Review Article Open Tibial Shaft Fractures: I. Evaluation and Initial Wound Management Abstract J. Stuart Melvin, MD Open fractures of the tibial diaphysis are often associated with se- Derek G. Dombroski, MD vere bone and soft-tissue injury. Contamination of the fracture site and devitalization of the soft-tissue envelope greatly increase the Jesse T. Torbert, MD risk of infection, nonunion, and wound complications. Management Stephen J. Kovach, MD of open tibial shaft fractures begins with a thorough patient evalua- John L. Esterhai, MD tion, including assessment of the bone and soft tissue surrounding Samir Mehta, MD the tibial injury. Classification of these injuries according to the sys- tem of Gustilo and Anderson at the time of surgical débridement is useful in guiding treatment and predicting outcomes. Administration of antibiotic prophylaxis as soon as possible after injury as well as urgent and thorough débridement, irrigation, and bony stabilization are done to minimize the risk of infection and improve outcomes. The use of antibiotic bead pouches and negative-pressure wound From the Department of Orthopaedic Surgery (Drs. Melvin, therapy has proved to be efficacious for the acute, temporary man- Dombrowski, Torbert, and Esterhai), agement of severe bone and soft-tissue defects. the Division of Plastic Surgery (Dr. Kovach), and the Orthopaedic Trauma and Fracture Service (Dr. Mehta), University of he subcutaneous location of the Pennsylvania, Philadelphia, PA. Tanteromedial tibial surface is the Epidemiology and Patient Dr. Mehta or an immediate family reason for the high proportion of di- Evaluation member is a member of a speakers’ aphyseal fractures that are open. bureau or has made paid Fractures of the tibial diaphysis are presentations on behalf of AO and These fractures are associated with the most common long bone frac- Smith & Nephew, and has received severe bone and soft-tissue injury. ture, and approximately 24% of nonincome support (such as The often high-energy nature of equipment or services), these fractures are open.1 Road traf- commercially derived honoraria, or these injuries can lead to gross con- fic accidents are the mechanism of other non–research-related funding tamination of the bone and soft tis- (such as paid travel) from Wolters sue, thereby greatly increasing the injury in more than half of all open Kluwer Health–Lippincott Williams & risk of infection, nonunion, and tibial shaft fractures, with most of Wilkins. None of the following the remainder caused by falls, sports- authors or an immediate family wound complications. 1 member has received anything of Appropriate initial management of related injuries, and direct blows. value from or owns stock in a open tibial shaft fractures can pro- The high-energy nature of most of commercial company or institution these fractures contributes to the in- related directly or indirectly to the foundly affect the overall outcome. The subject of this article: Dr. Melvin, first step in treatment is assessment of creased proportion of Gustilo type Dr. Dombroski, Dr. Torbert, the patient and the involved extremity. III (ie, high-energy open) injuries. In Dr. Kovach, and Dr. Esterhai. The goals of initial treatment are to ac- their large epidemiologic study, curately define the extent of the injury Court-Brown et al2 found that nearly J Am Acad Orthop Surg 2010;18: 10-19 and minimize the risk of infection 60% of open tibial shaft fractures through prompt administration of an- were Gustilo type III. Copyright 2010 by the American Academy of Orthopaedic Surgeons. tibiotics as well as urgent débridement Because more than half of patients and copious irrigation. with open tibial shaft fracture present 10 Journal of the American Academy of Orthopaedic Surgeons J. Stuart Melvin, MD, et al with other injuries, the initial evalua- Table 1 tion should follow the guidelines of the AO Classification of Soft-tissue Injury in Open Fractures Advanced Trauma and Life Support protocol.2,3 After initial resuscitation, Type of Injury Description a detailed history of the injury should Skin lesion (open be sought, with a focus on the mechan- fracture) ism and setting. Tetanus immunization IO 1 Skin breakage from inside out status should also be determined. Dur- IO 2 Skin breakage from outside in <5 cm, with contused edges ing physical examination of the injured IO 3 Skin breakage from outside in >5 cm, with increased contusion and devitalized edges extremity, special attention should be IO 4 Considerable, full-thickness contusion, abrasion, extensive open paid to the neurovascular examination, degloving, and skin loss status of the compartments, and the ex- IO 5 Extensive degloving tent of soft-tissue injury and contam- Muscle/tendon ination. It is important to compare MT 1 No muscle injury pulses between legs and to observe for MT 2 Circumscribed muscle injury, one compartment only capillary refill. In all patients with an MT 3 Considerable muscle injury, two compartments abnormal vascular examination, the MT 4 Muscle defect, tendon laceration, and extensive muscle