue
              Management
             Fixation
             Long term issues
DIAGNOSIS
  The diagnosis of an open fracture is straight forward in
  most cases. An injured patient usually has:-
 bleeding deep laceration overlying or near a fracture of the
  underlying bone.
 In some cases, the fractured bone may be exposed.

  However, not all open fractures are obvious, and their
  timely and proper diagnosis and treatment depend on a
  careful examination of the patient, delineating salient
  features from the patient's history, a critical reading of x-
  rays, and good clinical judgment.
 Examine the neurologic function and vascular function of
  each extremity.
 Note the state of circulation to the limb as indicated by
    capillary blush,
    the filling of veins, and
    the status of peripheral pulses.
 Examine meticulously for peripheral nerve function.
    Initial sensory examination by pressure and light touch gives
     a gross evaluation of limb sensation.
    Examination for motor function is difficult in the injured
     limb owing to pain and muscle spasm. The normal side
     should be compared with the abnormal side.
Mechanism of Injury
 Can occur in low energy, torsional type injury.
  (e.g. skiing)

 More common with high energy, direct force.
 (e.g. car bumper)
ENVIROMENTAL FACTOR
The location where the injury occurred is essential to delineate.
   People exposed to feces or dirt may occur in a farm setting have
    possibility of clostridial infection and need additional antibiotics
    (penicillin) and more aggressive surgical debridement.
   In automobile collisions there is less risk for development of a
    clostridial infection.
   Unusual environments, such as a barnyards or gardens, streams or
    lakes, will likely be contaminated by unusual organisms, such as soil
    anaerobes and Aeromonas hydrophilia, respectively.
   Injuries caused by lawn-mowers and other motorized garden
    equipment are high-energy injuries with severe contamination.
   Animal Bite or presence of oral flora.
HISTORY
 The patient's tetanus immunity must be determined.

 The surgeon must also inquire about medical illnesses:-
    diabetes mellitus,
    peripheral vascular disease,
    liver disease, and
    any immune deficiency syndromes.


 Any previous injuries and their treatments.

 Finally, a history of smoking or chronic use of steroids.
Physical Examination
 Due to subcutaneous nature of
  tibia, deformity and open wound
  usually readily apparent.

 Circumferential inspection of soft
  tissue envelope, noting any
  lacerations, ecchymosis, swelling,
  and tissue turgidity necessary.
 Neurologic and vascular exam of extremity must be done.

 Wounds should be assessed and then covered with sterile
 gauze dressing until treated or through digital camera /
 cell phone.

 True classification of wound best done after surgical
 debridement completed.
IMAGING EVALUATION
 Full length AP and lateral views
  from knee to ankle required for all
  tibia fractures.

 Ankle views suggested to examine
  mortise.

 Arteriography indicated if vascular
  compromise present after
  reduction .
Associated Injuries
 Approximately 30% of patients
  have multiple injuries.
 Fibula commonly fractured
  and its degree of comminution
  correlates with severity of
  injury.
 Proximal or distal tib-fib joints
  may be disrupted.
 Ligamentous knee injury
  and/or ipsilateral femur
  (‘floating knee’) more
  common in high energy
  fractures.
 Neurovascular structures
  require repeated assessment.

 Foot fractures also common.


 Compartment syndrome
  must be looked.
CLASSIFICATION
      OF
    OPEN
  FRACTURES
HELPFUL FOR
 Communication between health care professionals


 Formulating a treatment plan


 Decision on limb salvage


 Detailed audit of care to ensure optimal management
METHODS OF CLASSIFICATION
 GRADING SYSTEM – focus on severity of limb injury only
  Eg: Gustilo Anderson , Tscherne and Gotzen, Byrd and
 Spicer etc

 SCORING SYSTEM – focuses on limb injury and general
 health; also give ‘amputation score’.
 Eg: MESS , NISSSA ,LSI,etc

 COMPREHENSIVE SYSTEM – combines the above two
 systems
 Eg: AO system , Ganga hospital score
GRADING SYSTEMS
Gustilo Anderson System
 In 1976 , Gustilo and Anderson treated 1025 open fractures
  based on his grading system that offered prognosis about
  outcome of infected fractures
 In 1984, it was modified and was based on
    a.   Size of wound
    b. Soft tissue damage
    c. Periosteal stripping
    d. Vascular injury
    Segmental fractures, farmyard injuries, fractures occurring in a highly
     contaminated environment, shotgun wounds, or high-velocity
     gunshot wounds automatically result in classification as type III open
     fracture.
Type   Wound                 Level of     Soft Tissue Injury                Bone Injury
                             Contaminatio
                             n
 I     <1 cm long             Clean        Minimal                           Simple, minimal
                                                                            comminution

 II    >1 cm long             Moderate    Moderate, some muscle              Moderate comminution
                                          damage
 III
       Usually >10 cm long    High         Severe with crushing              Usually comminuted;
  A                                                                         soft tissue coverage of
                                                                            bone possible


       Usually >10 cm long    High         Loss of coverage; periosteal      Bone coverage poor;
  B                                       stripping & usually requires      variable, may be
                                          soft tissue reconstructive        moderate to severe
                                          surgery                           comminution


       Usually >10 cm long    High         Very severe loss of coverage      Bone coverage poor;
  C                                       plus vascular injury requiring    variable, may be
                                          repair; may require soft tissue   moderate to severe
                                          reconstructive surgery            comminution
Tscherne System
GRADE                            DESCRIPTION

   1      Skin laceration mostly inside out injury with little or no contusion
                                         of skin

   2        Skin laceration with circumscribed skin or soft tissue contusion
                             with moderate contamination

   3      Fractures with severe soft tissue injury often with NV injury , severe
                    bone comminution or compartment syndrome

   4           Sub total (remaining soft tissue not exceeding ¼ of limb
                          circumference) or total amputation


 This system includes compartment syndrome which is not
included in other grading systems
Byrd and Spicer
TYPE                           DESCRIPTION

