(Smith &Nephew,Inc.logo) Grant FundsProvidedBy: patient care,andsafety. Perioperative nurses andsurgicalte Intended Audience: (Smith &Nephew,Inc.logo) Grant FundsProvidedBy: patient care,andsafety. Perioperative nurses andsurgicalte Intended Audience: (“First come,FirstServedLimitedOffering”) (“First come,FirstServedLimitedOffering”) #1 OpenTibialFractures: DamageControlandTreatmentOptions #1 OpenTibialFractures: DamageControlandTreatmentOptions #2 Eliminating the Need for Imagi #2 Eliminating the Need for Imagi To secure these1.0credit work CE ONLINE To secure these1.0credit work Two Orthopaedic CESeminars Two Orthopaedic CESeminars FREE FORTHEASKING! FREE FORTHEASKING! Options Damage Control and Treatment Fractures: Open Tibial chnologists who areinterestedinne Sponsored By An OnlineContinuing Education Activity chnologists who areinterestedinne [email protected] [email protected]
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Welcome to Open Tibial Fractures: Damage Control and Treatment Options (An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS This educational activity is being offered online and may be completed at any time.
Steps for Successful Course Completion
To earn continuing education credit, the participant must complete the following steps: 1. Read the overview and objectives to ensure consistency with your own learning needs and objectives. At the end of the activity, you will be assessed on the attainment of each objective. 2. Review the content of the activity, paying particular attention to those areas that reflect the objectives. 3. Complete the Test Questions. Missed questions will offer the opportunity to re- read the question and answer choices. You may also revisit relevant content. 4. For additional information on an issue or topic, consult the references. 5. To receive credit for this activity complete the evaluation and registration form. 6. A certificate of completion will be available for you to print at the conclusion.
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© 2016 All rights reserved Pfiedler Enterprises, 2170 South Parker Road, Suite 125, Denver, CO 80231 www.pfiedlerenterprises.com Phone: 720-748-6144 Fax: 720-748-6196 Overview The tibia is the most common fractured long bone in the body. These fractures, especially when open, often present with other complex injuries, and it is essential for perioperative nurses and surgical technologists to have an understanding of tibial fracture management. This course will provide information on treatment for open tibial fractures. The incidence of tibial fractures, types, and classifications of tibial fractures will be presented. Approaches to the immediate management of open tibia injuries will be outlined including: fixation options, indications, operative positioning, instrumentation, and nursing documentation will be described.
Objectives After completing this continuing education activity, the participant should be able to: 1. Describe the various types of open tibial fractures, both proximal and distal. 2. Discuss the incidence of occurrence. 3. Identify patient implications. 4. Discuss emergent external treatment fixations. 5. Describe internal treatment options. 6. Outline procedure and instrumentation for internal and external fracture fixation.
Intended Audience This continuing education activity is intended for perioperative registered nurses and surgical technologists involved with the care of orthopedic patients who want to learn more about the treatment of open tibial fractures.
CREDIT/CREDIT INFORMATION State Board Approval for Nurses Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing, Provider Number CEP14944, for 2.0 contact hours. Obtaining full credit for this offering depends upon attendance, regardless of circumstances, from beginning to end. Licensees must provide their license numbers for record keeping purposes. The certificate of course completion issued at the conclusion of this course must be retained in the participant’s records for at least four (4) years as proof of attendance.
Release and Expiration Date: This continuing education activity was planned and provided in accordance with accreditation criteria. This material was originally produced in July 2016 and can no longer be used after July 2018 without being updated; therefore, this continuing education activity expires July 2018.
3 Disclaimer Pfiedler Enterprises does not endorse or promote any commercial product that may be discussed in this activity.
Support Funds to support this activity have been provided by Smith & Nephew.
Authors/Planning Committee/Reviewer Julia A. Kneedler, RN, MS, EdD Denver, CO Program Manager/Planning Committee Pfiedler Enterprises
Judith I. Pfister, RN, BSN, MBA Denver, CO Program Manager/Planning Committee Pfiedler Enterprises
Dondra Tolerson, BS, MA Woodstock, GA Medical Writer/Author
Melinda T. Whalen, BSN, RN, CEN Denver, CO Program Manager/Reviewer Pfiedler Enterprises
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4 Dondra Tolerson, BS, MA No conflict of interest Melinda T. Whalen, BSN, RN, CEN No conflict of interest
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5 INTRODUCTION The lower leg is made up of the tibia and fibula bones. The tibia is the larger bone that supports most of the weight of the body and is an important part of the knee and ankle joints. Tibial fractures are common long-bone injuries and can fracture in a number of patterns and locations along the bone; the severity of the fracture typically is dependent upon the amount of force that caused the break. There are five main categories of fractures:1 1. Incomplete: the fracture involves only a portion of the cross-section of the bone. One side breaks; the other usually just bends. 2. Complete: the fracture line involves the entire cross-section of the bone and fragments are usually displaced. 3. Closed: the fracture does not extend through the skin. 4. Open: bone fragments extend through the muscle and skin. 5. Pathological: the fracture occurs in diseased bone (e.g., cancer, osteoporosis) with minimal to no trauma Reports indicate that approximately 492,000 tibial fractures occur in the United States annually;2 greater than 70,000 hospitalizations, 800,000 office visits, and 500,000 hospital days have been attributed to tibial fractures.3 The skin and subcutaneous tissue are thin over the surface of the bone, therefore tibial fractures are frequently open or compound, which means the broken bone protrudes through the skin or a wound penetrates down to the broken bone.4 Roughly 25% of tibial shaft fractures are open and represent the most common open fracture. Open fractures can lead to infection in both the wound and the bone. Both the broken bone(s) and any soft-tissue injuries must be treated together and in many cases require surgery to restore strength, motion, and stability to the leg. This open fractures are particularly serious because, once the skin is broken, infection can occur in both the wound and the bone. Urgent treatment is required to prevent infection. Antibiotics, surgical debridement, and internal fixation improve outcomes for open fractures; however, the underlying principles for treating open fractures-- primary asepsis, adequate debridement, immobilization, and protection of wounds against disturbance and reinfection--have not changed in almost a century.
OPEN TIBIAL FRACTURES: TYPES AND CAUSES Fractures of the tibia can be classified as: proximal tibia, tibial shaft, distal tibia, and pilon fractures. The proximal tibia is the upper one-fourth of the tibia and includes epiphysis and metaphysis. These fractures occur in the upper portion of the bone where it widens (and forms part of the knee joint) and may or may not involve the knee.
