You are in: eMedicine Specialties > Orthopedic Surgery > KNEE Tibia Fractures, OpenArticle Last Updated: Mar 30, 2006AUTHOR AND EDITOR INFORMATIONSection 1 of 10
  Author: Minoo Patel, MBBS, MD, MS, FRACS, Senior Lecturer, Monash University; Consulting Adult/Pediatric Orthopedic Surgeon, Department of Orthopedic Surgery, Monash Medical Center, Australia Minoo Patel is a member of the following medical societies: American Academy of Orthopaedic Surgeons, AO Foundation, Australian Association of Surgeons, Australian Medical Association, Australian Orthopaedic Association, Orthopaedic Research Society, Orthopaedics Overseas, Pediatric Orthopaedic Society of North America, and Royal Australasian College of Surgeons Coauthor(s): John Herzenberg, MD, FRCSC, Head of Pediatric Orthopedics, Co-director of International Center for Limb Lengthening, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore Editors: Dennis P Grogan, MD, Clinical Professor, Department of Orthopedic Surgery, University of South Florida College of Medicine; Chief of Staff, Department of Orthopedic Surgery, Shriners Hospital for Children of Tampa; Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine; Shepard R Hurwitz, MD, Executive Director, American Board of Orthopaedic Surgery; Dinesh Patel, MD, FACS, Associate Clinical Professor of Orthopedic Surgery, Harvard Medical School; Chief of Arthroscopic Surgery, Department of Orthopedic Surgery, Massachusetts General Hospital; Carlos J Lavernia, MD, FAAOS, Adjunct Clinical Professor, Department of Orthopedic Surgery, University of Miami School of Medicine; Medical Director, Orthopedic Institute at Mercy Hospital Author and Editor Disclosure Synonyms and related keywords: tibia fracture, open tibia fractures, open tibial fractures, open tibial fracture, tibial fracture, broken leg, fractured leg, fractured tibia, MESS, Mangled Extremity Severity Score, Gustilo-Anderson fracture, Gustilo fracture, reamed nailing INTRODUCTIONSection 2 of 10
  Because the tibia is a subcutaneous bone, tibial fractures are frequently open fractures. ProblemWhen an individual presents with an open tibial fracture, the physician strives to save the life of the patient and the limb, to unite the fracture, and to prevent infection. Maintaining a functional limb is the goal; when that is not possible, the physician must consider amputation. FrequencyBehrens et al reported an incidence of 2 open tibia fractures per 1000 injuries per year in a defined population group in an industrialized western society; this is 0.2% of all injuries (Behrens, 1982; Behrens, 1986). The incidence and severity may be even higher in the developing world. EtiologyMotor vehicle accidents, skiing accidents, and high-energy falls are the common causes. The mechanism of injury determines the fracture configuration (eg, skiing injuries typically cause spiral fractures). Most fractures are comminuted. Pedestrians who are hit in the upper and middle one third of the tibia sustain bumper injuries. Distal tibial and plafond fractures are commonly a result of a fall from a significant height. ClinicalAll persons who have undergone high-energy trauma should be examined in accordance with the principles defined by the Road Trauma Committee of the Royal Australasian College of Surgeons/Emergency Management of Severe Trauma (Geller, 1997; Shuler, 1996). The primary survey includes the ABCs (ie, airway, breathing, circulation). A Glasgow Coma Scale score indicates the severity of any head injury component. The secondary survey should include the chest, abdomen, and pelvis for associated injuries, as well as the upper limbs and the contralateral lower limb. The ipsilateral limb also may have other fractures, such as a femur fracture, leading to a floating knee, or joint injuries such as knee dislocations. The dictum is to save the patient first and the limb next. Limb examination should consist of a detailed examination of the vascularity of the limb, including limb color, warmth and perfusion, palpable pulses, capillary return (normal <3 seconds), and transcutaneous oxygenation and pulse wave forms using pulse oximetry. A detailed neurologic examination should document the sensory and motor function. The skin over the fracture should be carefully examined. Any break in the skin at the level of the fracture should be considered indicative of a possible open fracture. Remember that wounds away from the fracture can communicate with the fracture. Periarticular open fractures almost always contaminate the associated joints. Signs of crush injury should be sought if indicated by the mechanism of injury (eg, pedestrian hit by a car). These injuries may exhibit few external signs. Compartment syndrome Persons who sustain high-energy tibial fractures have a high frequency of compartment syndrome. Importantly, note that even open fractures can be associated with a compartment syndrome. Assuming that the open wound has decompressed the compartment is wrong. Blood clots can impede effective decompression. The muscle or fascial layers can close the trap door with similar effects. Blick et al from the Adam Cowley Shock Trauma Centre reported a 9% rate of compartment syndrome in persons with open tibial fractures (Blick, 1986). The earliest signs of compartment syndrome are stretch pain and loss of the sensations (eg, fine touch, proprioception) carried by the fast conducting, and therefore more hypoxia-susceptible, fibers. Because these patients require surgical debridement and stabilization, performing a fasciotomy and compartment release is imperative. With delayed presentations or