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The Journal of Bone and Joint Surgery 78:1428-37 (1996)
© 1996 The Journal of Bone and Joint Surgery, Inc.

Instructional Course Lecture

Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Open Fractures of the Tibial Shaft. Current Treatment*{dagger}

STEVEN A. OLSON, M.D.{ddagger}, SACRAMENTO, CALIFORNIA

An Instructional Course Lecture, The American Academy of Orthopaedic Surgeons


   Introduction
Top
 Introduction
Treatment in the Emergency...
 Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
 Rehabilitation
 Overview
 References
 
The tibial shaft is one of the most common sites of an open fracture18, a fracture that involves a break in the skin with soft tissues communicating with the fracture or its hematoma, or both. The specific methods of skeletal stabilization and soft-tissue treatment of open and closed fractures continue to be topics of debate in orthopaedic traumatology. The type of treatment selected for open tibial fractures depends on the individual characteristics of the fracture and the concomitant soft-tissue injury, making experience and clinical judgment an important part of the over-all treatment13,42. Most orthopaedists treat only a few of these injuries each year; however, there are increasing expectations for surgeons to understand and apply the techniques of treatment of open fractures, such as the use of flap coverage and bone transplant techniques, to help patients to obtain an optimum functional outcome13.


   Treatment in the Emergency Room
Top
 Introduction
 Treatment in the Emergency...
Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
 Rehabilitation
 Overview
 References
 
In the emergency room, initial attention should be given to resuscitation and assessment of the patient according to the guidelines of Advanced Trauma Life Support1. Specific assessment of the extremities other than to control active hemorrhage should be part of a secondary survey. The orthopaedist must be aware of other injuries because severe pulmonary, intra-abdominal, or head injuries may limit the extent of initial débridement and stabilization that can be performed acutely for the open tibial fracture18. Concomitant fractures of the long bones and unstable fractures of the posterior part of the pelvic ring associated with hemodynamic instability should be stabilized within the first twenty-four hours after the injury whenever possible.

The physical examination should include a thorough inspection and palpation of the extremities18. Occult open fractures may be missed if the examining physician does not elevate the extremity and inspect it circumferentially. The initial evaluation should include assessment of the neurovascular status, the soft-tissue injury, and the osseous deformity. The vascular status can be documented by palpation of pulses, examination for capillary refill, and notation of the color of the limb and the presence of bleeding from open wounds. Any osseous deformity should be evaluated. Legs that have a gross rotational deformity or angular deformity, or both, at the site of a tibial fracture should be realigned promptly in an anatomical position1,18. Associated deformities of the foot, ankle, knee, or femur should also be noted. Pulses should be documented before and after alignment. The pulses often improve with realignment; persistently diminished pulses may indicate a vascular injury and the need for arteriographic evaluation. Gross motor function and sensibility of the foot and leg should be documented whenever possible. The presence or absence of plantar sensation can be an important factor in the determination of whether a limb-salvage procedure is the best treatment for a severe injury18,30.

Often, soft-tissue injuries can be assessed only superficially in the emergency room. Knowledge of the history of the injury and its location is often helpful when determining the extent of soft-tissue damage and the level of contamination. Blistering, contusions, crushed areas of skin, and burns reflect the transfer of a large amount of energy to the limb5. Gross contamination with soil, grass, or other foreign material should be noted. The dimensions and location of all open wounds should be recorded. A photograph of the open wound helps to document its characteristics. Extensive or contaminated wounds should be lavaged with a liter of sterile saline solution. Superficial foreign bodies, such as leaves and grass, that are immediately accessible should be removed from the wound before it is sealed. The surgeon should take care to use a sterile technique so as not to increase the contamination of the wound during the initial inspection phase. A clean sterile dressing should be applied to the wound and should not be removed until the patient is taken to the operating room5,18. The limb should be placed in a well padded plaster splint in grossly normal alignment.