 I     Both endosteal and periosteal supply intact and surrounding soft tissue
                                     is healthy

 II      Endosteal supply interrupted but periosteal supply maintained by
                              surrounding soft tissues

 III          Devascularised bone fragment and requires flap coverage




  This system lacks sophistication and hence not widely used
SCORING SYSTEMS
Mangled Extremity Severity Score
            (MESS)
TYPE   CHARACTERISTICS                  INJURIES                   POINTS

SKELETAL/ SOFT-TISSUE GROUP
 1      Low energy       Simple closed #, small calibre gun shot     1
 2     Medium energy        Open # , D/L , mulltiple level #         2
 3      High energy      Shot gun blast , high velocity gun shot     3
 4     Massive crush           Rail road, oil rig accidents          4

SHOCK GROUP
 1      Normotensive           BP stable in field and OT             0
 2       Transiently     BP unstable in field but responds to IV     1
         hypotensive                      fluids
 3        Prolonged       SBP<90 in field and responding to IV       2
        hypoptensive               fluids only in OT
MESS Contd…
TYPE   CHARACTERISTICS                  INJURIES                 POINTS

ISCHEMIA GROUP
  1        None          Pulsatile limb w/o signs of ischemia      0*
  2        Mild            Diminished pulses w/o signs of          1*
                                       ischemia
  3      Moderate         No pulse, sluggish capillary refill,     2*
                            paraesthesia, motor activity
  4      Advanced        Pulseless, cool, paralysed, numb, no      3*
                                     capillary refill
AGE GROUP
  1       < 30 yrs                                                 0
  2      30 – 50 yrs                                               1
  3       > 50 yrs                                                 2


* If ischemia time > 6 hrs, add 2 points.
MESS Contd…
 It was developed to identify those patients who will be
  benefited by primary amputation
 In retrospective analysis, the outcome of injured limb
  was either salvage or amputation
 A score of 7 or greater is predictive of amputation.
 MESS is found to be specific but lacks some sensitivity
  which infers that score predicting limb salvage(<7) is
  more reliable than score predicting amputation
  (> or =7) (Bosse MJ JBJS 83A:412,2001)
Injury Severity Score (ISS)
 More recently, Rajasekaran et al. proposed a new
  scoring system for Gustilo type IIIA and IIIB open
  fractures of the tibia that evaluated skin coverage,
  skeletal structures, tendon and nerve injury, and
  comorbid conditions .
 The high specificity of this new scoring system may
  make it a much better predictor of amputation.
Injury Severity Score for Gustilo Type IIIA and IIIB Open Tibial Fractures
Covering Structures: Skin and Fascia

        Wounds without skin loss
        Not over the fracture: 1
        Exposing the fracture: 2
        Wounds with skin loss
        Not over the fracture: 3
        Over the fracture: 4
        Circumferential wound with skin loss: 5

Skeletal Structures: Bone and Joints

       Transverse or oblique fracture or butterfly fragment <50% circumference: 1
       Large butterfly fragment >50% circumference: 2
       Comminution or segmental fractures without bone loss: 3
       Bone loss <4 cm: 4
       Bone loss >4 cm: 5
Functional Tissues: Musculotendinous and Nerve Units

     Partial injury to musculotendinous unit: 1
     Complete but repairable injury to musculotendinous units: 2
     Irreparable injury to musculotendinous units, partial loss of a compartment, or
     complete injury to posterior tibial nerve: 3
     Loss of one compartment of musculotendinous units: 4
     Loss of two or more compartments or subtotal amputation: 5


Comorbid Conditions: Add 2 Points for Each Condition Present

      Injury leading to débridement interval >12 h
      Sewage or organic contamination or farmyard injuries
      Age >65 y
      Drug-dependent diabetes mellitus or cardiorespirator diseases leading to
     increased anesthetic risk
      Polytrauma involving chest or abdomen with injury severity score >25 or fat
     embolism
      Hypotension with systolic blood pressure <90 mm Hg at presentation
      Another major injury to the same limb or compartment syndrome
Using this system, they divided type III open tibial
fractures into four groups to assess the possibilities of
limb salvage.
  Group 1 had scores of 5 or less.
  Group 2 had scores of 6 to 10.
  Group 3 had scores of 11 to 15 and,
  Group 4 had scores of 16 or greater.
A score of 14 or greater is an indicator for amputation.
Other Scoring Systems
• NISSSA – Nerve injury Ischemia Soft tissue injury
  Skeletal injury Shock & Age , is more sensitive and
  more specific than MESS.
• LSI – Limb Salvage Index
     a.This index is applied to limbs with arterial injury
     b.Warm ischemia time together with scores for
  injured skin , muscle , bone , NV are added to give
  total score.
COMPREHENSIVE
   SYSTEMS
 AO System :
   Skin lesions , muscle -tendon , NV , bone injuries are
   graded separately
   AO system allows better prediction of outcome when
   compared to Gustilo
   Due to its complexity not widely accepted


• Ganga hospital score :
   Includes additional criteria like age >65 , DM , cardio-
    respiratory disease , trauma chest/abdomen,
    farmyard/sewage contaminations, delay in debridement
    >12h
ANTIBIOTIC
 A short course of first-generation cephalosporins, begun as
  soon as possible after injury, significantly lowers the risk of
  infection when used in combination with prompt, modern
  orthopaedic fracture wound management.
 A broad-spectrum antibiotic, first-generation cephalosporin
  + aminoglycoside, such as tobramycin or gentamicin, for highly
  contaminated wounds in which there is a risk of gram-negative
  contamination (Gustilo type III).
 If possibility of anaerobic organisms, such as Clostridium, high-
  dose penicillin is recommended.
 The duration of antibiotic treatment should be limited because
  in most series the infecting organisms are hospital acquired.
 Gustilo recommended
    Type I and II - 2 g of cefamandole on admission and 1 g every 8
     hours for 3 days.
    In type III - an aminoglycoside in dosages of 3 to 5 mg/kg daily.
    Farm injuries - add penicillin, 10 to 12 million U daily.