6 Figure 1. Proximal Tibia Fracture
The tibial shaft is the mid-section of the tibia and entirely diaphysis. The most common open tibial fracture involves the tibial shaft and occurs along the length of the shinbone, below the knee and above the ankle. In general, it takes a great deal of force to break a long bone, and other injuries often occur with these types of fractures.4
Figure 2. Tibial Shaft Fracture
The lower one-fourth of the tibia is the distal tibia. If a fracture occurs at the bottom of the tibia and involves the weight-bearing surface of the ankle joint, it is called a distal tibia fracture.
7 Figure 3. Distal Tibia Fracture
Fractures of the distal articular surface of the tibia are called plafond fractures or pilon fractures. A pilon fracture is a break that occurs at the bottom of the tibia and involves the weight-bearing surface of the ankle joint. With pilon fractures, the bone is often shattered into several pieces due to the high-energy impact that caused the injury.
Figure 4. Pilon Fracture
When injuries to the tibia result in open fractures, other bones (fibula) and soft tissues (skin, muscle, nerves, blood vessels, and ligaments) may be injured at the time of the fracture. In most cases, surgery is needed to restore the damaged bone to its normal position.
Fracture Patterns5 In certain types of tibial fractures, the bone breaks but its pieces still line up correctly. In other types of fractures, the injury moves the bone fragments out of alignment. The most common types of tibial shaft fractures include:1
8 Transverse fracture. In this type of fracture, the break is a straight horizontal line across the femoral shaft.
Oblique fracture. This type of fracture has an angled line across the shaft.
Spiral fracture. The fracture line encircles the shaft like the stripes on a candy cane. A twisting force to the lower leg causes this type of fracture.
Comminuted fracture. In this type of fracture, the bone has broken into three or more pieces. In most cases, the number of bone fragments directly correlates with the amount of force required to break the bone, thus the higher the number of bone fragments, the greater the amount of force involved in causing the fracture.
Figure 6. Types of Fractures
Open fracture. If a bone breaks in such a way that bone fragments pierce through the skin or a wound penetrates down to the broken bone, the fracture is called an open or compound fracture. Open fractures often involve more extensive damage to the surrounding muscles, tendons, and ligaments. They have a higher risk for complications — especially infections— and take a longer time to heal.
Figure 7. Open fracture of tibia
Causes Open fractures tend to be caused by more severe trauma than closed fractures. They typically occur due to mechanisms involving high-energy injuries (eg, motor vehicle
9 collisions [MVCs], skiing accidents, and high-energy falls), or penetrating injuries (eg, gunshot wounds).6 However, fractures due to low-energy, indirect, torsional trauma can penetrate the skin from within, particularly in locations where the bone lies close to the skin and is not protected by a muscular envelope such as the tibia. For pediatric patients with open tibial fractures, a high index of suspicion for child abuse should be maintained especially if there is a history of multiple long bone fractures or fractures in non-ambulatory children.7
When an individual presents with an open tibial fracture, maintaining a functional limb is the goal. The surgeon endeavors to save the patient’s limb and life by realigning the fracture and preventing infection. Exposure of bone and deep tissue to the environment leads to increased risk of infection, wound complications, and non-union of the fracture.8, 9, 10 CLASSIFICATION SYSTEMS A classification system is a tool utilized to assist physicians and nurses with methodically and accurately describing similar injuries or conditions.11 Open fractures often involve much more damage to the surrounding muscles, tendons, and ligaments; they have a higher risk for complications and take longer to heal.5 The variable outcomes among different patterns and severities of open fractures prompted the development of classification systems11 based on the extent of the associated soft tissue injuries and serve as a guide for treatment, estimated prognosis, communication, and research. The classification systems offer decision support to surgeons for making clinical judgments on the most appropriate management of fractures and aims to prevent treatment errors that may lead to complications.
Gustilo-Anderson Classification The Gustilo-Anderson classification for open fractures is most commonly used.11Although it has limitations, the Gustilo-Anderson classification system has proven to be a good prognostic indicator and originated as a refinement of the Veliskakis grading system.12, 13 Through their research on infection prevention in open long bone fractures, Gustilo et al outlined the general principles of management of open fractures and helped define the current methodology for treating open fractures. Decades of research correlating the Gustilo-Anderson grade with infection risk have helped refine surgical protocols, change antibiotic recommendations, and determine appropriate timing for interventions.14, 15 The system categorizes open injuries into three primary categories based on wound size, level of contamination, and osseous injury; the higher grades of injury are commonly associated with infection and nonunion (Table 1).
10 Table 1. Gustilo-Anderson Classification System13, 16, 17
Gustilo and Anderson initially recommended surgical debridement and irrigation for all open fractures, with primary closure for Types I and II fractures, and secondary closure for Type III fractures. Gustilo et al later modified these recommendations to include fixation devices for Type III fractures that have more extensive soft tissue injuries16
Tscherne Classification In the 1980’s Oestern and Tscherne18 initially developed a classification for closed limb fractures. Later, they developed a grading system for open fractures and soft-tissue injuries. The Tscherne classification system includes soft tissue damage, fracture severity, contamination, and amputation as assessment parameters for open fractures.
11 Table 2. Tscherne Classification of Open Soft-Tissue Injuries18, 19
SEVERITY SOFT FRACTURE ADDITIONAL GRADE CONTAMINATION TISSUE DAMAGE SEVERITY CRITERIA
O-1 Mild Mild to moderate None to mild O-2 Moderate Mild to severe Moderate O-3 Severe Mild to severe Severe Impending compartment syndrome O-4 Severe Mild to severe Mild to severe Amputation, subtotal or total; Compartment syndrome
Within the orthopedic industry it is felt that the aforementioned classifications have poor interobserver agreement;20 however, they do serve as good general guides. Results of contemporary research indicate that these classification systems may not be sufficient in meeting modern objectives. As a result, a more robust grading system has been made available in the AO Soft Tissue grading system.21
AO Classification Systems The AO classification system was developed by the AO Foundation, which originated from the research study group, Arbeitsgemeinschaft für Osteosynthesefragenis. The AO Foundation specializes in research and treatment of trauma and disorders of the musculoskeletal system and is guided by an extensive network of international surgeons, operating room personnel, and scientists.22, 23
The system identifies injuries to the different anatomical structures: skin, muscles and tendons, and neurovascular system (Tables 3 - 5). The injuries to these anatomical structures are then graded based on specific criteria as shown (Tables 3 - 5). Fractures are separately classified using a detailed and comprehensive set of criteria according to the AO classification of fractures.1 The AO classification of long bone fractures is descriptive and grounded in identifying the pattern of the primary fracture and counting the number of fragments.24 When used in a large database for research, its alphanumeric classification allows for precise comparison of injury types; however, its intricacy renders it somewhat impractical for daily clinical practice and there is no conclusive evidence that this classification is superiorly helpful in clinical decision-making.25 The classification system is illustrated in a 10-page publication from AO Trauma and can be found at: https://www.aofoundation.org/Documents/mueller_ao_class.pdf.