Early intravenous administration of antibiotics is associated with a decreased rate of infection54 and thus should be begun in the emergency room5,13,18,54. Coverage for gram-positive organisms with cefazolin (one gram every eight hours) should be routine for all open fractures. Coverage for gram-negative organisms, typically with an aminoglycoside, is used for open fractures with more extensive soft-tissue injury or extensive contamination, or both5,18. Coverage for anaerobic organisms, typically with penicillin, should be used whenever there is the possibility of infection with Clostridium perfringens, such as from contamination with soil (particularly with injuries that occur on a farm) or public waters such as rivers or lakes18,55. Antibiotic therapy should be continued for forty-eight to seventy-two hours after the initial débridement for type-I and type-II open fractures, as classified by Gustilo and Anderson28. Antibiotics should be given for as long as 120 hours after débridement of a type-III open fracture5,13,18,54.

Prophylaxis against tetanus should also be considered with any open fracture. Patients who were immunized in the last five years before the injury do not need prophylaxis. Those who were immunized more than five years before the injury should receive a tetanus booster. Patients for whom the time of the last immunization is unknown or who have never been immunized should receive a tetanus immunization booster as well as tetanus immune globulin1.


   Classification
Top
 Introduction
 Treatment in the Emergency...
 Classification
Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
 Rehabilitation
 Overview
 References
 
Classification of an open fracture facilitates the description of the severity of the injury among physicians, and it can provide useful guidance for treatment as well. The classification of an open fracture is based on a number of factors, including the mechanism of injury, the vascular status of the extremity, the size of soft-tissue defects and lacerations of the extremity, the extent of soft-tissue crush or loss, the extent of comminution, the amount of bone loss, the degree of periosteal stripping, and the degree of bacterial contamination13,28. The final classification of an open fracture should be delayed until the time of the initial operative débridement, as many of these factors cannot be assessed fully before that time5.

The most common classification system for open fractures used in the United States is that of Gustilo et al.28,29. As originally described by Gustilo and Anderson28 in 1976, this classification divided fractures into types I, II, and III. With its revision29 in 1984, the classification subdivided type-III injuries into types IIIA, IIIB, and IIIC.

A type-I fracture is a low-energy injury with minimum soft-tissue damage and a small (less than one-centimeter) wound; the fracture typically occurs as an inside-to-out puncture from an underlying spike of bone. Typically, there is slight comminution of the bone28.

A type-II fracture represents a transition between the low-energy type-I and the high-energy type-III fracture. Type-II fractures may have associated soft-tissue lacerations one to ten centimeters long, slight or moderate comminution, and no or slight periosteal stripping of the bone fragments28.

The most severe pattern of open fractures is type III. Gustilo et al. defined type-IIIA open fractures as those having adequate coverage with soft tissue despite extensive soft-tissue lacerations or flaps or injuries reflecting high-energy trauma, such as extensive osseous comminution, a segmental fracture pattern, or extensive soft-tissue injury (irrespective of the size of the wound), or a combination of any of these29. Open fractures that occur in an environment that predisposes to extensive bacterial contamination, such as a barnyard setting or a public waterway, are also classified as type-IIIA.

Type-IIIB fractures were originally defined as fractures with extensive soft-tissue injury, periosteal stripping, and exposed bone29. This definition has led to debate as to whether a fracture with areas of periosteal stripping but adequate muscle coverage of the bone should be classified as type IIIA or type IIIB. We prefer to define type-IIIB open fractures as those that necessitate local or distant flap coverage of areas of exposed bone18. These fractures are commonly associated with extensive periosteal stripping.

A type-IIIC fracture is associated with a vascular injury that requires repair for survival of the limb29. A tibial fracture with only an isolated injury of the anterior or posterior tibial artery should not be considered type IIIC.

The introduction of the classification of Gustilo et al.28,29 for open fractures was a major step forward in the treatment of these complex injuries. Recently, Brumback and Jones surveyed a group of orthopaedic surgeons interested in the treatment of open fractures, in order to assess the interobserver reliability associated with this classification system14. The surgeons viewed video presentations of the history, physical examination, radiographs, and operative débridement of the wound for thirteen open fractures. The average over-all interobserver agreement for classification was 60 per cent (range, 42 to 94 per cent). The average agreement was 59 per cent (range, 33 to 94 per cent) for residents and fellows and 66 per cent (range, 39 to 100 per cent) for trauma-fellowship-trained, academic orthopaedic surgeons who treated more than twelve open tibial fractures a year14. These low levels of interobserver agreement emphasize that the classification of open fractures is subjective.