 Gustilo continued double antibiotic therapy for 3 days only and
  repeated the antibiotic regimen during wound closure, internal
  fixation, and bone grafting.

 Okike and Bhattacharyya recommended the administration of
  cefazolin, 1 g intravenously, every 8 hours until 24 hours after the
  wound is closed, with intravenous gentamicin (with weight-
  adjusted dosing) or levofloxacin (500 mg every 24 hours) added
  for type III fractures.

 Campbell recommend obtaining cultures when obvious clinical
  findings of infection are present at the second débridement.
MANAGEMENT
Initial Management
 ABC of initial management is addressed first.
 Compressive dressings for extremity hemorrhage..
 Rule out cervical injuries , chest , abdominal injuries ,
  head injuries in polytrauma patients .
 As soon as possible careful examination of wound is
  carried out and serial photographs of wound taken.
Initial wound management
In emergency room :
   Don’t do digital exploration (to avoid infection and
    bleeding).
   Obvious Foreign Body are removed with forceps.
   If patient will undergo formal debridement in<1 hour
    just do sterile saline dressing if not irrigate with 1 or 2 ltr
    of NS.
   Povidone dressing alters color and impairs osteoblast
    function (controversial) so better avoided.
   Patients immunity to tetanus is determined.
   I.V. antibiotics are given as soon as possible .
Objectives of Surgical
           Treatment

 Prevent Sepsis
 Achieve Union
 Restore Function
DEBRIDEMENT
 Timing - Debridement done as soon as possible.
 Skin and wound preparation - dirt and debris removed by gentle scrub
  brush.
 Sterile tourniquets kept ready but not used.

SUPERFICIAL DEBRIDEMENT:
  Traumatic wounds extended – to identify and explore the entire zone of
  injury and to access ends of bone fragments
       Skin incisions – extensile longitudinal incision to visualize deep
        tissue and can be extended till (N) tissue encountered.
       Clearly Nonviable skin and subcutaneous tissue excised but of
        marginal viability may be left for later debridement.
       Don’t detach skin and subcutaneous tissue from the fascia.
       Any nonviable shredded fascia and even the marginally viable ones
        excised.
Extensile longitudinal skin incision
DEEP DEBRIDEMENT:
      Where skin tend to tear , fascia split or shred , muscle
       because of water content are subjected to hydraulic damage
       by fluid waves during injury.
      In muscle debridement the concept ‘when in doubt take it
       out’.
      In type I,II and IIIa open # all non-vital and in doubt
       muscle can be debrided but IIIb and IIIc removal of entire
       muscle compartment may be needed so marginally viable
       ones are left for later re-debridement
      Viability of muscle checked by its 4C’s = color, capacity to
       bleed, contractility and consistency(last 2 more reliable).
 Tendons , unless injured beyond repair should be
  preserved.
 In open wounds tendons are subject to dessication and
  hence it should be covered with soft tissues if not with
  moist dressings.
 In general bone devoid of soft tissue attachment
  removed and large ones are utilized provisionally for
  skeletal fixation and removed once fixation achieved.
 One exception to strict removal of bone without soft
  tissue attachment ,is significant portion of articular
  surface attached to bone fragment.
IRRIGATION
After meticulous debridement irrigation of wound is
done.
        Additives – antiseptics, antibiotics and
surfactants can be used.
Compound Fracture Tibia
Compound Fracture Tibia
Skeletal Stabilization
 Once the vascular repair has been completed and limb
  salvaged or irrigation and debridement done
  , stabilization of bone is next concern.
 Restoring the length ,rotational and angular alignment
  has many benefits for healing of soft tissue
   fracture reduction unkinks NV conduits and helps in
   soft tissue healing
   minimizing motion of fragments also decreases further
   damage, pain and permits mobilization of joints
Stabilization of Open Tibia
              Fractures
Multiple options depending on fracture pattern and
soft tissue injury:

  Extra osseous immobilisation
  IM nail- reamed vs. unreamed
  External fixation
  ORIF
Extra Osseous Immobilisation
Extra osseous immobilisation –eg: plasters ,weight
bearing casts , splints and skeletal tractions

Used in Low grade open fractures – eg: Grade-I Tibia #
(plasters) and open shaft fractures (skeletal traction).
IM Nail
 IM Nail- currently
  the treatment of
  choice for grade
  I,II,IIIa and IIIb
  fractures.
 Excellent results
  with type 1 open
 fractures.
Unreamed IM Nail
 Time to union with unreamed
  nails can be prolonged- in one
  study of 143 open tibia
  fractures 53% were united at 6
  months.

 Vast majority of fractures
  united, but 11% required at
  least one secondary procedure
  to achieve union.
Reamed Tibial Nailing
 In one study of type 2 and type
  3a fractures good results-
  average time to union 24 and 27
  weeks respectively; deep
  infection rate 3.5%.

 Complications increased with
  type 3b fractures- average time
  to union was 50 weeks and
  infection rate 23%.
External Fixation
 Used in high grade open
  fractures gives excellent
  access to wound dressing
  and surveillance possible.

 Compared to IM nails,
  increased rate of malunion
  and need for secondary
  procedures.

 Most common complication
  with ex-fix is pin track
  infection.
Conversion from Ex-Fix to IM Nail

 Conversion between ex-
  fix and IM nail.
 9% infection 90%union.
 Infection rates decreased
  with shorter duration of
  ex-fix time.
Plate Fixation
 Traditional plating technique with
  extensive soft tissue dissection and
  devitalization has generally fallen out of
  favor for open tibia fractures.

 After meticulous debridement, copious
  irrigation with minimal stripping and
  accurate anatomical reduction in
  extraperiosteal plate fixation can be done.

 Increased incidence of superficial and deep
  infections compared to other techniques.