a diagnosis of compartment syndrome, performing an early fasciotomy may be preferable to merely monitoring it with a wick catheter (McQueen, Christie, 1996; McQueen, Court-Brown, 1996; McQueen, 2000). The traumatized soft tissues and bone are susceptible to hypoxia, and delaying a compartment release decreases oxygen delivery and impedes healing. In fractures treated with intramedullary nailing, McQueen et al found no difference in the pressures recorded between the different Tscherne soft tissue grades, between open and closed fractures, between low- and high-energy injuries, or between fractures treated early and those not treated until more than 24 hours after injury (McQueen, 1990). Classification Open fractures are typed using the Gustilo-Anderson classification, which was first proposed in 1976 (Gustilo, 1976) and subsequently modified in 1984 (Gustilo, 1987; Gustilo, 1984). Table 1. Gustilo-Anderson Classification of Open Fractures
Table 2. Tscherne Classification of Soft Tissue Injuries
Note that both of these classifications have poor interobserver agreement (Brumback, 1994). However, they serve as a good general guide for management and for comparison in studies. Patients who are polytraumatized and immunocompromised develop infections more frequently, and their fractures take longer to unite. Sterett et al found that patients with splenectomies had a significantly higher prevalence of chronic osteomyelitis (25% vs 4.6%), their fractures took almost twice as long to unite, and they required additional tibial surgeries to achieve union (75% vs 16%) following open tibial fractures (Sterett, 1995). INDICATIONSSection 3 of 10
The various limb salvage scoring systems, such as the MESS (Mangled Extremity Severity Score), are good indicators for salvage but poor indicators for amputation; thus, a limb with a good MESS usually should be salvaged, but a limb with a poor MESS does not necessarily require amputation. Regarding nailing versus external fixation, Bhandari et al reported from a meta-analysis that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in persons with open tibial fractures (Bhandari, 2001; Bhandari, 2000). They also found a reduced risk of reoperation with using reamed nails compared with unreamed nails. This appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail. Plate fixation was found to be uniformly the worst of all methods of internal fixation. Although it may be tempting to use plate fixation for a fracture that is exposed (ie, because of the open nature of injury), the risk of nonunion, malunion, and deep infection is too high to justify the action (Bhandari, 2001). RELEVANT ANATOMYSection 4 of 10
See Surgical therapy. CONTRAINDICATIONSSection 5 of 10
Absolute contraindications to limb salvage are a completely mangled limb, the presence of warm ischemia for longer than 6 hours, and poor facilities for salvage. Absolute contraindications to nailing an open fracture are untreated compartment syndrome and types IIIB and IIIC open fractures. WORKUPSection 6 of 10
Lab Studies
Imaging Studies
TREATMENTSection 7 of 10
Medical therapyIntravenous antibiotics are administered promptly. First-generation cephalosporins (gram-positive coverage) such as cephalothin (1-2 g q6-8h) suffice for Gustilo-Anderson type I fractures. An aminoglycoside (gram-negative coverage) such as gentamycin (120 mg q12h; 240 mg/d) is added for types II and III injuries. Additionally, metronidazole (500 mg q12h) or penicillin (1.2 g q6h) can be added for coverage against anaerobes. Tetanus prophylaxis should be instituted. Antibiotics generally are continued for 72 hours following wound closure. After initial assessment, the wound is irrigated in the emergency department. A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room as soon as feasible. Debridement within 6 hours is necessary to keep the rate of infection low (Kindsfater, 1995). A key factor in infection prevention is early, rigid stabilization of the fracture. The aim of antibiotic therapy and debridement is to sterilize the wound to a negligible bacterial load and render the wound similar to a typical surgical wound. The first debridement is the best chance for infection prevention. A tourniquet should not be used. This helps in identifying the devitalized tissue. The skin is sharply cut back to bleeding edges. Radical debridement is performed using sharp dissection until bleeding tissue is visualized. "Red is good, and gray is bad" is the general dictum. Devitalized muscle can also be identified by its lack of response to electrical stimulus. All extrinsic debris is meticulously removed. Copious irrigation is used. "The solution to pollution is dilution" is another dictum. Irrigation works predominantly by mechanical means. A pulsatile lavage system works by creating local eddy currents and dislodging the debris from the soft tissues. High-pressure pulsatile lavage should be avoided because it can cause soft tissue damage. Bhandari et al also found that high-pressure pulsatile lavage resulted in bacterial seeding into the intramedullary canal and significant damage to the architecture of the bone (Bhandari, 1998). However, both high- and low-pressure lavage were associated with similar degrees of periosteal separation from the cortical bone surface (Bhandari, 1998). Both high- and low-pressure lavage were effective in removing adherent bacteria from bone after a delay of 3 hours before irrigation, but only high-pressure lavage removed adherent bacteria from bone at a delay of 6 hours before irrigation (Bhandari, 1999). The bone ends should be thoroughly