Other classification systems for open fractures are available. The AO/ASIF classification for soft-tissue injuries uses a combination of the alpha-numeric fracture classification system and an IMN system wherein the injury to the integument (I), muscle (M), and nerve (N) is each judged independently. This classification system has several potential benefits for clinical research; however, it is cumbersome in clinical situations. The Hannover open-fracture classification, developed by Südkamp et al.66, is based on a point-scale system for bone injury, soft-tissue injury, vascular injury, and contamination. Open fractures are classified as types I through IV. This system has not been widely used in North America.


   Initial Operative Treatment
Top
 Introduction
 Treatment in the Emergency...
 Classification
 Initial Operative Treatment
Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
 Rehabilitation
 Overview
 References
 
An open tibial fracture is an operative emergency. The primary treatment is early operative débridement and stabilization of the bone. Débridement of an open tibial fracture involves operative exploration of the wound or wounds to define the zone of injury, removal of devitalized tissue, and use of pulsed lavage to achieve additional mechanical débridement of the wound5,13,18. Experience and judgment are required to determine the appropriate extent of débridement. The wound should be extended with the use of sharp dissection until healthy tissue is seen at each end. The wound should then be explored systematically to ensure complete débridement of all contaminants and devitalized tissue.

Débridement should begin with the skin. After operative extension, the edges of the skin should be inspected carefully about the entire wound. Evidence of skin and subcutaneous tissue that has been avulsed from underlying fascial structures should be noted as this is an indicator of high-energy trauma and may be indicative of underlying muscle injury18,59. The débridement should continue in a methodical way with careful inspection of the subcutaneous tissue, muscle, and finally bone to avoid overlooking any devitalized tissue. The skin and subcutaneous tissue are inspected throughout the entire extent of the wound. Any obviously non-viable or crushed skin should be excised. Skin with questionable viability can be retained until a later débridement. This is especially important in the area of the subcutaneous border of the tibia, where injudicious removal of skin may necessitate later use of a local or distant flap to cover the bone18,59.

Muscle should be inspected carefully for signs of viability, which can be assessed with the so-called four c's: color, consistency, contractility, and capacity to bleed18. Of these four, the latter two, particularly contractility, are the more sensitive indicators of viable muscle. Clearly non-viable muscle should be debrided. Muscle that is weakly contractile and appears contused can be left and reinspected in twenty-four to forty-eight hours. Attempts should be made to maintain the integrity of musculotendinous units whenever possible without compromising the débridement. It must be remembered that the presence of an open fracture does not preclude the development of a compartment syndrome18,31, and fasciotomy of the compartment or compartments containing structures that may have been damaged by the injury through the open fracture wound should be performed routinely as part of the initial débridement18. However, fasciotomy of all four compartments should be reserved for injuries with extensive soft-tissue swelling and increased intracompartmental pressures (to within twenty to thirty millimeters of mercury [2.66 to 4.00 kilopascals] of the diastolic blood pressure)32,43. The more extensive use of fasciotomy may be warranted for patients who have moderate swelling of the leg (intracompartmental pressures of twenty-five to thirty-five millimeters of mercury [3.33 to 4.67 kilopascals]), for those who have sustained systemic hypotension (diastolic blood pressure of approximately fifty-five millimeters of mercury [7.33 kilopascals] or less), for those with severe polytrauma in whom an accurate clinical examination may be difficult postoperatively, or after revascularization for salvage of the limb18.