 In one study 13% patients developed
  osteomyelitis after plating compared to 3%
  of patients after ex-fix.
Percutaneous Plate Fixation
 Newer
  percutaneous
  plating techniques
  using indirect
  reduction may be a
  more beneficial
  alternative

 Large prospective
 studies yet to be
 evaluated
Gunshot Wounds
 Tibia fractures due to
  low energy missiles
  rarely require
  debridement and can
  often be treated like
  closed injuries

 Fractures due to high
  energy missiles (e.g.
  assault rifle or close
  range shot gun)
  treated as standard
  open injuries
Amputation
 Lange proposed two absolute
  indications for amputation of tibia
  fractures with arterial injury:
    crush injury with warm ischemia
     greater than 6 hours, and
    anatomic division of the tibial nerve.

 In general amputation performed
  when limb salvage poses significant
  risk to patient survival, when
  functional result would be better with
  a prosthesis, and when duration and
  course of treatment would cause
  intolerable psychological disturbance.
Bone Defects
PMMA –aminoglycoside +/- vancomycin
  Bead pouch
  Solid spacer
Large Fragments: What to do?

•   Infection Rates with retained - 21%
•   Infection Rates with removed- 9%
•   Use to assist in determining length,
    rotation and alignment
Wound closure and coverage
Wounds without skin loss :
 Definitive coverage should be performed within 7-10 days if possible.
 Most type 1 wounds will heal by secondary intent or can be closed
  primarily.
 Delayed primary closure usually feasible for type 2 and type 3a fractures.
 Tension free primary closure after thorough debridement
 Contraindications for primary closure are
   1.  Delayed presentation >12hr
   2.  Delayed administration of antibiotic >12hr
   3.  Deep seated contamination
   4.  Immunocompromised
   5.  NV injury
   6.  Inability to achieve tension free suture
   7.  High risk of anaerobic contamination like farm yard injuries
Wounds with skin loss:
Type 3b fractures require either local advancement
or rotation flap, split-thickness skin graft, or free
flap.
Soft Tissue Coverage
 Proximal third tibia
  fractures can be covered
  with gastrocnemius
  rotation flap.
 Middle third tibia
  fractures can be covered
  with soleus rotation
  flap.
 Distal third fractures
  usually require free flap
  for coverage
Negative Pressure Would Therapy
    (NPWT)/ Vacuum Dressing
 Can lower need for free flaps Dedmond BT, The use of negative-
  pressure wound therapy (NPWT) in the temporary treatment of soft-tissue
  injuries associated with high-energy open tibial shaft fractures. J Orthop
  Trauma 2007
 Cannot lower infection rates for Type IIIB open
  fractures Bhattacharyya T, Routine use of wound vacuum-assisted closure
  does not allow coverage delay for open tibia fractures. Plast Reconstr Surg
  2008
Compound Fracture Tibia
BMPs
 BMP-2 (Infuse) FDA approval in subset of open tibia
  fractures BESTT study group JBJS 84, 2002
 Significant reduction in the incidence of secondary
  procedures
 Accelerated healing
 Lower infections
COMPLICATIONS
Complications
1.   Nonunion.
2.   Malunion.
3.   Infection- deep and superficial.
4.   Compartment syndrome.
5.   Fatigue fractures.
6.   Hardware failure.
7.   Chronic Osteomyelitis.
Nonunion
 Time limits vary from 6
  months to one year
 Fracture shows no radiologic
  progress toward union over 3
  month period
 Important to rule out infection
 Treatment options for
  uninfected nonunions include
  onlay bone grafts, free
  vascularized bone
  grafts, reamed
  nailing, compression
  plating, or ring fixator
Malunion
 In general varus malunion
  more of a problem than
  valgus

 In one study deformity up to
  15 degrees did not produce
  ankle complications*

 For symptomatic patients
  with significant deformity
  treatment is osteotomy.
Deep Infection
 Often presents with
  increasing pain, wound
  drainage, or sinus formation.

 Treatment involves
  debridement, stabilization
  (often with ex-fix), coverage
  with healthy tissue including
  muscle flap if needed, IV
  antibiotics, delayed bone graft
  of defect if needed.

 Staged reconstruction with
  the used of PMMA +
  antibiotics.
Superficial Infection
 Most superficial infections respond to elevation of
  extremity and appropriate antibiotics (typically
  gram + cocci coverage)

 If uncertain whether infection extends deeper
  and/or it fails to respond to antibiotic treatment
  , then surgical debridement with tissue cultures
 necessary
Compartment Syndrome
 Diagnosis same as
  in closed tibial
  fractures

 Common with high
  energy tibia
  fractures

 Release ALL 4
  compartments
Hardware Failure
 Usually due to delayed union
  or nonunion
 Important to rule out
  infection as cause of delayed
  healing
 Treatment depends on type of
  failure- plate or nail breakage
  requires revision, whereas
  breakage of locking screw in
  nail may not require operative
  intervention
Chronic Osteomyelitis
 Osteomyelitis is a common complication of compound
  fracture of long bones which is difficult to treat.
 Fever, Pain, swelling are seen in acute exacerbation of
  chronic osteomyelitis.
 Sequestrectomy and saucerization.
 Open Bone Grafting (Papineau Technique).
Management of sequelae of chronic osteomyelitis by Illizarov’s technique
Group A – acute onset but ends up as chronic osteomyelitis with
          persistent infection

   A 1- no alteration in bone length    bifocal osteosynthesis resection and
                                        bone transport
   A 2 – with limb length               monofocal osteosynthesis and
         discrepancy                    lenthgning.
   A 3 – with deformities               monofocal osteosynthesis and
                                        deformities correction
   A 4- with both length discrepancy    monofocal or bifocal osteosynthesis
        and deformity                   with simultaneously lengthening
                                        and deformity correction

   A 5 – infective pseudoarthosis and   bifocal osteosynthesis compression
         non union                      distraction or distraction –
                                        compression osteosynthesis
Outcomes
Outcomes
 Outcome most affected by severity of soft tissue
  and neurovascular injury

 Most studies show major change in results
   between type 3a and 3b/c fractures

 In one study of reamed nailing, the deep infection
  rate was 3.5% for type 2 and 3a fractures, but 23%
  for type 3b fractures*
*Court-Brown JBJS 1991
Outcomes
 For type 3b and 3c fractures early soft tissue
  coverage gives best results

 In one study of 84 type 3b and 3c fractures, results
  with single stage procedure involving fixation with
  immediate flap coverage better than when
  coverage delayed more than 72 hours (deep
  infection 3% vs. 19%)*
*Gopal et al. JBJS[Br] 2000
Suggested
treatment
algorithm
Melvin JS, Open Tibial
Shaft Fractures: I and
II, JAAOS, Jan-Feb 2010
THANK YOU….!!

