Open tibia/fibula fractures

1. Standards for
the Management
of open fractures
of the lower limb
Dr Nikki Walsh
18.2.2013

2. BOA/BAPRAS
2009 last update – 20 principal recommendations
Open fractures of lower limb – below knee
Few randomized trials
Evidence based plus data from associated areas and
experience of the working party
Specialist centres
Orthopaedic surgeons and plastic surgeons
British Infection Society and Association of Medical
Microbiologists reviewed guidelines on antibiotic prophylaxis

3. Recommendation 1:Specialist
Centres
MDT approach
Characteristics of open injuries requiring referral to specialist
centre
Fracture pattern
Transverse or short oblique with similar level fibular fracture
Tibial fracture comminution with similar level fibular fracture
Segmental tibial fractures
Fractures with bone loss
Soft tissue Injury pattern
Skin loss
Degloving
Injury requiring excision of devitalised muscle via wound extension
Arterial injury

4. 2. ED Management
ATLS
Careful assessment
Photograph
Minimal handling – no ‘provisional cleaning’
Control haemorrhage with pressure
Sterile dressing
IVAB’s
Anti-tetanus prophylaxis
Splintage – No provisional external fixators
Radiographic assessment to include 2 orthogonal views of
tibia plus knee and ankle joint

5. 3. Antibiotic prophylaxis
ASAP, ideally within 3 hours of injury
Cephalosporin 1.5g TDS until 1st debridement
At time of debridement
Cephalosporin
Gentamicin 1.5mg/Kg
Continued until soft tissue closure or 72 hours
On induction of anaesthesia for skeletal stabilization– above and
Vancomycin 1g or teicoplanin 800mg
Clindamycin if allergic to penicillin/cephalosporin

6. 4. Timing of wound excision
Immediate
Gross contamination
Compartment syndrome
Devascularized limb
Multiple – injured patient
Marine/agricultural or sewage contamination
Senior orthopaedic and plastic surgeons working together
on a scheduled trauma operating list, within normal
working hours and within 24 hours of injury

7. 5. Wound debridement
Excision of all devitalised tissue (except neurovascular bundles)
Wash with soapy solution and tourniquet applied
Prep with alcoholic chlorhexidine solution avoiding contact with
open wound
Systematic debridement and assessment from superficial to
deep and from the periphery to the centre of the wound
Classify wound and plan definitive reconstruction
If definitive skeletal stabilisation and soft tissue coverage is not
undertaken in a single setting – apply VAC +/- antibiotic bead
pouch

8. 6. Debridement of bone
Extend traumatic wounds along nearest fasciotomy
incision
Deflate tourniquet before bone debridement to assess
viability
Careful surgical delivery of bone ends through the wound
Remove fragments which fail to ‘tug test’
Major articular fragments preserved as long as they can
be reduced and fixed with absolute stability
Lavage – high pressure pulsatile lavage Not
recommended

9. 7. degloving
Thrombosis of subcutaneous veins usually indicates the
need to excise the overlying skin
Circumferential degloving often indicates that the involved
skin is not viable
Severe injuries – multi-planar degloving – second stage
debridement may be needed

10. 8. Classification of open
fractures
Accurate, simple and reproducible system
Gustillo and Anderson best applied after wound excision

11. 9. Temporary Wound dressings
VAC
Antibiotic impregnated beads under a semi-permeable
membrane
combination

12. 10. Skeletal stabilisation
Spanning Ex-fix
Change from ex-fix to definitive fixation as early as
possible
Internal fixation safe if minimal contamination and soft
tissue coverage at same time.
Multiplanar/circular fixators if significant contamination,
bone loss and multilevel fractures of the tibia

13. 11. Timing of soft tissue
reconstruction
Local flaps same time as fixation
Free flaps
on scheduled trauma lists
Dedicated specialist team
after CT scan, angiography as needed
Little evidence for 5 day rule
Microsurgery best performed in first week
Recommend definitive soft tissue reconstruction within
first 7 days

14. 12. Types of soft tissue
reconstruction
All open fractures covered with vascularised soft tissue
Low energy injuries can be covered by local
fasciocutaneous flaps
Diaphyseal tibial fractures with periosteal stripping best
covered by muscle flaps rather than fasciocutaneous flaps
Metaphyseal fractures – fasciocutaneous flaps including
free flaps

15. 13. Compartment syndrome
Diagnose and treat early
Clinical picture may be distorted by nerve injury
Loss of pulses usually due to vascular injury
Measure intracompartment pressures
Inappropriate fasciotomy can be associated with
significant morbidity
2 incision, 4 compartment decompression
Late diagnosis may result in amputation

16. 14. Vascular injuries
Immediate management
Aim to restore vascularity within 3-4 hours of the injury
Maximum acceptable delay is 6 hours warm ischaemic
time
Shunting reduces ischaemic time
Stabilise skeleton, then replace shunts
Assess if limb is salvagable

17. 15. Open fractures of foot and
ankle
Challenging as limited soft tissue flap options
Consider amputation vs final functional outcome
Initial fixation with spanning ex-fix, no fibular plate at initial stage
Difficulties with distal anchor points for ex-fix
Definitive fixation at same time as soft tissue coverage
Consider amputation with open hind foot, open mid-foot injuries.
Ist Metatarsal injuries treated aggressively. Ray amputation for
lesser MT’s.

18. 16. Things go wrong with soft
tissues
Revision to healthy tissue
Leeches for limited tip congestion
Revascularization if needed
Some local fasciocutaneous flaps may be more prone to
develop complications in patients with comorbidities.

19. 17. Bone complications
Wound leakage
Sepsis
Loss of alignment
Common causes include
Inadequate debridement
Haematoma formation
Inapproriate or delayed soft tissue cover
Unstable fixation
Each cause is sought and remedied promptly

20. 18 Primary amputation
Damage control – uncontrollable haemorrhage, crush
injuries with warm ischaemic time > 6 hours
Incomplete traumatic amputations