Bone that is stripped of all soft-tissue attachments is necrotic and can act as a substrate for organisms that cause infection5,18,22. Small-to-moderate avascular segments of bone should be removed. The decision to debride large portions of devascularized diaphyseal or metaphyseal bone, or both, is often a difficult one. Major articular segments of the tibial plateau and the tibial plafond should be retained, even when there is extensive stripping, if the surgeon believes that salvage of the involved joint is possible18. Areas of bone that have been stripped of periosteum but that are in continuity with a vascularized portion of the tibia can be retained if there is adequate soft-tissue coverage to allow early revascularization. Débridement of free segments of devascularized diaphyseal bone has been reported to result in a decreased prevalence of infection22. In the first part of their series, Edwards et al. reported deep infection associated with eighteen of eighty-five tibial fractures in which visually clean necrotic bone had been retained22. In the second half of the series, the prevalence of deep infection decreased to eight of eighty-six fractures with débridement of all necrotic bone. The retention of completely free segments of devascularized diaphyseal or metaphyseal bone should be considered only rarely. The surgeon should be aware that the risk of postoperative infection is higher when necrotic bone remains in the wound5,22,59.

After thorough operative débridement of the wound, mechanical débridement is performed with pulsed lavage irrigation7,27. Pulsed lavage with use of several different types of irrigation solution resulted in decreased bacterial counts compared with those associated with standard irrigation with use of a bulb syringe3. Recently, investigators found that antiseptic solutions of hydrogen peroxide, Betadine (povidone-iodine) solution, and Betadine scrub are toxic to osteoblasts in culture at concentrations used clinically, while bacitracin in normal saline solution had no similar toxic effects38.


   Stabilization of Open Fractures
Top
 Introduction
 Treatment in the Emergency...
 Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
Treatment of the Wound
 Bone-Grafting
 Rehabilitation
 Overview
 References
 
After the initial irrigation and débridement, the next step is stabilization of the osseous injury. Controlling instability of the bone provides several benefits: continued damage to the surrounding soft tissue by displaced bone fragments is decreased, care of the soft-tissue injuries is facilitated, and the patient's comfort is increased. Options for stabilization include immobilization in a cast, external fixation, internal fixation with plates and screws, and intramedullary nailing. Immobilization of open fractures in a cast is associated with an increased prevalence of non-union and delayed union (ten of 205 to forty-five of 112 fractures in reported series) as well as late osseous deformity (seventeen of thirty-three fractures in reported series)2,12,36,51. Sarmiento et al. reported that the average time to union in a series of thirty-four grade-III open tibial fractures was twenty-six weeks61. Prolonged immobilization in a cast or orthosis may increase stiffness, muscle atrophy, and dysfunction of the limb50. Type-I and some type-II open fractures with minimum soft-tissue injuries and slight-to-moderate displacement of the bone can be treated with immobilization in a cast. However, such treatment precludes access for wound care for fractures with more extensive soft-tissue injury18. Hooper et al. performed a prospective randomized trial comparing the results of immobilization in a cast with those of intramedullary nailing of closed and type-I open fractures of the tibial shaft and demonstrated a significantly (p < 0.05) higher prevalence of varus or valgus malalignment and shortening with the former treatment36. Seventeen of the thirty-three fractures that were treated in a cast had a malunion, as defined by more than 5 degrees of varus or valgus angulation, at least 10 degrees of anteroposterior angulation, and at least one centimeter of shortening. One of the twenty-nine fractures treated with intramedullary nailing had a malunion36.

External fixation offers several advantages in the treatment of open tibial fractures16,22,24,39. Most modern external fixation frames provide acceptable stability for such fractures6. Generally, there is good access to the soft tissues, and most forms of external fixation do not substantially impair the range of motion of the knee or ankle. External fixation is typically applied as a static form of immobilization to maintain skeletal alignment. Newer forms of external fixation allow compression of the fracture site with weight-bearing44,48.