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Compound Fracture Tibia

  • 2. INTRODUCTION An open fracture is one in which a break in the skin allows for direct communication of the fracture site or fracture hematoma with the elements external to the usual protection of the skin. The prognosis in open fractures is determined by :-  the amount of devitalized soft tissue.  the level and type of bacterial contamination.  geometry of fracture.
  • 3. Incidence  Open fractures of the tibia are more common than in any other long bone  Rate of tibial diaphysis fractures reported 2 per 1000 population and of these approximately one fourth are open tibia fractures.
  • 4. PRINCIPLES OF MANAGEMENT  ABC’S  Assoc Injuries  Tetanus  Antibiotics  Soft Tissue Management  Fixation  Long term issues
  • 5. DIAGNOSIS The diagnosis of an open fracture is straight forward in most cases. An injured patient usually has:-  bleeding deep laceration overlying or near a fracture of the underlying bone.  In some cases, the fractured bone may be exposed. However, not all open fractures are obvious, and their timely and proper diagnosis and treatment depend on a careful examination of the patient, delineating salient features from the patient's history, a critical reading of x- rays, and good clinical judgment.
  • 6.  Examine the neurologic function and vascular function of each extremity.  Note the state of circulation to the limb as indicated by  capillary blush,  the filling of veins, and  the status of peripheral pulses.  Examine meticulously for peripheral nerve function.  Initial sensory examination by pressure and light touch gives a gross evaluation of limb sensation.  Examination for motor function is difficult in the injured limb owing to pain and muscle spasm. The normal side should be compared with the abnormal side.
  • 7. Mechanism of Injury  Can occur in low energy, torsional type injury. (e.g. skiing)  More common with high energy, direct force. (e.g. car bumper)
  • 8. ENVIROMENTAL FACTOR The location where the injury occurred is essential to delineate.  People exposed to feces or dirt may occur in a farm setting have possibility of clostridial infection and need additional antibiotics (penicillin) and more aggressive surgical debridement.  In automobile collisions there is less risk for development of a clostridial infection.  Unusual environments, such as a barnyards or gardens, streams or lakes, will likely be contaminated by unusual organisms, such as soil anaerobes and Aeromonas hydrophilia, respectively.  Injuries caused by lawn-mowers and other motorized garden equipment are high-energy injuries with severe contamination.  Animal Bite or presence of oral flora.
  • 9. HISTORY  The patient's tetanus immunity must be determined.  The surgeon must also inquire about medical illnesses:-  diabetes mellitus,  peripheral vascular disease,  liver disease, and  any immune deficiency syndromes.  Any previous injuries and their treatments.  Finally, a history of smoking or chronic use of steroids.
  • 10. Physical Examination  Due to subcutaneous nature of tibia, deformity and open wound usually readily apparent.  Circumferential inspection of soft tissue envelope, noting any lacerations, ecchymosis, swelling, and tissue turgidity necessary.
  • 11.  Neurologic and vascular exam of extremity must be done.  Wounds should be assessed and then covered with sterile gauze dressing until treated or through digital camera / cell phone.  True classification of wound best done after surgical debridement completed.
  • 12. IMAGING EVALUATION  Full length AP and lateral views from knee to ankle required for all tibia fractures.  Ankle views suggested to examine mortise.  Arteriography indicated if vascular compromise present after reduction .
  • 13. Associated Injuries  Approximately 30% of patients have multiple injuries.  Fibula commonly fractured and its degree of comminution correlates with severity of injury.  Proximal or distal tib-fib joints may be disrupted.  Ligamentous knee injury and/or ipsilateral femur (‘floating knee’) more common in high energy fractures.
  • 14.  Neurovascular structures require repeated assessment.  Foot fractures also common.  Compartment syndrome must be looked.
  • 15. CLASSIFICATION OF OPEN FRACTURES
  • 16. HELPFUL FOR  Communication between health care professionals  Formulating a treatment plan  Decision on limb salvage  Detailed audit of care to ensure optimal management
  • 17. METHODS OF CLASSIFICATION  GRADING SYSTEM – focus on severity of limb injury only Eg: Gustilo Anderson , Tscherne and Gotzen, Byrd and Spicer etc  SCORING SYSTEM – focuses on limb injury and general health; also give ‘amputation score’. Eg: MESS , NISSSA ,LSI,etc  COMPREHENSIVE SYSTEM – combines the above two systems Eg: AO system , Ganga hospital score
  • 19. Gustilo Anderson System  In 1976 , Gustilo and Anderson treated 1025 open fractures based on his grading system that offered prognosis about outcome of infected fractures  In 1984, it was modified and was based on a. Size of wound b. Soft tissue damage c. Periosteal stripping d. Vascular injury  Segmental fractures, farmyard injuries, fractures occurring in a highly contaminated environment, shotgun wounds, or high-velocity gunshot wounds automatically result in classification as type III open fracture.
  • 20. Type Wound Level of Soft Tissue Injury Bone Injury Contaminatio n I <1 cm long Clean Minimal Simple, minimal comminution II >1 cm long Moderate Moderate, some muscle Moderate comminution damage III Usually >10 cm long High Severe with crushing Usually comminuted; A soft tissue coverage of bone possible Usually >10 cm long High Loss of coverage; periosteal Bone coverage poor; B stripping & usually requires variable, may be soft tissue reconstructive moderate to severe surgery comminution Usually >10 cm long High Very severe loss of coverage Bone coverage poor; C plus vascular injury requiring variable, may be repair; may require soft tissue moderate to severe reconstructive surgery comminution