12 Table 3. AO Soft-tissue Classification: Open Skin Lesions.21 Table 3. AO Soft-tissue Classification: Open Skin Lesions.21 TableGRADE 3. AO Soft-tissueCRITERIA Classification: Open Skin Lesions.21 GRADE CRITERIA IO 1 Skin breakage from inside out Table 3. AO Soft-tissue Classification: Open Skin Lesions.21 IO 21 Skin breakage from outinsideside out in <5 cm, contused edges GRADE CRITERIA IO 23 Skin breakage from outsideoutside in <5>5cm, cm, increased contused contusion,edges devitalized edges IO 43 SkinConsiderable, breakage full-thicknessfrom outside incontusion, >5cm, increased abrasion, contusion, extensive devitalizedopen degloving, edges skin loss IO 15 SkinExtensive breakage degloving from inside out IO 42 Considerable,Skin breakage full-thicknessfrom outside incontusion, <5 cm, contused abrasion, edges extensive open degloving, skin loss IO 35 SkinExtensive breakage degloving from outside in >5cm, increased contusion, devitalized edges TableIOTable 4 4. 4. AO AO Soft-tissueConsiderable, Cla ssification:Classification: full-thickness Muscles andMuscles contusion, Tendons. and abrasion,21 Tendons. extensive21 open degloving, skin loss IO 5 Extensive degloving TableGRADE 4. AO Soft-tissueCRITERIA Classification: Muscles and Tendons.21 GRADE CRITERIA MT 1 No muscle injury Table 4. AO Soft-tissue Classification: Muscles and Tendons.21 MT 21 CircumscribedNo muscle injury muscle injury, one compartment only GRADE CRITERIA MT 32 CircumscribedConsiderable muscle muscle inju injury,ry, two one compartments compartment only MT 43 MuscleConsiderable defect, muscle tendon inju laceration,ry, two compartments extensive muscle contusion MT 51 CompartmentNo muscle injury syndrome/crush syndrome with wide injury zone MT 42 CircumscribedMuscle defect, muscletendon laceration,injury, one extensivecompartment muscle only contusion MT 5 Compartment syndrome/crush syndrome with wide injury zone TableMT 3 5. AO Soft-tissueConsiderable Classification: muscle Neurovascular injury, two System. compartments21 MT 4 Muscle defect, tendon laceration, extensive muscle contusion TableGRADE 5. AO Soft-tissueCRITERIA Classification: Neurovascular System.21 MT 5 Compartment syndrome/crush syndrome with wide injury zone TableGRADE 5. AO Soft-tissueCRITERIA Classification: Neurovascular System.21 NV 1 No neuromuscular injury Table 5. AO Soft-tissue Classification: Neurovascular System.21 NV 12 NoIsolated neuromuscular nerve injury injury NVGRADE 32 IsolatedLocalizedCRITERIA nerve vascular injury injury NV 34 LocalizedExtensive vascularsegmental injury vascular injury NV 514 ExtensiveCombineNo neuromuscular of segmental neurovascular injury vascular injury, injury including total or total amputation NV 52 CombineIsolated nerve of neurovascular injury injury, including total or total amputation ForNV 3consistency, the contentLocalized that vascular follows willinjury refer to the Gustilo-Anderson classification system, as it is the NV 4 Extensive segmental vascular injury Formost consistency, widely referenced the content classification that follows syste willm referin published to the Gustilo-Anderson studies on fractures. classification system, as it is the NV 5 Combine of neurovascular injury, including total or total amputation most widely referenced classification system in published studies on fractures. 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As would becontamination, expected, these and injuriessecondary can in causejuries significantfrom the broken pain, decreasedbone.26 ability to bear weight on the leg, IndividualsFracturesdeformity, and“tenting”that Injuries: have or protrusion sustainedThe bone(s) of openthe can bone, be tibial broken and fractures occasionally vertically, typically horizontally, loss of feelingenter and/or inthe lower in healthcare several leg and pieces. foot. 4 The Open systempiecesfractures throughof varythe fractured significantly the emergency bone in canseverity; be departmentvery however sharp andthese (ED). tear fractures through Initial have caresoft atissue insignificant the from emergency within.risk for When infection, setting the bone is Fractures and Injuries: The bone(s) can be broken vertically, 26horizontally, and/or in several pieces. The dependentshatterspiecescontamination, of there the upon fractured may and the besecondary type abone multiple andcan in juries fragments,beseverity very from sharp ofthewhic injuries: andbrokenh may tear bone.lacerate through life-saving surroundingsoft tissue measures from neurovascular within. must When be and the soft bonefirst priorityshatterstissues. of Patients therecare may and with be limb-salvaging Type a multiple III fractures fragments, careare at whicsecond. significanth may Aslacerate risk would for life-threateningsurrounding be expected, neurovascular hemorrhage these injuries and from soft can tissues.Fractures Patients and Injuries: with Type The IIIbone(s) fractures can are be atbroken significant vertically, risk forhorizontally, life-threatening and/or hemorrhage in several pieces. from The causepieces significant of the fractured pain, bone decreased can be very ability sharp toand bear tear throughweight softon thetissue leg, from deformity within. When, “tenting” the bone or shattersprotrusion there of may the be bone, a multiple and fragments, occasionally whic hloss may oflacerate feeling surrounding in lower neurovascularleg and foot. and4 Open soft fracturestissues. Patientsvary significantly with Type III frinactures severity; are athowever significant these risk for fractures life-threatening have hemorrhage a significant from risk for infection, contamination, and secondary injuries from the broken bone.26 12 Fractures and Injuries: The bone(s) can be broken vertically, horizontally, and/or in 12 several pieces. The pieces of the fractured bone can be very sharp and tear through soft tissue from within. When the bone shatters there may be a multiple fragments, which 12
13 may lacerate surrounding neurovascular and soft tissues. Patients with Type III fractures are at significant risk for life-threatening hemorrhage from associated vascular injuries. Not all severely damaged limbs can be salvaged and amputation may be required.
