Open Fractures Of The Tibia - Everything You Need To Know - Dr. Nabil Ebraheim

Dr. Ebraheim’s educational animated video describes open fractures of the tibia.

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25% of tibial shaft fractures can be open. Open fractures can lead to complications including wound problems, osteomyelitis, nonunions, and infected nonunions. The treatment of open fractures of the tibia can be challenging. A lot of the concepts are not black and white; they may be in the grey zone. We don’t know the best time for debridement. We don’t know what the optimal irrigation solution is and what the optimal pressure for the fluid is. We don’t know for sure the ideal duration of giving antibiotic prophylaxis, but we know that it is important to give the appropriate antibiotics early and do meticulous debridement. We know that the IM rod is better than the plate fixation or external fixator, and the result of the reamed IM rod or unreamed IM rod is the same. We need to close or cover the wound before 1 week and the vac can be used provisionally when we cannot close the wound, primarily at the optimal time. A grade I fracture is less than 1 cm. a grade II fracture is 1-10cm. A grade III fracture is more than 10 cm, and there is contamination. Grade III fractures are divided into three types. Grade IIIa fractures require adequate tissue for closure (or skin graft). Grade IIIb fractures require extensive periosteal stripping and the patient will need a flap (rotational or free flap). Grade IIIc fractures have a vascular injury that requires repair or amputation. The relative indication for amputation is warm ischemia for more than 6 hours, absent plantar sensation and severe ipsilateral foot trauma. The most predictive factor for amputation is the severity of the soft tissue injury in the ipsilateral extremity. When comparing limb salvage versus amputation, the patient’s outcome is generally the same at 1-5 years. Lack of plantar sensation does not predict poor outcome after limb salvage. Segmental fractures are Grade III fractures, even if the open fracture is 1 cm. The ideal irrigation solution and the pressure used to controversial. Timing of the initial debridement is controversial. Irrigation and debridement within 6 hours was the gold standard in the past. Debridement is performed as a priority procedure no later than the morning after admission. There is no difference in infection rate for a patient who has the initial surgery before or after 6 hours, including patients with Type III open fractures. More than 40% of the patients usually wait longer than 6 hours for their initial surgery after arrival at the hospital. Delayed surgery for less severe fractures is acceptable as long as the debridement is done as a priority the following day. Unless there is a gross contamination, evidence is not clear as to when is the best time for the debridement. It seems like giving the patient antibiotics promptly is more important than the time of debridement. The preferred solution is normal saline and low pressure irrigation. Low pressure lavage may reduce reoperation rates due to infection, nonunions, and wound healing problems. Normally the tradition is to use 3, 6, and 9 liters of solution for Type I, Type II, and Type III open fractures (just recommendations). There is increased risk of wound healing with antibiotic solution. Meticulous irrigation and debridement of open fractures is important in decreasing the infection risk. Prophylaxis should be started as soon as possible. All patients with open fractures should receive first generation Cephalosporin’s that will cover gram-positive bacteria. You can give penicillin for farm injuries and clostridia prone wounds. You will give clindamycin if there is a penicillin allergy. In Type III open fractures, add aminoglycoside, such as gentamicin. It was found that local antibiotics delivery at the site of injury decreased the infection risk, such as cement beaded loaded with antibiotics. Antibiotic should be given within 3 hours of the time of injury (preferably given as soon as possible). There is reduction of 59% of acute infection in patients with open fractures treated with antibiotics. The infection rate is 1.6 times greater if antibiotics are given after 3 hours. Type I and Type II open fractures require antibiotic coverage for 24 hours after wound closure. For Type III open fractures, antibiotic administration should be given for a period of 72 hours after the injury and no more than 24 hours after wound closure. After the initial debridement, the patient will need staged debridement within 24-48 hours. There is a reduction infection rate, acute and chronic, for Type III open fractures with the use of systemic antibiotics and aminoglycoside cement beads compared with antibiotics alone.

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