  • 21. Tscherne System GRADE DESCRIPTION 1 Skin laceration mostly inside out injury with little or no contusion of skin 2 Skin laceration with circumscribed skin or soft tissue contusion with moderate contamination 3 Fractures with severe soft tissue injury often with NV injury , severe bone comminution or compartment syndrome 4 Sub total (remaining soft tissue not exceeding ¼ of limb circumference) or total amputation  This system includes compartment syndrome which is not included in other grading systems
  • 22. Byrd and Spicer TYPE DESCRIPTION I Both endosteal and periosteal supply intact and surrounding soft tissue is healthy II Endosteal supply interrupted but periosteal supply maintained by surrounding soft tissues III Devascularised bone fragment and requires flap coverage  This system lacks sophistication and hence not widely used
  • 24. Mangled Extremity Severity Score (MESS) TYPE CHARACTERISTICS INJURIES POINTS SKELETAL/ SOFT-TISSUE GROUP 1 Low energy Simple closed #, small calibre gun shot 1 2 Medium energy Open # , D/L , mulltiple level # 2 3 High energy Shot gun blast , high velocity gun shot 3 4 Massive crush Rail road, oil rig accidents 4 SHOCK GROUP 1 Normotensive BP stable in field and OT 0 2 Transiently BP unstable in field but responds to IV 1 hypotensive fluids 3 Prolonged SBP<90 in field and responding to IV 2 hypoptensive fluids only in OT
  • 25. MESS Contd… TYPE CHARACTERISTICS INJURIES POINTS ISCHEMIA GROUP 1 None Pulsatile limb w/o signs of ischemia 0* 2 Mild Diminished pulses w/o signs of 1* ischemia 3 Moderate No pulse, sluggish capillary refill, 2* paraesthesia, motor activity 4 Advanced Pulseless, cool, paralysed, numb, no 3* capillary refill AGE GROUP 1 < 30 yrs 0 2 30 – 50 yrs 1 3 > 50 yrs 2 * If ischemia time > 6 hrs, add 2 points.
  • 26. MESS Contd…  It was developed to identify those patients who will be benefited by primary amputation  In retrospective analysis, the outcome of injured limb was either salvage or amputation  A score of 7 or greater is predictive of amputation.  MESS is found to be specific but lacks some sensitivity which infers that score predicting limb salvage(<7) is more reliable than score predicting amputation (> or =7) (Bosse MJ JBJS 83A:412,2001)
  • 27. Injury Severity Score (ISS)  More recently, Rajasekaran et al. proposed a new scoring system for Gustilo type IIIA and IIIB open fractures of the tibia that evaluated skin coverage, skeletal structures, tendon and nerve injury, and comorbid conditions .  The high specificity of this new scoring system may make it a much better predictor of amputation.
  • 28. Injury Severity Score for Gustilo Type IIIA and IIIB Open Tibial Fractures Covering Structures: Skin and Fascia Wounds without skin loss Not over the fracture: 1 Exposing the fracture: 2 Wounds with skin loss Not over the fracture: 3 Over the fracture: 4 Circumferential wound with skin loss: 5 Skeletal Structures: Bone and Joints  Transverse or oblique fracture or butterfly fragment <50% circumference: 1  Large butterfly fragment >50% circumference: 2  Comminution or segmental fractures without bone loss: 3  Bone loss <4 cm: 4  Bone loss >4 cm: 5
  • 29. Functional Tissues: Musculotendinous and Nerve Units  Partial injury to musculotendinous unit: 1  Complete but repairable injury to musculotendinous units: 2  Irreparable injury to musculotendinous units, partial loss of a compartment, or complete injury to posterior tibial nerve: 3  Loss of one compartment of musculotendinous units: 4  Loss of two or more compartments or subtotal amputation: 5 Comorbid Conditions: Add 2 Points for Each Condition Present  Injury leading to débridement interval >12 h  Sewage or organic contamination or farmyard injuries  Age >65 y  Drug-dependent diabetes mellitus or cardiorespirator diseases leading to increased anesthetic risk  Polytrauma involving chest or abdomen with injury severity score >25 or fat embolism  Hypotension with systolic blood pressure <90 mm Hg at presentation  Another major injury to the same limb or compartment syndrome
  • 30. Using this system, they divided type III open tibial fractures into four groups to assess the possibilities of limb salvage.  Group 1 had scores of 5 or less.  Group 2 had scores of 6 to 10.  Group 3 had scores of 11 to 15 and,  Group 4 had scores of 16 or greater. A score of 14 or greater is an indicator for amputation.
  • 31. Other Scoring Systems • NISSSA – Nerve injury Ischemia Soft tissue injury Skeletal injury Shock & Age , is more sensitive and more specific than MESS. • LSI – Limb Salvage Index a.This index is applied to limbs with arterial injury b.Warm ischemia time together with scores for injured skin , muscle , bone , NV are added to give total score.
  • 32. COMPREHENSIVE SYSTEMS
  • 33.  AO System :  Skin lesions , muscle -tendon , NV , bone injuries are graded separately  AO system allows better prediction of outcome when compared to Gustilo  Due to its complexity not widely accepted • Ganga hospital score :  Includes additional criteria like age >65 , DM , cardio- respiratory disease , trauma chest/abdomen, farmyard/sewage contaminations, delay in debridement >12h
  • 34. ANTIBIOTIC  A short course of first-generation cephalosporins, begun as soon as possible after injury, significantly lowers the risk of infection when used in combination with prompt, modern orthopaedic fracture wound management.  A broad-spectrum antibiotic, first-generation cephalosporin + aminoglycoside, such as tobramycin or gentamicin, for highly contaminated wounds in which there is a risk of gram-negative contamination (Gustilo type III).  If possibility of anaerobic organisms, such as Clostridium, high- dose penicillin is recommended.  The duration of antibiotic treatment should be limited because in most series the infecting organisms are hospital acquired.