Contamination: The environment the fracture is exposed to affects the degree of contamination. Dirt, broken glass, or fabric can be driven into a wound. Due to the contaminated nature of Type III open fractures, initial treatment is often external fixation, although some surgeons advocate use of intramedullary nails.
Infection: Open fractures are associated with a significantly higher rate of infection than closed fractures. However, the degree of infection depends on many variables. In general, the more extensive the damage to the bone, soft tissues, nerves, and blood vessels, the higher the corresponding risk for infection. A bone infection can be difficult to eliminate and may necessitate long-term antibiotic treatment and multiple surgical procedures. In some severe cases, amputation of the infected limb is the only way to effectively treat the infection.
Wound Healing: Normally, as a wound heals, new skin cells are formed and added to the edges and base of the wound and this process continues until the wound is closed. Wounds associated with open tibial fractures, do not heal normally and the wounds fail to close. Clinical research into non-healing wounds has highlighted several barriers to healing that include infection, non-viable or dead tissue, and an imbalance of moisture levels in the wound. Use of evidence-based treatment protocols help promote wound healing. An effective wound measurement system should be utilized to track the progress of wound closure and the effectiveness of prescribed treatment.
Compartment Syndrome: Acute compartment syndrome may develop in an open tibial fracture and is a medical emergency. The condition can be extremely painful for the patient and occurs when the tissue pressure within the muscles exceeds the tissue perfusion pressures. This results in lack of oxygenated blood to the tissue and accumulation of waste products in the tissue resulting in ischemia to the muscles and nerves. Peripheral sensation decreases secondary to nerve irritation and damage, and late manifestations include: absence of distal pulses, paresthesia and hypothesia, and extremity paralysis. If the elevated pressure in the compartment is not relieved quickly by fasciotomy, permanent disability due to loss of function of the limb may result. Compartment syndrome should be diagnosed based on clinical findings such as: 27, 28 • Pain and increased pain with passive toe stretch • Neurological changes (eg, paresthesia, hypothesia, paralysis) • Swelling of the muscle compartments • Compartment pressure measurement with intra-compartment pressure monitoring device
Compartment syndrome is more common in closed tibial fractures; however, it can also be associated with open fractures so it cannot be assumed that the open wound
14 decompresses the compartment. Blick et al from the Adam Cowley Shock Trauma Centre reported a 9% rate of compartment syndrome in patients with open tibial fractures.29 Recent studies show that in diaphyseal tibial fractures, the rate of associated compartment syndrome may be as high as 11.5 %.27 In particular, pediatric patients have a significantly increased risk of developing compartment syndrome with open fractures.27, 30, 31 In some cases of open fractures, blood clot formation can impede effective decompression and the muscle or fascial layers can close like trap door causing the pressure to increase in the muscle compartment.
MANAGEMENT OF OPEN TIBIAL FRACTURES The majority of open fractures require urgent irrigation and debridement. Antibiotics are essential in preventing infection. Timely wound therapy and closure after all necrotic tissue has been debrided also decreases complications. Lastly, fixation of the patient’s broken bone to restore it to normal alignment must be performed. This section will discuss the most common principles in managing fractures.
Radiographic Evaluation Radiographic evaluation (x-rays) of tibial fractures allow for assessment of displacement, translation, shortening and angulation. As a standard, anterior-posterior and lateral radiographs of the injured bone along with x-rays of the adjacent knee and ankle joint are recommended. Computer tomography (CT) scans of the tibial plateau or ankle may be required in order to identify and depict fracture lines extending into the tibial plafond as well as associated non-contiguous ankle injuries.32, 33
Antibiotic Therapy Open fractures are associated with a significantly higher rate of infection and preventing infection is the focus of early treatment. Many variables impact the degree of infection such as the amount of damage is to the bone, soft tissues, nerves, and blood vessels. The environment the fracture is exposed to – shards of glass, dirt, and fabric – also affects the degree of contamination.34 Experts, such as the Surgical Infection Society, recommend that antibiotics be started as soon as possible in open fractures.35, 36 There is also evidence that antibiotic regimens as short as one day are as effective as regimens of three to five days.37 Osteomyelitis, or infection of the bone, can be difficult to treat and often results in long-term antibiotic therapy and multiple surgeries. In severe cases, amputating the infected limb is the only way to eliminate the infection.
A Canadian study published in 2014 evaluated the association between time to surgery, antibiotic administration, Gustilo grade, fracture location, and development of deep infection in open fractures. There were a total of 736 participants with tibia and fibula fractures being the most common. The overall infection rate among participants was 6% with a median time to surgery of nine hours for patients without infection and seven hours for those with infection. The significant finding in the study was infection after open fracture was associated with increasing Gustilo grade, but not time to surgery or antibiotics.38
15 An observational study published in 2015 analyzed the association between antibiotic timing and deep infection of type III open tibia fractures. Outcomes revealed that the time from injury to antibiotic administration and to wound coverage independently predict infection of these fractures. Predictors for infection were greater than five days from injury to wound coverage and more than 66 minutes from time of injury to administer antibiotics to patients. Immediate antibiotics and wound coverage within less than five days of the initial injury limited infection rates to 2.8%. However, with a delay in one of the factors--antibiotic administration or wound coverage—infection rates were 10.2% and the infection rate rose to 40.5% in cases with a delay in both factors.39
Debridement and Irrigation Patients should be scheduled for debridement and irrigation promptly as to not increase the risk of infection.40 A recent study explored the relationship between delayed surgical debridement and deep infection and found a statistically significant increase in the rate of deep infection per hour of delay in high grade and substantially contaminated open fractures.41
Tissue Viability Wound assessment begins with evaluating tissue viability. Viable tissue is granulating (red) or epithelializing (pink), while non-viable tissue may be necrotic (black) or sloughy (yellow). Slough (Figure 1) can be soft or firm and is comprised of fibrinous material, pus, and proteins. Necrotic tissue (Figure 2) presents as a black or dark brown scab that may cover all or part of the wound. Non-viable tissue creates an environment that is conducive to infection and bacterial growth.
Figure 8. Representation of Sloughy Figure 9. Representation of Necrotic Tissue42 Tissue42
Necrotic and sloughy tissue can be removed from the wound through debridement after vascular supply is established. Wound debridement can be performed surgically or by manual methods, such as irrigating with a solution or autolytic debridement where antimicrobial or hydrogel dressings are used to separate dead tissue from healthy tissue.