debrided. Aggressive bone debridement has been demonstrated to lower infection rates in high-grade open fractures (Gustilo, 1984; Gustilo, 1990). Soft tissue coverage can be achieved primarily in all cases except those with extensive contamination and risk of anaerobic infection. A delayed primary closure or coverage is provided for wounds with extensive contamination and risk of anaerobic infection. If the wound cannot be primarily closed, skin grafting or flap coverage can be provided, although muscle flaps provide better coverage and results (Richards, 1991). Gustilo-Anderson types I and II injuries can also be allowed to granulate and spontaneously close by secondary intention. Surgical therapyFollowing primary debridement, the surgical set-up should be changed and the limb redraped without losing sterility. Fracture repair Intramedullary nailing is the best option for Gustilo-Anderson types I, II, and III fractures (Tornetta, 1997). Type IIIB fractures can also be treated with unreamed nails. Solid core nails are associated with the lowest rate of infection (Riemer, 1995). External fixation is used for Gustilo-Anderson types IIIA and IIIB fractures. Thakur and Patankar have demonstrated excellent results using a protocol of early bone grafting and fixator dynamisation with monolateral fixators (Thakur, 1991). Alternatively, an exchange nailing can be performed after removal of the fixator. This procedure is associated with a high risk of infection. Infection risk can be minimized by avoiding and treating pin site infection and by exchanging to a nail after less than 15 days of external fixation (Antich-Adrover, 1997; Blachut, 1990). Alternately, the fixator can be removed and the limb immobilized in a cast until the pins sites have healed; the tibia can then be nailed. Bhandari et al, in a meta-analysis, found that compared with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in open tibial fractures (Bhandari, 2001; Bhandari, 2000). They also found a reduced risk of reoperation with reamed nails compared with unreamed nails. This appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail. Plate fixation was found to be uniformly the worst of all methods of internal fixation. Although plating a fracture that is exposed may be tempting (ie, because of the open nature of the injury), the risk of nonunion, malunion, and deep infection is too high to justify it (Bhandari, 2001). Cast treatment is avoided for many reasons. It does not provide rigid fracture stabilization, the wound is not open for inspection and regular dressing changes, and a circumferential cast increases the risk of circulatory compromise. Delayed union or nonunion may be avoided with early prophylactic posterolateral bone grafting (Blick, 1989; Thakur, 1991). Monolateral external fixators generally are preferred for the tibia, although multiplanar and circular fixators provide greater stability. For periarticular plateau and plafond fractures, circular or hybrid frames yield the best results, with the lowest morbidity, especially related to infection and soft tissue complications. Newer devices such as the Taylor Spatial Frame can be applied quickly in an emergent situation. Using the so-called rings-first method, each ring is applied individually orthogonal to each fragment and the struts are connected. The fracture is then reduced gradually in a nonemergent fashion by bringing all the struts to equal length and all the rings parallel. The reduction can then be fine-tuned using the residual correction program. This is especially useful when rapid stabilization is required prior to a vascular repair, although the device may impede surgical access. Amputation Not every severely injured limb can be salvaged. Several scoring methods have been developed to predict the chances of limb salvage. The MESS is the best known. Many authors have found these scoring systems to be unreliable (Tornetta, 1997). The presence of warm ischemia for longer than 6 hours, infrapopliteal vascular injury, and posterior tibial and/or common peroneal nerve neurotmesis are the strongest indications for amputation (Tornetta, 1997). With a good MESS, a limb should be considered salvageable; however, a poor MESS should not automatically prompt amputation. Clinical judgment and availability of limb reconstruction facilities should be the ultimate factors in decision making. Preoperative detailsSee Medical therapy. Follow-upOpen tibial fractures have higher rates of nonunion, infection, and chronic pain syndrome (CPS). Close follow-up is required until union. CPS should be anticipated and treated early, rather than after the pain patterns are entrenched. Osteomyelitis can be acute, subacute, or chronic and may surface many months or years after injury. Pin site infections are common with external fixation and should be dealt with aggressively with oral or parenteral antibiotics and debridement or even pin exchange. Pin site chronic osteomyelitis is also relatively common. COMPLICATIONSSection 8 of 10
Open tibial fractures have higher rates of nonunion, infection, and CPS. Osteomyelitis may occur and can be acute, subacute, or chronic. It may surface many months or years after injury. Pin site infections are common with external fixator treatment. Chronic osteomyelitis in the pin sites is relatively common. OUTCOME AND PROGNOSISSection 9 of 10
The Gustilo-Anderson classification system is a good prognostic indicator. The higher grades of injury (eg, type III fractures) are commonly associated with infection and nonunion. REFERENCESSection 10 of 10
Article Last Updated: Mar 30, 2006 |