External fixation has also been associated with some difficulties. Irritation of the pin track with inflammation of the skin at the interface between the bone and the pin is a common problem25 that can present in a variety of ways, ranging from mild erythema about the pin to a frank pin-track infection. Pin-track infections are associated with thermal necrosis of bone at the time of insertion of the pin. Green and Ripley reported fourteen cases of osteomyelitis that occurred in the tracks of pins that had been placed entirely in cortical bone26. Infection can be avoided by predrilling pin tracks and by not placing the pin entirely through cortical bone26,45. External fixator pins have a limited life span and typically loosen between three to six months after application of the fixator, necessitating either revision of the fixator or conversion to another form of treatment. Iliac-crest bone-grafting early (within the first six weeks) after the injury frequently is recommended to accelerate union of the fracture before the fixator becomes loose9. Delayed conversion from an external fixator to an intramedullary nail has been associated with an increased prevalence of infection73. Wiss and Stetson reported on a series in which thirty-three non-unions of open fractures of the tibia were treated with intramedullary nailing73. An infection developed at the sites of five of the fractures, all of which had been treated initially with external fixation, with the removal of the fixator at least eleven weeks before the intramedullary nailing73. McGraw and Lim found an infection around seven of sixteen open fractures of the tibial shaft that had been treated with external fixation followed by intramedullary nailing42. In a study of two groups of comparable open fractures of the tibial shaft treated with external fixation followed by delayed intramedullary nailing, Maurer et al. observed that the rate of infection was much higher (five of seven compared with one of seventeen) when a pin-track infection had developed before the intramedullary nailing46. In fact, those authors found that a pin-track infection during the course of external fixation was the most sensitive predictor of infection after intramedullary nailing. Fractures that have been treated with external fixation for more than twenty-one days and are being considered for treatment with delayed intramedullary nailing should be assessed carefully for any history of drainage around or infection of the pin track to evaluate the risk of deep infection. However, good results have been reported with intramedullary nailing following short-term (ten to eighteen-day) use of external fixation to facilitate initial soft-tissue treatment8.

Edwards et al. reported on 171 type-III open fractures that had been treated with external fixation22. They reported complications related to the pin track following treatment of fifty fractures and only four cases of pin-induced local osteomyelitis. The prevalence of drainage associated with anteromedial half-pins in the tibial diaphysis was noted to be approximately one-third that associated with comparably placed transfixion pins22. Marsh et al. reported thirty-nine pin-track complications after the treatment of 101 open tibial fractures with the dynamic axial fixator44. Ten of the complications necessitated removal or reinsertion of the screw or some other change in the treatment of the fracture. The over-all prevalence of deep infection at the site of the fracture was 6 per cent (six of 101)44.

Fixation with a plate typically is reserved for the treatment of open periarticular fractures of the tibial plateau and selected fractures of the tibial plafond5,18,59. Rhinelander demonstrated that the normal pattern of bone circulation (from the medullary artery to the periosteum) is reversed following a fracture56. A transient increase in periosteal blood flow supplies most of the circulation in the first weeks after a fracture56,57. The application of a plate requires extensive dissection, which devitalizes soft tissue and bone and may lead to more frequent complications4,15. Ruedi et al. reported a prevalence of infection of 12 per cent (twelve of 101) after fixation of open fractures of the tibial shaft with a plate58. In a prospective randomized study, Bach and Hansen compared the use of external fixation with that of open reduction and internal fixation with plates and screws for type-II and type-III open fractures of the tibial shaft4. They found a prevalence of infection of 35 per cent (nine of twenty-six fractures) and a prevalence of osteomyelitis of 19 per cent (five of twenty-six fractures) after fixation with plates and screws, compared with prevalences of 13 per cent (four of thirty fractures) and 3 per cent (one of thirty fractures) after external fixation. The prevalence of malunion was slightly lower (one of twenty-six; 4 per cent) after fixation with a plate than after external fixation (three of thirty; 10 per cent).

Stabilization with an intramedullary nail has become increasingly popular for the treatment of fractures of the tibial shaft17,20,21,35,40,47,49,69,72. One study demonstrated a decreased prevalence of deep infection with use of Ender nails (two of twenty-nine) compared with the prevalence with use of external nails (four of twenty-eight), and there were no pin-track infections associated with the Ender nails35. Similar findings were noted in a comparison of external fixation with Lottes nails64,67. However, the use of Ender or Lottes nails for axially unstable fractures often results in malunion and creates the need for prolonged immobilization in a cast35,37,40,47,69. The development of the interlocking technique has greatly enhanced the use of tibial nailing in the treatment of more extensively comminuted fractures (Figs. 1-A and Figs. 1-B).