During debridement, all dirt, foreign bodies, and unhealthy, contaminated skin, muscle, and other soft tissue are removed. The bone is also cleaned and any unattached pieces of bone are removed. Surgical debridement is performed in a methodical manner starting with each layer of the skin around the circumference of the wound and down to the level of the bone. Necrotic tissue is removed and only viable tissue is salvaged. The exception
16 is skin, where no skin is removed unless obviously necrotic. The quality of the muscle tissue is also evaluated for color, consistency, circulation, and contractility. The bone ends are inspected, the fractured edges are curetted to remove fibrous tissue and debris, and all dirt and non-viable bone are removed.
Infection and Inflammation43, 44 Wound healing is delayed when harmful bacteria in the wound cause infection or worsen inflammation. If untreated, life-threatening, systemic infection can result. Localized areas of infection can be removed from a wound by debridement or by utilizing antiseptic or antimicrobial products to reduce bacterial counts and accelerate healing time. Causative agents of infected wounds can be confirmed with a wound culture and typically display the characteristics indicated below: • Redness • Inflammation • Exudate • Increased odor • Increased tenderness • Irregular tissue that bleeds easily
Moisture Management As part of the healing process, wounds release fluid called exudate which is mainly comprised of water but also contains electrolytes, proteins, and various types of cells. Although the skin layers of moist wounds heal faster and scar less than dry wounds, too much (maceration) or too little (desiccation) exudate can interfere with wound healing. Therefore, it is important to properly assess exudate levels and select a suitable dressing that will either remove excess fluid or add hydration (i.e., hydrogels) to the wound in order to improve wound healing.
Wound Coverage Open fractures accompanied by complex wounds where substantial soft tissue has been lost (Type IIIB) can create a wound that is too large to be closed. This may be a result of the injury itself or from delayed wound necrosis. In these complex wounds, temporary coverage of the fracture must be established to decrease the risk of infection and promote healing. Adequate debridement and close monitoring of the soft-tissue defect are necessary so that definitive soft-tissue coverage can be achieved within the first one to two weeks.45
The extent of damage to the soft tissue determines the method of wound coverage. The surgeon may elect to conduct a local flap procedure where the muscle tissue from the involved limb is rotated to cover the fracture. A skin graft is then performed, which involves removing skin from another area of the body, and is placed over the exposed muscle. With a free flap procedure, a complete transfer of full-thickness skin and muscle is taken from a donor site such as the patient’s back, opposite leg, or abdomen. This
17 procedure usually requires the assistance of a microvascular surgeon to ensure the blood vessels connect and circulation is established. It is recommended that the time to flap coverage not exceed seven days because the odds of flap contamination and other flap-related adverse outcomes increase significantly beyond that time.46
For complex open wounds, many types of dressings can be used. Sometimes the wound is sealed with a semipermeable material until the soft-tissue closure procedure can be completed. Antibiotic beads are often placed into the wound bed before sealing to provide high concentrations of antibiotics directly to the site of the injury. Vacuum assisted closures (VACs) are negative pressure wound dressings that can provide temporary coverage of an open wound. These dressings help reduce bacterial counts in wounds, remove excess fluid and exudate, help diminish wounds, and promote growth of granulation tissue. VACs may allow definitive closure with the subsequent use of split- thickness skin grafts, instead of more complex flap procedures. Debate continues over timing and type of definitive wound coverage. Ideally, VAC usage should not extend beyond seven days to avoid higher infection rates and amputation risks.47
Fracture Stabilization and Fixation Devices It is essential to stabilize the broken bone(s) as soon as possible to prevent further soft tissue damage, reduce bleeding, and help relieve pain. There are multiple external and internal fixation options for surgical bone stabilization. Average time to union for severe open tibial fractures can be up to a year, and delay or failure of bone healing is a common risk with open tibial fractures. Failure to unite may require additional surgical procedures, such as bone grafting and/or revised fixation. Stimulation of bone healing remains a developing field.48
Internal Treatment Options49, 50 For less severe open tibial fractures with minimal contamination, the fracture can be stabilized with internal fixation after the wound has been thoroughly debrided.The stabilization procedure is called an Open Reduction Internal Fixation (ORIF) and prevents the bones from healing abnormally. During the procedure, bone fragments are first reduced (repositioned) into proper alignment. Appropriate alignment must be maintained throughout internal fixation placement. Special screws or plates are placed on the outer surface of the bone for alignment. Insertion of metal rods through the marrow space in the center of the bone can also hold bone fragments together. Most patients who have an ORIF do very well and complications are rare. The risk of complication varies according to age, anatomy of the fracture, and other medical conditions. For example, smokers and individuals with diabetes or low bone mass may be at greater risk of complications.