  • 35.  Gustilo recommended  Type I and II - 2 g of cefamandole on admission and 1 g every 8 hours for 3 days.  In type III - an aminoglycoside in dosages of 3 to 5 mg/kg daily.  Farm injuries - add penicillin, 10 to 12 million U daily.  Gustilo continued double antibiotic therapy for 3 days only and repeated the antibiotic regimen during wound closure, internal fixation, and bone grafting.  Okike and Bhattacharyya recommended the administration of cefazolin, 1 g intravenously, every 8 hours until 24 hours after the wound is closed, with intravenous gentamicin (with weight- adjusted dosing) or levofloxacin (500 mg every 24 hours) added for type III fractures.  Campbell recommend obtaining cultures when obvious clinical findings of infection are present at the second débridement.
  • 37. Initial Management  ABC of initial management is addressed first.  Compressive dressings for extremity hemorrhage..  Rule out cervical injuries , chest , abdominal injuries , head injuries in polytrauma patients .  As soon as possible careful examination of wound is carried out and serial photographs of wound taken.
  • 38. Initial wound management In emergency room :  Don’t do digital exploration (to avoid infection and bleeding).  Obvious Foreign Body are removed with forceps.  If patient will undergo formal debridement in<1 hour just do sterile saline dressing if not irrigate with 1 or 2 ltr of NS.  Povidone dressing alters color and impairs osteoblast function (controversial) so better avoided.  Patients immunity to tetanus is determined.  I.V. antibiotics are given as soon as possible .
  • 39. Objectives of Surgical Treatment  Prevent Sepsis  Achieve Union  Restore Function
  • 40. DEBRIDEMENT  Timing - Debridement done as soon as possible.  Skin and wound preparation - dirt and debris removed by gentle scrub brush.  Sterile tourniquets kept ready but not used. SUPERFICIAL DEBRIDEMENT: Traumatic wounds extended – to identify and explore the entire zone of injury and to access ends of bone fragments  Skin incisions – extensile longitudinal incision to visualize deep tissue and can be extended till (N) tissue encountered.  Clearly Nonviable skin and subcutaneous tissue excised but of marginal viability may be left for later debridement.  Don’t detach skin and subcutaneous tissue from the fascia.  Any nonviable shredded fascia and even the marginally viable ones excised.
  • 42. DEEP DEBRIDEMENT:  Where skin tend to tear , fascia split or shred , muscle because of water content are subjected to hydraulic damage by fluid waves during injury.  In muscle debridement the concept ‘when in doubt take it out’.  In type I,II and IIIa open # all non-vital and in doubt muscle can be debrided but IIIb and IIIc removal of entire muscle compartment may be needed so marginally viable ones are left for later re-debridement  Viability of muscle checked by its 4C’s = color, capacity to bleed, contractility and consistency(last 2 more reliable).
  • 43.  Tendons , unless injured beyond repair should be preserved.  In open wounds tendons are subject to dessication and hence it should be covered with soft tissues if not with moist dressings.  In general bone devoid of soft tissue attachment removed and large ones are utilized provisionally for skeletal fixation and removed once fixation achieved.  One exception to strict removal of bone without soft tissue attachment ,is significant portion of articular surface attached to bone fragment.
  • 44. IRRIGATION After meticulous debridement irrigation of wound is done. Additives – antiseptics, antibiotics and surfactants can be used.
  • 47. Skeletal Stabilization  Once the vascular repair has been completed and limb salvaged or irrigation and debridement done , stabilization of bone is next concern.  Restoring the length ,rotational and angular alignment has many benefits for healing of soft tissue  fracture reduction unkinks NV conduits and helps in soft tissue healing  minimizing motion of fragments also decreases further damage, pain and permits mobilization of joints
  • 48. Stabilization of Open Tibia Fractures Multiple options depending on fracture pattern and soft tissue injury:  Extra osseous immobilisation  IM nail- reamed vs. unreamed  External fixation  ORIF
  • 49. Extra Osseous Immobilisation Extra osseous immobilisation –eg: plasters ,weight bearing casts , splints and skeletal tractions Used in Low grade open fractures – eg: Grade-I Tibia # (plasters) and open shaft fractures (skeletal traction).
  • 50. IM Nail  IM Nail- currently the treatment of choice for grade I,II,IIIa and IIIb fractures.  Excellent results with type 1 open fractures.
  • 51. Unreamed IM Nail  Time to union with unreamed nails can be prolonged- in one study of 143 open tibia fractures 53% were united at 6 months.  Vast majority of fractures united, but 11% required at least one secondary procedure to achieve union.
  • 52. Reamed Tibial Nailing  In one study of type 2 and type 3a fractures good results- average time to union 24 and 27 weeks respectively; deep infection rate 3.5%.  Complications increased with type 3b fractures- average time to union was 50 weeks and infection rate 23%.
  • 53. External Fixation  Used in high grade open fractures gives excellent access to wound dressing and surveillance possible.  Compared to IM nails, increased rate of malunion and need for secondary procedures.  Most common complication with ex-fix is pin track infection.
  • 54. Conversion from Ex-Fix to IM Nail  Conversion between ex- fix and IM nail.  9% infection 90%union.  Infection rates decreased with shorter duration of ex-fix time.
  • 55. Plate Fixation  Traditional plating technique with extensive soft tissue dissection and devitalization has generally fallen out of favor for open tibia fractures.  After meticulous debridement, copious irrigation with minimal stripping and accurate anatomical reduction in extraperiosteal plate fixation can be done.  Increased incidence of superficial and deep infections compared to other techniques.  In one study 13% patients developed osteomyelitis after plating compared to 3% of patients after ex-fix.
  • 56. Percutaneous Plate Fixation  Newer percutaneous plating techniques using indirect reduction may be a more beneficial alternative  Large prospective studies yet to be evaluated