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  		Figs. 1-A through 1-D: A type-IIIA open fracture of the distal third of the tibial shaft.

 


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  		Anteroposterior and lateral radiographs made after débridement and stabilization with a static locking tibial nail. There is segmental loss of the distal third of the tibial shaft.

 
Nailing without reaming has been advocated for open tibial fractures to minimize the injury to the endosteal circulation caused by reaming5,18,59. Several authors have reported on the use of locking nails without reaming for the treatment of open fractures of the tibial shaft10,33,34,60,63,65,70 (Table I). Over-all, the prevalence of both deep infection and non-union in association with type-I, II, and IIIA open fractures treated with intramedullary nailing without reaming has been lower than that associated with similar fractures treated with other fixation devices.


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  		TABLE I REPORTED RATES OF DEEP INFECTION, MALUNION, DELAYED UNION, AND NON-UNION FOLLOWING FIXATION WITH INTERLOCKING NAILING WITHOUT REAMING

 
The role of interlocking tibial nailing without reaming in the treatment of type-IIIB fractures remains controversial. The early results reported with this technique have been promising10,33,34,60,63,65,70. Since such extensive soft-tissue injuries to the leg are relatively uncommon, multicenter studies may be needed to address this issue fully.

Henley et al.34 and Tornetta et al.68 performed prospective randomized studies comparing the use of external fixation with interlocking tibial nailing without reaming. Henley et al. reported the results of 174 type-II, IIIA, and IIIB open fractures of the tibial shaft and found that the prevalence of deep traumatic wound infections after intramedullary nailing was 7 per cent (seven of 104 fractures) and the prevalence of such infections after external fixation was 11 per cent (eight of seventy fractures)34. There was no difference in the time to union between the two groups. Tornetta et al. reported on twenty-nine type-IIIB open fractures of the tibial shaft that had been randomized alternatively to treatment with external fixation or with interlocking nailing68. There was one deep infection in each group and no difference in the time to union between the two groups.

The use of reaming in the treatment of open fractures continues to be a source of controversy5,13,18,21. A small, prospective randomized series in which tibial nailing of open fractures with reaming was compared with that without reaming demonstrated no detectable differences between the techniques; an infection developed at the site of two of forty-nine fractures treated with intramedullary nailing with reaming compared with none of thirty-eight fractures treated without reaming52. However, Bone and Johnson reported an infection at the site of two of eight type-II or type-III open fractures of the tibial shaft that had been treated with intramedullary nailing with reaming, compared with two of sixty-eight closed or grade-I open fractures that had been treated with primary intramedullary nailing with reaming11. Furthermore, in a laser Doppler flow-metry study of cortical circulation after intramedullary nailing with and without reaming in a sheep tibial-fracture model, revascularization occurred six weeks after nailing without reaming but not until twelve weeks after nailing with reaming; this finding suggests an advantage of nailing without reaming in the treatment of severe open tibial fractures62.

The transition from a nine-millimeter-diameter nail to a ten-millimeter-diameter nail in most current tibial nailing systems includes the use of larger-diameter cross-locking screws that increase the stability of the fixation. Thus, the debate regarding reaming versus non-reaming techniques centers on fractures with a small-diameter canal. In this case, it is not clear whether the benefits of minimum reaming to allow a ten-millimeter nail to be used outweigh the risks of increased vascular injury from the reaming. I believe that tibial nailing without reaming is still preferable and that reaming to accommodate nail sizes of eleven millimeters or larger is contraindicated for open fractures of the tibia.

