Open Tibia Fracture

Clinical image

Clinical photograph of an open tibial and fibular shaft fracture. Source: Wikimedia Commons — MustafaSalahalden; CC BY-SA 4.0. Image binary is embedded locally in this package; original source and licence are retained.

Principles

• Initial approach will be along ATLS protocol
• Assuming that the injury is isolated, I will follow the BOAST 4 guideline
• I will follow a MDT approach involving ortho plastic care
• Because the consequences of infection can be great both for the community and the individual patient

Principles based on BOAST 4

• Initial management
• Ward management: Timing of Debridement
  • immediate: High contamination/asso V/C
  • <12hr: solitary high energy open fracture
  • <24 hrs: all other low energy open fracture
• Theatre management
• Post op management

Initial management

- Antibiotic with in 1hr of injury
- examine for NV injury and compartment syndrome
- Realign and splint and repeat examination of NVC
- Repeat examination
- Minimum handling of wound
  - Remove gross contamination
  - Saline soaked dressing covered with occlusive film
- Photographs: first seen, after debridement , every key stages
- CT: scanogram head to toe, angiogram if arterial injury suspected

Initial Antibiotic

• IV antibiotic with in 1 hour of injury
• Gustilo Type I and II
  • 1st generation cephalosporin (clindamycin or vancomycin can also be used if allergic)
• Gustilo Type III
  • 1st generation cephalosporin + aminoglycoside
• Farm injuries, heavy contamination, or possible bowel contamination
  • add high dose penicillin for anaerobic coverage (clostridium)
• Special considerations
  • fresh water wounds
    • fluoroquinolones or 3rd or 4th generation cephalosporin
  • saltwater wounds
    • doxycycline + ceftazidime or a fluoroquinolone
• Duration
  • continue for 24 hours after initial injury if wound is able to be closed primarily
  • continue for 24 hours after final closure if wound is not closed during initial surgical debridement (72 hours for Type III wounds)

Theatre management

- Combined Orthoplastic approach
- Debridement with wound extended through fasciotomy lines
- Any further procedure is considered a clean surgery
- Internal Fixation only if definitive wound cover possible immediately
- MDT assessment if decision on limb salvage/amputation planned

Debridement

• Remove all contamination
• Low pressure pulse lavage
• Remove dead and devitalised tissue
• Dead muscle is identified by color, consistency, contractility and ability to bleed
• Remove all loose bone , pull test

Post op management

- Information regarding
  - expected function,
  - rehabilitation,
  - when to return to work and driving

Mangled Extremity Severity Score (MESS)

score of five in functional units

• a score of five in any of two components

• 15 points

Key points

Compartment Syndrome

Principles

• with significant limb injuries,

• after surgery for limb injuries, and

• after any prolonged surgical procedure which may result in hypoperfusion of a limb.

• I will suspect CS in the following situations

• I will follow BOAST 10 guideline and My first priority is clear documentation of

• Time and MOI

• Time of evaluation

• Level of pain and consciousness

• Response to analgesia

• whether regional analgesia was given or not

• Initial evaluation

• Initial management

• Ward management

• Theatre management

My initial evaluation involves

• Looking for pain out of proportion to the associated injury
• Pain on passive movement of the muscles of involved compartment
• Record Limb Neuro vascular status, but donot contribute to initial diagnosis

Initial management

• Avoid regional anaesthesia
• Rate and dose of Patient controlled analgesia recorded
• Release all circumferential dressing
• Elevate limb to heart level
• Maintain normal BP
• re evaluate in 30 min
• Measure compartment pressure when in doubt/unconscious patient
• Record all actions

Ward management

• At risk limb should have hourly limb observations of early signs
• When pain scores not reducing, a senior clinical review is needed

Theatre management

• Surgery should be done with in 1 hour of decision to operate
• Open fascial decompression of all involved compartments
• Necrotic muscle excised
• Document the procedure
• Re explore in 48 hours
• Early involvement of plastic
• Follow BOAST 4 guideline for leg compartment (2 incision )
• No consensus for foot compartment
• Late presentation/diagnosis should involve 2 consultants. non operative is an option

Compartment pressure

• Measure diastolic pressure and compartment pressure
• If difference is <30mmHg
• or Absolute pressure >40mmHg
• If so urgent surgical decompression

Key points

• Acute compartment syndrome of a limb is due to raised pressure within a closed fascial compartment causing local tissue ischaemia and hypoxia.
• In clinical practice, it is most often seen after tibial and forearm fractures, high-energy wrist fractures and crush injuries.
• Other important causes include restrictive dressings or casts, prolonged immobilization and reperfusion of ischaemic limbs.
• Early diagnosis and treatment is vital to avoid severe disability.
• Pulses are normally present in compartment syndrome. Absent pulses are usually due to systemic hypotension, arterial occlusion or vascular injury.

Arterial injuries

I will approach the patient based on ATLS protocol

• Life threatening injuries are given priority
• Assuming an isolated injury, I will follow the BOAST 6 guideline

Principles

• Initial Management
• Theatre management
• Post operative management

Initial management

• Active haemorrhage should be controlled by direct pressure or tourniquet
• An injured limb should be considered to have NV injury unless definitely excluded and documented
• Realign and reduce any dislocation and splint
• Repeat NV examination
• I will look for following clinical signs: altered sensation, expanding haematoma, absent pulses, pink pulselessness

Theatre management

• Urgent exploration with in 3-4 hrs of injury
• Only delay should be due to treating life threatening injuries
• Hight risk of amputation should be informed to the patient
• A decision to amputation taken by 2 consultants
• Vascular and orthopaedic teams should cooperate
• Duplex, ct angiogram and on table angiogram assess must not delay repercussion injury as injury pattern predicts the level
• Sequence: temporary shunt, assess viability, skeletal stabilisation, finally definite reconstruction
• Incisions should preserve perforators

Post operative management

• Post-operative care should be provided in an appropriate area with nursing and medical staff competent in the as- sessment of the critically injured limb.