  • 57. Gunshot Wounds  Tibia fractures due to low energy missiles rarely require debridement and can often be treated like closed injuries  Fractures due to high energy missiles (e.g. assault rifle or close range shot gun) treated as standard open injuries
  • 58. Amputation  Lange proposed two absolute indications for amputation of tibia fractures with arterial injury:  crush injury with warm ischemia greater than 6 hours, and  anatomic division of the tibial nerve.  In general amputation performed when limb salvage poses significant risk to patient survival, when functional result would be better with a prosthesis, and when duration and course of treatment would cause intolerable psychological disturbance.
  • 59. Bone Defects PMMA –aminoglycoside +/- vancomycin  Bead pouch  Solid spacer
  • 60. Large Fragments: What to do? • Infection Rates with retained - 21% • Infection Rates with removed- 9% • Use to assist in determining length, rotation and alignment
  • 61. Wound closure and coverage Wounds without skin loss :  Definitive coverage should be performed within 7-10 days if possible.  Most type 1 wounds will heal by secondary intent or can be closed primarily.  Delayed primary closure usually feasible for type 2 and type 3a fractures.  Tension free primary closure after thorough debridement  Contraindications for primary closure are 1. Delayed presentation >12hr 2. Delayed administration of antibiotic >12hr 3. Deep seated contamination 4. Immunocompromised 5. NV injury 6. Inability to achieve tension free suture 7. High risk of anaerobic contamination like farm yard injuries
  • 62. Wounds with skin loss: Type 3b fractures require either local advancement or rotation flap, split-thickness skin graft, or free flap.
  • 63. Soft Tissue Coverage  Proximal third tibia fractures can be covered with gastrocnemius rotation flap.  Middle third tibia fractures can be covered with soleus rotation flap.  Distal third fractures usually require free flap for coverage
  • 64. Negative Pressure Would Therapy (NPWT)/ Vacuum Dressing  Can lower need for free flaps Dedmond BT, The use of negative- pressure wound therapy (NPWT) in the temporary treatment of soft-tissue injuries associated with high-energy open tibial shaft fractures. J Orthop Trauma 2007  Cannot lower infection rates for Type IIIB open fractures Bhattacharyya T, Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg 2008
  • 66. BMPs  BMP-2 (Infuse) FDA approval in subset of open tibia fractures BESTT study group JBJS 84, 2002  Significant reduction in the incidence of secondary procedures  Accelerated healing  Lower infections
  • 68. Complications 1. Nonunion. 2. Malunion. 3. Infection- deep and superficial. 4. Compartment syndrome. 5. Fatigue fractures. 6. Hardware failure. 7. Chronic Osteomyelitis.
  • 69. Nonunion  Time limits vary from 6 months to one year  Fracture shows no radiologic progress toward union over 3 month period  Important to rule out infection  Treatment options for uninfected nonunions include onlay bone grafts, free vascularized bone grafts, reamed nailing, compression plating, or ring fixator
  • 70. Malunion  In general varus malunion more of a problem than valgus  In one study deformity up to 15 degrees did not produce ankle complications*  For symptomatic patients with significant deformity treatment is osteotomy.
  • 71. Deep Infection  Often presents with increasing pain, wound drainage, or sinus formation.  Treatment involves debridement, stabilization (often with ex-fix), coverage with healthy tissue including muscle flap if needed, IV antibiotics, delayed bone graft of defect if needed.  Staged reconstruction with the used of PMMA + antibiotics.
  • 72. Superficial Infection  Most superficial infections respond to elevation of extremity and appropriate antibiotics (typically gram + cocci coverage)  If uncertain whether infection extends deeper and/or it fails to respond to antibiotic treatment , then surgical debridement with tissue cultures necessary
  • 73. Compartment Syndrome  Diagnosis same as in closed tibial fractures  Common with high energy tibia fractures  Release ALL 4 compartments
  • 74. Hardware Failure  Usually due to delayed union or nonunion  Important to rule out infection as cause of delayed healing  Treatment depends on type of failure- plate or nail breakage requires revision, whereas breakage of locking screw in nail may not require operative intervention
  • 75. Chronic Osteomyelitis  Osteomyelitis is a common complication of compound fracture of long bones which is difficult to treat.  Fever, Pain, swelling are seen in acute exacerbation of chronic osteomyelitis.  Sequestrectomy and saucerization.  Open Bone Grafting (Papineau Technique).
  • 76. Management of sequelae of chronic osteomyelitis by Illizarov’s technique Group A – acute onset but ends up as chronic osteomyelitis with persistent infection A 1- no alteration in bone length bifocal osteosynthesis resection and bone transport A 2 – with limb length monofocal osteosynthesis and discrepancy lenthgning. A 3 – with deformities monofocal osteosynthesis and deformities correction A 4- with both length discrepancy monofocal or bifocal osteosynthesis and deformity with simultaneously lengthening and deformity correction A 5 – infective pseudoarthosis and bifocal osteosynthesis compression non union distraction or distraction – compression osteosynthesis
  • 78. Outcomes  Outcome most affected by severity of soft tissue and neurovascular injury  Most studies show major change in results between type 3a and 3b/c fractures  In one study of reamed nailing, the deep infection rate was 3.5% for type 2 and 3a fractures, but 23% for type 3b fractures* *Court-Brown JBJS 1991
  • 79. Outcomes  For type 3b and 3c fractures early soft tissue coverage gives best results  In one study of 84 type 3b and 3c fractures, results with single stage procedure involving fixation with immediate flap coverage better than when coverage delayed more than 72 hours (deep infection 3% vs. 19%)* *Gopal et al. JBJS[Br] 2000
  • 80. Suggested treatment algorithm Melvin JS, Open Tibial Shaft Fractures: I and II, JAAOS, Jan-Feb 2010