I prefer interlocking intramedullary nailing without reaming for skeletal stabilization of type-I, II, and IIIA open fractures of the tibial shaft with a nailable fracture pattern (fractures involving the middle three-fifths of the tibial shaft). For type-IIIB fractures, the results with interlocking intramedullary nailing without reaming are equivalent to, but not better than, those with external fixation34,68. Intramedullary nailing offers several advantages in the treatment of these severe soft-tissue injuries. No external fixation pins or circumferential plaster dressing is needed, facilitating free-tissue transfer or local rotational flap coverage. An early range of motion of the knee and ankle is also facilitated with intramedullary fixation. Intramedullary nailing offers many of the advantages of external fixation; moreover, several of the drawbacks associated with external fixation, such as loosening of the pins and loss of fixation, are avoided10,33,34,60,63,65,70. It should be appreciated that both external fixation and intramedullary nailing of open tibial fractures require technical expertise to obtain acceptable reduction and stable fixation13,22,34,44.


   Treatment of the Wound
Top
 Introduction
 Treatment in the Emergency...
 Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
Bone-Grafting
 Rehabilitation
 Overview
 References
 
After the initial irrigation and débridement and stabilization of the bone, the surgeon must treat the traumatic wounds. Operative extensions of the initial wound may be sutured primarily18. The initial traumatic wound should be left open. Early intensive repeated débridement is a fundamental principle of treatment of severe soft-tissue injuries. Patients who have a type-III injury with extensive soft-tissue damage should be returned to the operating room within twenty-four to forty-eight hours for reinspection and additional débridement of the soft tissues5,18,59. The goal of repeated débridement is to remove all necrotic tissue from the wound so as to remove the substrate for infection. Repeated débridement every twenty-four to forty-eight hours may be necessary to achieve this goal. When the soft-tissue bed is stable and no necrotic tissue is evident, delayed closure or coverage of the fracture can be performed. Gustilo and Anderson originally recommended delayed primary closure of open-fracture wounds five days after the initial débridement28. In general, delayed primary closure or split-thickness skin-grafting can be performed when there is a healthy soft-tissue envelope with adequate muscle coverage over the fracture. Ideally, this objective is achieved within five to seven days after the initial débridement.

Polymethylmethacrylate beads impregnated with antibiotics can be used in severe soft-tissue injuries53 to deliver locally high concentrations of antibiotics without serious systemic effects other than the possibility of an allergic reaction. An occlusive dressing must be placed over the wound to form a bead pouch, which allows the antibiotics to remain in the local environment. The bead-pouch technique is an excellent way to deal with dead space and to prevent desiccation of exposed bone in open wounds before soft-tissue coverage18. Ostermann et al. reported a significant decrease (p < 0.05) in the rate of infection with the combined use of systemic antibiotics administered intravenously and antibiotic beads for type-IIIB open fractures (an infection developed in ten of 144 fractures treated with antibiotic beads and systemic antibiotics, compared with eleven of twenty-seven fractures treated with systemic antibiotics alone) and type-IIIC open fractures (an infection developed in two of forty fractures treated with antibiotic beads and systemic antibiotics, compared with eight of thirty-two fractures treated with systemic antibiotics alone)53.

Exposed tendon and bone without peritenon or periosteal coverage necessitates flap coverage5,18,59. Ideally, if rotational or free-flap coverage of the fracture is needed, it should be done within the first seven days after the injury19,23. Delay beyond this time has been associated with an increased prevalence of late infection19. Flap coverage can be performed with a local rotational muscle flap, a free vascularized muscle flap, or a local fasciocutaneous flap. Muscle flaps have been shown to aid revascularization of underlying exposed bone5,18, and they are superior to fasciocutaneous flaps in the treatment of dead space caused by a loss of bone or soft tissue5,18,59. In general, tissue defects in the proximal third of the tibia are covered with a gastrocnemius rotational flap. A soleus rotational flap is recommended for defects in the middle third of the tibial shaft, and a free vascularized muscle flap typically is needed for those in the distal third of the tibia18. However, the success of a local muscle rotational flap may be precluded if the muscle to be mobilized—that is, the gastrocnemius or the soleus—was involved in the zone of injury5,18,59, and severe muscle contusion precludes the local rotation of the muscle for flap coverage. In these cases, free vascularized flaps may be necessary.