Intramedullary Nails Intramedullary nails (IM) are specially designed titanium alloy rods used to treat fractures of the long bones by inserting them into the medullary cavity of a bone. They are solid or hollow (cannulated), come in a variety of sizes, and have locking screw holes close to both ends. Contemporary IM nails permit placement of locking screws through bone
18 Internal Treatment Options49, 50 For less severe open tibial fractures with minimal contamination, the fracture can be stabilized with internal fixation after the wound has been thoroughly debrided. The stabilization procedure is called an Open Reduction Internal Fixation (ORIF) and prevents the bones from healing abnormally. During the procedure, bone fragments are first reduced (repositioned) into proper alignment. Appropriate alignment must be maintained throughout internal fixation placement. Special screws or plates are placed on the outer surface of the bone for alignment. Insertion of metal rods through the marrow space in the center of the bone can also hold bone fragments together. Most patients who have an ORIF do very well and complications are rare. The risk of complication varies according to age, anatomy of the fracture, and other medical conditions.Internal TreatmentFor example, Options smokers49, 50 and individuals with diabetes or low bone mass may be at greater risk of For less severe open tibial fractures with minimal contamination, the fracture can be stabilized with internal complications.fixation after the wound has been thoroughly debrided. The stabilization procedure is called an Open Reduction Internal Fixation (ORIF) and prevents the bones from healing abnormally. During the procedure, Intramedullarybone fragments Nails are first reduced (repositioned) into proper alignment. Appropriate alignment must be Intramedullarymaintained throughout nails (IM) internal are fixationspecially placement. designed Specia titaniuml screws or alloy plates rods are placed used on to the treat outer fractures surface of the long bones of the bone for alignment. Insertion of metal rods through the marrow space in the center of the bone can by insertingalso hold bonethem fragments into the together. medullary Most patientscavity whoof a have bone. an ORIF They do are very solid well and or complicationshollow (cannulated), are come in a varietyrare. of The sizes, risk of and complication have locking varies according screw toholes age, anatomyclose to of boththe fracture, ends. and Contemporary other medical IM nails permit placement of lockingconditions. screws For example, through smokers bone and and individuals nail to withimprove diabetes fixati or lowon bone both mass proximally may be at andgreater distally, risk of to allow secure complications. fixation, and to control length, rotation and alignment. They are suitable for the mid diaphysis; however, newerIntramedullary nailand designs nail toNails improve and consideration fixation both proximally of technique and distally, has extendedto allow secure the procedurefixation, and toto include treatment of fracturesIntramedullary in the proximalnails (IM) are and specially distal designed third of titanium the tibia. alloy rodsThe used nails to alsotreat fractures provide of suitable the long bones biomechanical fracture by insertingcontrol them length, into rotationthe medullary and alignment. cavity of a bone.They areThey suitable are solid for or the hollow mid (cannulated), diaphysis; however, come in a stabilizationvarietynewer of sizes, and nail andacts designs have as lockingaand weight-sharing consideration screw holes closeof devicetechnique to both o ftenends. has extended leadingContemporary tothe early procedure IM nails postoperative permit to include placement mobilization. An advantageof lockingtreatment of screws the of IMthrough fractures nails bone is in that andthe nailproximalthey to improverequire and distal fixati minimalon third both of surgicalproximally the tibia. dissectionandThe distally, nails also to with allow provide appropriate secure preservation of bloodfixation, supplysuitable and to to biomechanicalthecontrol fracture. length, rotation 51fracture Reamers and stabilization alignmen can t.also andThey beacts are used suitableas a weight-sharingwith for thethe mid IM diaphysis; nail device to often enlargehowever, the medullary canal for largernewer diameterleading nail designs to nails early and and postoperative consideration produce ofmobilization. no technique differences has An extended advantage in he alingthe ofprocedure the rate, IM nailssecondary to include is that treatment they surgery, of implant failure rate, fractures in the proximal and distal third of the tibia. The nails also provide suitable biomechanical fracture compartmentrequire syndrom minimal surgicale, or infection. dissection52 with appropriate preservation of blood supply to the stabilizationfracture. and51 actsReamers as a weight-sharing can also be used device with often the leading IM nail to to early enlarge postoperative the medullary mobilization. canal An advantagefor larger of the diameter IM nails isnails that andthey produce require minimal no differences surgical dissectionin healing with rate, appropriate secondary preservation surgery, of blood supply to the fracture.51 Reamers can also be used with the IM nail to enlarge the medullary canal for Figure 10. Examples of IM Nails 52 Figure 11. Example of IM Nails largerimplant diameter failure nails andrate, produce compartment no differences syndrome, in he alingor infection. rate, secondary surgery, implant failure rate, compartment syndrome, or infection.52 Figure 10. Examples of IM Nails Figure 11. Example of IM Nails Figure 10. Examples of IM Nails Figure 11. Example of IM Nails
The Thetechnique techniqueThe technique for for insertion for insertion of IMof nailsIM of nails IMbegins nails begins with begins appli with withcation appliapplication of suctioncation toof theofsuction suctionentry totool the to entry assistthe entry in blood tool to assist in blood evacuationevacuationtool andto and assist minimize minimize in blood aerosolizatio aerosolizatio evacuationn of and blood.n minimizeof Theblood. reamer aerosolization The is insertedreamer ofover isblood. theinserted guide The reamerwire over and theis into guide the wire and into the proximal portion of the tibia. Once it is confirmed that the reamer has advanced to the medullary canal of proximalinserted portion over of the the tibia.guide wireOnce and it intois confirmed the proximal that portion the of reamer the tibia. has Once advanced it is confirmed to the medullary canal of the tibia,that it theis removed reamer andhas theadvanced fracture tois reduced.the medullary The appropriate canal of the size tibia, nails it areis removed selected andand positioned the the tibia,and locked it is intoremoved place. Final and position the fracture of the fracture is reduced. is confirmed The via appropriate x-ray. size nails are selected and positioned fracture is reduced. The appropriate size nails are selected and positioned and locked and locked into place. Final position of the fracture is confirmed via x-ray. Despiteinto its place. popularity, Final IM position nail fixa oftion the of fracturedisplaced is tibial confirmed shaft fr acturesvia x-ray remains. challenging and is associated with multiple potential pitfalls. Union rates vary among different studies. According to Despite itsDespite popularity, its popularity, IM nail IM nailfixa fixationtion of displacedof displaced tibial tibial shaft fractures fractures remains remains challenging and is associatedchallenging with multiple and is associatedpotential withpitfalls. multiple Union potential rates pitfalls. vary amongUnion rates different vary among studies. According to different studies. According to contemporary studies, union rates are 90% or higher with contemporary implants and appropriate surgical techniques.53, 54, 55 Tibial shaft fractures 17 that fail to heal following IM nail fixation typically respond well to exchange reamed nailing procedures.56 IM nails yield excellent results for Type I open fractures. In Type II and Type IIIB fractures they yield an average time to union of 24 to 27 weeks and a deep infection rate of 3.5%. Complications increase with Type IIIB fractures with an average 17 time to union of 50 weeks and infection rate of 23%.57
It has been documented that patients have long-term, functional deficits following repair of tibial shaft fractures with IM nail fixation. Outcome evaluations at one year post-surgical repair demonstrated that as many as 44 % of patients continued to have functional limitations with regard to their injured leg58 and as many as 47 % of patients reported work-related disability.59 Additional follow-up studies indicated that nearly 20%
19 of patients do not return to their previous occupation at two years post-intramedullary nail fixation 30 % do not return to their previous level of recreation.60 A review of patients 14 years post- procedure found that 73.2 % of patients complained moderate knee pain and 33.9 % voiced concerns with swelling. The physical examination revealed decreased range of motion (ROM) of the ankle joint in 42.4 % of patients while 93.9 % of patients demonstrated full range of motion of the knee joint. X-rays of the knee and ankle showed osteoarthritis in 35.4 % of patients although misalignment was not present in the films.61
Plates and Screws The primary indication for the use of plates and screws is a fractured tibia involving the knee or ankle, and they are also utilized to treat malunions. A variety of locking and conventional tibial plates are available. Locking plates do not rely on plate-to-bone compression or friction forces to obtain stability which preserves the local blood supply to the bone. In theory, this allows for more rapid bone healing, decreased incidence of delayed or non-union, evades stress shielding below the plate, and prevents bone necrosis and infection.62, 63, 64
Distal Locking Plates: Anterior and posterior distal tibia locking plates are scalloped and permit lag screw placement without compromising plate position, and the contour of the plates facilitate an anterior approach to distal tibia fractures in the coronal plane. The plates are left and right-side specific and has consistent 1.5mm thickness. Medial distal tibia locking plates are smooth and feature a tabless distal tip which minimizes soft tissue irritation over the medial malleolus. These plates are also right and left-specific and the shape enables a medial approach to distal tibia fractures in the sagittal plane.