contusion fracture should be reduced and the ex- MT 5 Compartment syndrome/crush syndrome with a wide zone of tremity evaluated using the ankle- injury brachial index or Doppler ultrasonog- Neurovascular raphy. A patient with an ankle-brachial NV 1 No neurovascular injury index of <0.9 should be evaluated with NV 2 Isolated nerve injury angiography. Absent pulse and clinical NV 3 Localized vascular injury ischemia constitute an emergency and NV 4 Extensive segmental vascular injury should prompt angiographic evaluation NV 5 Combined neurovascular injury, including subtotal or even total in the operating room with emergent amputation vascular surgery consultation. Tempo- rary revascularization should be per- Adapted with permission from Rüedi TP, Murphy WM: Soft-tissue grading system of the AO, in Rüedi TP, Buckley RE, Moran CG, eds: AO Principles of Fracture Management. New formed for all arterial injuries, followed York, NY, Thieme, 2000, pp 72-73. by débridement, irrigation, external fixation, fasciotomy, and definitive vas- classified according to the standard wounds (usually <1 cm in length) cular repair. Definitive fracture fixation AO/OTA classification scheme; soft- with minimal contamination. Type II is often best deferred until closure of tissue injury is categorized by the injures have a wound >1 cm in the fasciotomies. Compartment syn- damage imparted to three distinct length but do not present with exten- drome can occur in open fractures. Fol- anatomic structures: integument, sive soft-tissue damage, flaps, or lowing initial assessment and in the ab- muscle and tendon, and neurovascu- avulsions. Generally, type II open sence of vascular injury, the wound lar system. Injury to the skin is fur- fractures are low-energy injuries, but should be cleared of gross debris and ther classified as open or closed (Ta- they have more soft-tissue involve- covered with a sterile permeable dress- ble 1). This framework enables ment than do type I fractures. Type ing, after which the limb should be re- accurate classification of the fracture III injuries are high-energy wounds. aligned and immobilized in a well- and associated soft-tissue injury; These have been subclassified into padded splint. The decision to perform however, it is not commonly used in categories A, B, and C. Type IIIA in- limb salvage or to pursue primary am- the United States.4 juries have extensive soft-tissue dam- putation is made at this time. More commonly, open fractures of age secondary to high-energy trauma the tibial diaphysis are classified ac- but have adequate soft-tissue cover- Classification cording to the system of Gustilo and age. Type IIIB injures exhibit severe Anderson.5 First proposed in 1976, periosteal stripping and bone expo- The AO classification system of open this classification was modified to its sure, often associated with massive fractures offers a comprehensive current form in 19846 (Table 2). contamination. The patient with type method of classifying both bony and Type I injuries are low energy and IIIB injury may require treatment soft-tissue injuries. Bony injury is are associated with small soft-tissue with soft-tissue coverage procedures. January 2010, Vol 18, No 1 11 Open Tibial Shaft Fractures: I. Evaluation and Initial Wound Management Table 2 the tibial shaft. However, diabetes, HIV status, and smoking, in particu- Gustilo Classification of Open Fractures6 lar, have been associated with de- Type Description layed union as well as a higher rate I Clean wound <1 cm in length and increased severity of infections. II Clean wound >1 cm in length without extensive soft-tissue damage, Aderinto and Keating13 reported flaps, or avulsions deep infection in two of four open IIIA Adequate soft-tissue coverage despite extensive soft-tissue damage, tibial shaft fractures in patients with flaps, or high-energy trauma irrespective of the wound size diabetes. One patient with deep in- IIIB Inadequate soft-tissue coverage with periosteal stripping, often associ- ated with massive contamination fection required transtibial amputa- IIIC Arterial injury requiring repair tion 4 months after intramedullary nailing. Infection rates of 71% to 100% were reported in two series of open tibia fractures in HIV-positive Type IIIC fractures require vascular a series of 1,104 open fractures, Patza- patients.14,15 In addition, a trend to- repair. The full extent of the injury to kis and Wilkins8 showed the tibia to ward nonunion was demonstrated in the deep soft tissue and its viability is be more prone to infection than are HIV-positive persons with open tibia often underestimated on presenta- other long bones (10.5% [38/363] fracture compared with persons with tion and may not correlate with the versus 5.3% [39/741], respectively). such fracture who were HIV- size of the skin defect. The definitive This is likely because of the large negative. Smoking has been more ex- classification of an open fracture subcutaneous extent of the tibia, tensively evaluated as a factor in should be made in the operating which leads to greater soft-tissue wound healing.