With fasciocutaneous flap coverage, a segment of the skin, the underlying subcutaneous tissue, and fascia are mobilized to cover the exposed bone or tendon, or both41. Fasciocutaneous flaps are based on circulation from the posterior tibial or peroneal systems. With careful planning, a flap with as high as a 3:1 length-to-width ratio can be created safely, while a 1:1 ratio is necessary for random flaps41. Recently, good results have been reported following treatment of open tibial fractures with fasciocutaneous flaps20.


   Bone-Grafting
Top
 Introduction
 Treatment in the Emergency...
 Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
Rehabilitation
 Overview
 References
 
Early iliac-crest bone-grafting is recommended for fractures with extensive soft-tissue stripping, especially those treated with external fixation, as well as fractures with a loss of more than 50 per cent of the circumference of the bone or areas of segmental loss9,18. The bone-grafting should be performed after soft-tissue coverage has been achieved (Figs. 1-C and 1-D). Fischer et al.23 reported that bone-grafting of type-IIIA and IIIB fractures before a healed soft-tissue envelope was present led to an infection in four of fifteen patients, whereas delayed bone-grafting performed after a well vascularized soft-tissue envelope was present (six to eight weeks after the fracture) did not lead to an infection in any of the sixteen patients who were managed in this fashion. Bone-grafting should be considered for type-IIIB fractures that are not associated with a loss of bone if there is no callus three months after the injury18.



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  		Fig. 1-C: Anteroposterior radiograph made eight weeks after the initial injury. A posterolateral iliac-crest bone graft was inserted and internal fixation of the fibula was performed.

 


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  		FIG. 1-D: Anteroposterior radiograph made ten months after the initial injury. The fracture united, with good incorporation of the bone graft.

 


   Rehabilitation
Top
 Introduction
 Treatment in the Emergency...
 Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
 Rehabilitation
Overview
 References
 
Early functional rehabilitation should be a key part of the treatment of open fractures of the tibial shaft. Physical therapy programs to emphasize the range of motion of the knee and ankle are critical in the first few weeks after the injury5,18. The patient should be encouraged to maintain good muscle tone, even if no weight-bearing or only toe-touch weight-bearing is allowed. Patients who have an axially stable fracture pattern can begin bearing weight immediately18,71, whereas those who have an axially unstable fracture pattern should delay weight-bearing until the first callus is seen. Patients who have a fracture with segmental bone loss should not be allowed to bear weight on the affected extremity until there are radiographic signs of incorporation of the bone graft (callus)18.


   Overview
Top
 Introduction
 Treatment in the Emergency...
 Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
 Rehabilitation
 Overview
References
 
In summary, open fractures of the tibial shaft represent a limb-threatening, and potentially life-threatening, emergency. Optimum treatment involves appropriate initial evaluation and administration of antibiotics; urgent operative débridement and skeletal stabilization; repeated soft-tissue débridements; and early soft-tissue closure or flap coverage, or both. This intensive treatment allows early functional rehabilitation and an improved clinical outcome for patients who have an open fracture of the tibial shaft.


   Footnotes
 
*Printed with permission of The American Academy of Orthopaedic Surgeons. This article will appear in Instructional Course Lectures, Volume 46, The American Academy of Orthopaedic Surgeons, Rosemont, Illinois, March 1997.

{dagger}The author has received or will receive benefits for personal or professional use from a commercial party (Howmedica, Rutherford, New Jersey) related indirectly to the subject of this article. No funds were received in support of this study.

{ddagger}Department of Orthopaedic Surgery, University of California, Davis Medical Center, 2230 Stockton Boulevard, Sacramento, California 95817. E-mail address: SZPelvis@Peseta.UCDavis.Edu.


   References
Top
 Introduction
 Treatment in the Emergency...
 Classification
 Initial Operative Treatment
 Stabilization of Open Fractures
 Treatment of the Wound
 Bone-Grafting
 Rehabilitation
 Overview
 References
 

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