Figure 13. Distal Locking Plates and Screws
Proximal Locking Plates: Proximal tibial locking plates offer the advantage of locked plating with the flexibility and benefits of traditional plating.These plates offer a construct that resists angular collapse while simultaneously acting as an effective aid to fracture
20 reduction. The pre-contour of this plate provides an excellent fit against the surface of the bone and the scalloped proximal end allow easy placement of lag screws outside the plate for fixation of articular fractures.
Figure 12. Proximal Locking Plate with Screw
The length of locking plates should be selected using a proximal or distal template prior to surgery--longer plates allow for better mechanical advantage over short plates. During the procedure, the fracture is reduced and then the locking screws placed. The plate is inserted and positioned to the lateral proximal tibia.
External Treatment Options Once used primarily as a last resort method of fracture fixation, external fixation has evolved into a conventional technique.65 The purpose of the external fixation is to serve as a bridge between fracture reduction and insertion of an internal fixator such as an intramedullary nail.66, 67 External fixation involves the use of percutaneously placed pins and/or wires secured to external frames to provide support to a fractured limb. They are fixed angle devices and create the ability to provide superior fixation in compromised bones. Indications for external fixation include:65 • Severe open fractures • Highly comminuted closed fractures • Arthrodesis • Infected joints • Infected non-unions • Fracture stabilization to protect arterial or nerve anastomosis • Major alignment and length deficits
More severe open tibial fractures are often initially stabilized by external fixation.The external fixator is a frame applied outside of the leg that holds the leg and ankle in proper position with pins and/or wires until an internal fixation procedure can be tolerated. External fixators can be rapidly applied (especially in polytrauma cases) and allow for regular inspection of the soft-tissue of the leg and ankle without frequent splint changes.68
21 The device also allows postoperative adjustability, which is a distinction from internal plates and IM nails. When limb lengthening or deformity correction is indicated, gradual manipulation is possible with frame adjustment.65 External fixators can be applied using either a modular or uniplanar frame technique. While modular frames are more versatile and the configuration can be individualized to suit the specific application, they are less rigid than uniplanar fixators due to multiple connections.69
Single Plane External Fixators: This type of external fixator can be used for temporary or definitive stabilization of pilon fractures of the tibia and as an adjunct to internal fixation for treatment of tibial fractures. The variety of clamps and bar lengths permits versatility in assembling the frame. Cartridge clamp design is positive locking, allowing no passive release of pins or bars. The clamps also provide extra flexibility and the ability to angle pins to 25 degrees. The ball joint component of the clamps allows linear reduction of fractures, with true translation of long bone fragment ends.
Figure 14. Single Plane External Fixator
Unilateral External Fixators: This frame is indicated for fracture fixation post-traumatic joint contracture, which may result in loss of range of motion, and for fractures requiring distraction. It may also be used for limb lengthening by correction of bony or soft tissue deformity or infected fractures. This fixator is designed to provide flexibility in frame construction and ease of use. The clamps permit angulation of pins up to 50 degrees and allow for rapid application, stability, and single-point tightening. The cartridge clamp design is positive locking, and the four- and six-hole clamps offer several attachment posts to maximize construct alternatives.
Figure 15. Unilateral External Fixator
22 Circular Wire Fixators: These external fixators are used for open or closed fractures requiring distraction, are infected, or in cases of non-union. They offer a single solution for correcting the most challenging cases allows for post-operative fracture reduction and alignment correction. The circular construct permits the patient to bear weight almost immediately, thus accelerating fracture healing and increasing bone strength.70
Figure 16. Circular Wire Fixator
The most common complications with external fixation are pin track infection, increased rate of malunion and need for secondary procedures,71 nerve or vessel damage, and loosening or breakage of wires and pins.72,73 On the other hand, external fixation causes less disruption of the soft tissues, osseus blood supply, and periosteum when compared with internal plating and IM nailing techniques. External fixators are ideal for soft tissue management in cases of acute trauma with open wounds, in chronic trauma following skin grafting and flap procedures, and in patients with poor skin healing potential (ie, rheumatoid disease, diabetes, peripheral vascular disease).65 Both internal and external fixation techniques are associated with complications; however, both are equally acceptable strategies for managing tibial fractures.
Amputation: The Last Resort There are circumstances where an extremity cannot be salvaged following a severe tibial fracture. Multiple scoring methodologies have been developed to assist surgeons with the decision to salvage or amputate a limb, however, they cannot be used as the sole criterion by which an amputation decision is made. The literature is inconsistent in the support of the Mangled Extremity Severity Score (MESS) method, although it is the best-known method for predicting the odds of limb salvage.74 MESS analyzes the velocity involved in the skeletal and soft tissue injury, limb ischemia, presence and duration of shock, and the age of patient.
23 The presence of limb ischemia for longer than 6 hours, infrapopliteal vascular injury, and posterior tibial and/or common peroneal nerve neurotmesis are the strongest indications for amputation.75 A good MESS indicates that a limb should be considered salvageable; however, a poor MESS should not automatically prompt amputation. In recent years, new techniques to attempt limb salvage have been developed and surgeons should be cautious when interpreting scores and must rely on clinical judgment for decision-making.76, 77
CASE HISTORY It is also important to note that case history is important to help the surgeon determine the appropriate method of treatment and timing. Details about when, where, and how the injury occurred can be critical points of information. For example, an open tibial fracture sustained in a farming accident would likely have a high risk of infection. Prolonged entrapment in a vehicle would imply the potential for developing compartment syndrome. Most critical of all, is information on the amount and direction of the force or energy that caused the injury--the greater the force, the more serious the damage and sequelae.21
CONSIDERATIONS FOR THE PERIOPERATIVE NURSE Perioperative nurses and surgical technologists fulfill a variety of roles and functions with surgical management of open tibial fractures. As with any surgery, the priorities for the perioperative nurse caring for a patient with an open tibial fracture are safety, avoiding additional injury, preventing complications, preparing the operating room with appropriate instruments, and ensuring accurate documentation.
Patient Positioning The perioperative nurse and surgical technologist should be knowledgeable about ideal patient positioning for the surgical procedure to be accomplished in addition to intraoperative factors to consider in positioning the patient, which include the following:78, 79, 80
• Whether asleep or awake, the patient should be in a comfortable position as possible. • The operative area must be adequately exposed. • Vascular supply and nerves should not be obstructed by an awkward position or undue pressure. • There should be no interference with the patient’s respiration. • Patient safety must be observed at all times. • In case of excitement, the patient may need gentle restraint before induction.
Reduction of the tibial fracture for fixation requires careful planning, positioning, and mechanical aids. The fracture must be reduced before fixation can be accomplished. For internal fixation with IM nails, the patient should be placed supine on a radiolucent table with the uninjured leg extended. The injured leg should be placed with the knee flexed at least 90 degrees and the thigh supported with a bolster. The fracture must be reduced before the nail is placed across it. An external fixator or distractor can be used to hold the fracture reduced while the foot rests on the table surface.81
24 Figure 17. Supine Positioning for IM Nail Placement
When positioning a patient for external fixation, the patient should be in a supine position on a radiolucent table. Bolsters should be placed under the patient’s thigh and hindfoot to suspend the lower leg high enough to have maneuvering space for the rings. Leg positioning should allow anterior-posterior (AP) and lateral fluoroscopy with the image intensifier on the opposite side of the operating table. For patient positioning for internal fixation with plates and screws, gross metaphyseal alignment using manual traction or skeletal distraction should be achieved.
Figure 18. Positioning for External Fixation
A traction table may be used in some hospitals. Counter traction is provided by well– padded support under the distal femur. Figure 19. Positioning with Traction Table
Once the patient is properly positioned for the procedure, confirm all pressure points are protected and continuously observe the team during the procedure to ensure no additional pressure has been placed on the patient (ie, Mayo stands).78, 79, 82
25 Documentation The documentation in the patient’s medical record by the perioperative nurse should correspond to established guidelines for perioperative nursing care and meet professional and regulatory compliance requirements. Additionally, specific information related to the fixation devices used should be recorded.83 Documentation of the following is critical: • External Fixation o Placement of external fixation device o Manufacturer o Serial and lot number o Sterilization of external device • Internal Fixation o Type of implant o Size of implant o Manufacturer o Serial and lot numbers o Sterilization date
Instrumentation When preparing for an internal or external fixator procedure, one Mayo stand should be equipped with basic surgical instruments. A second Mayo should be prepared with appropriate instrumentation specific to the procedure (eg, wrenches, pins, clamps, drill bits, drill guides, countersink, depth gauge, taps, tap guides, screwdriver, plate contouring instruments, instruments for removing broken screws, etc). Bone clamps and forceps should be available.
Cutting, bending, or scratching the surface of components of fixator sets can reduce the strength and fatigue life of the device. As such, they should be handled with care. Any components damaged during the course of the surgery should be replaced with items from the same manufacturer. It is important for nurses and surgical technologists to be aware that components of sets from different manufacturers should never be mixed.
SUMMARY Treatment of open tibial fractures continues to be a challenge for orthopedic and trauma surgeons. The majority of open tibial fractures are contaminated; therefore, early diagnosis and treatment is critical. Aggressive debridement, prompt and appropriate antibiotic therapy, fracture stabilization, and appropriate wound closure are the principles of managment for open tibial fractures. The perioperative nurse and surgical technologist must have an awareness and understanding of how such injuries should be managed can greatly impact the patient’s overall functional outcome.
26 Clinical judgment, details regarding the mechanism of injury, and classification of the fracture and associated wound drive decision-making for individualized treatment. The circumstances under which the trauma was sustained can give insight to the level of contamination that might be present. Severity of injuries to soft tissues, bone, and neurovascular structures must be identified to determine wound coverage and fixation treatment. Associated arterial injury must be identified and treated urgently in order to salvage the limb. Once the injury has been fully assessed, an array of internal and external fixation devices (nails, screws, plates, braces) can be utilized to stabilize the fracture and aid in promoting fracture healing and restored function.
27 GLOSSARY Amputation The surgical removal of all or part of a limb or extremity such as an arm, leg, foot, hand, toe, or finger.
Aseptic Free from infection or septic material; called also sterile.
Aseptic Technique Methods by which contamination with microorganisms is prevented frequently referenced to sterile field during surgery.
Comminuted Fracture Fixation One in which the bone is splintered or crushed.
Debridement The removal of foreign material and devitalized or contaminated tissue from or adjacent to a traumatic or infected lesion until surrounding healthy tissue is exposed.
Desiccation The state of extreme dryness or the process of extreme drying.
Distal Tibia Lower one-fourth of the tibia.
Epithelializing To form a covering of epithelial cells over a wound.
Exudate Fluid that filters from the circulatory system into lesions or areas of inflammation.
Fixation The act or operation of holding, suturing, or fastening in a fixed position. The condition of being held in a fixed position.
Fracture The breaking of a part, especially a bone. A break or rupture in a bone.
Granulating Tissue New connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process.
Maceration The softening and breaking down of skin resulting from prolonged exposure to moisture.
28 Mangled extremity severity score A scoring tool developed to discriminate between salvageable (MESS) and doomed limbs in the setting of lower extremity trauma.
Necrotic Wound Dead tissue, which usually results from an inadequate local blood supply.
Open Fracture One in which there is an external wound leading to the break of the bone. Also called compound fracture.
Pilon Fracture Comminuted fracture of the inferior articular surface of the tibia and the malleoli, caused by axial compression of the ankle joint.
Proximal Tibia Upper one-fourth of the tibia.
Radiolucent Table Image guided surgical tables.
Sloughy Wound Dead yellow or black/yellow tissue, which needs to be debride
Tibial Shaft Mid-section of the tibia.
X-ray Image Intensifier Converts x-rays into visible light at higher intensity light to allow low-intensity x-rays to be converted to a conveniently bright visible light output. This effect allows the surgical team to more easily see the structure of the object being imaged.
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