Wheeless' Textbook of Orthopaedics
C.R. Wheeless MD
Wheeless' Textbook of Orthopaedics
- See:
- Infections of the Tibia:
- Preoperative Antibiotics;
- therapeutic doses of ancef and tobramycin for 48 hrs are appropriate;
- despite the added cost, tobramycin is more effective against Pseudomons
and has been shown to have lower incidence prevalence of nephrotoxicity;
- tetanus prophylaxis if appropriate;
- Soft Tissue Defects:
- initial wound care:
- debridement:
- consider debriding the wound with a separate set of surgical instruments / drapes
- in most cases, the surgeon will elect to loosely close any incisions made during the case but
to leave the traumatic wound open;
- leaving the wound open maximizes drainage and wound tension (which is frequently present
w/ primary closure);
- at second look debridement (at 48-36 hours), the edema will have diminished and the
wound can be closed w/ less tension;
- references:
Primary or delayed closure for open tibial fractures.
- wound dressings:
- antibiotic bead pouch:
- as noted by Keating et al 1996, bead pouches help reduce the infection rate
in open tibia fractures from 16% to 4%;
- add 2.4 gm of tobramycin per cement package, and fashion small beads attached
to a O silk suture;
- counting the beads and adding methylene blue helps ensure that none
of the beads will be left behind at removal;
- a small drain is left adjacent to the beads and the wound is sealed w/ Opsite;
- references:
Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch
Reduce the Deep Infection Rate?
JF Keating et al. J. Orthop. Trauma. 1996. Vol 10, No 5. p 298-303.
- soft tissue coverage for tibial defects
- note that if a external fixator is being considered, it should be placed in a way
so as not to interfere w/ flap application (eg a medially placed external fixator
might interfere w/ a medial gastrocnemius flap);
- references:
The Timing of Flap Coverage, Bone-Grafting, and Intramedullary
Nailing in Patients Who Have a Fracture of the Tibial Shaft With Extensive Soft-Tissue Injury.
MD Fischer et al. JBJS 73-A. 1991. p 1316-1322.
Early microsurgical reconstruction of complex trauma of the extremities.
Primary versus delayed soft tissue coverage for severe open tibial
fractures. A comparison of results.
- Management Based on Gustillo Classification:
- Grade I Frx:
- generally treated w/ intramedullary nail or a plates
- references:
- Closed intramedullary tibial nailing: its use in closed and type I open fractures.
CM Court-Brown et al. JBJS Vol 73-B. 1991. p 959-964.
- Grade II Frx:
- generally treated w/ intramedullary nail or an external fixator;
- Grade IIIb Frx:
- generally treated w/ intramedullary nail or an external fixator;
- note that if a external fixator is being considered, it should be placed in a way
so as not to interfere w/ flap application (eg a medially placed external fixator
might interfere w/ a medial gastrocnemius flap);
- Grade IIIc Frx: Treatment Options;
- generally treated w/ an external fixator;
- these fractures by definition are associated w/ vascular trauma, and have a
high prevalence of infection:
- its important to assess viability of the limb, both w/ common sense, as well
as w/ objective criteria such as the MESS;
- in many cases amputation is the best option;
- ref:
Classification of type III (severe) open fractures relative to treatment
and results.
Severe open fractures of the tibia
Severe open tibial fractures: a study protocol.
Open tibial fractures with associated vascular injuries: prognosis for
limb salvage.
- Early Bone Grafting:
- bone by history (high energy frx treated with early grafts)
- as soon as soft tissue envelope is closed and non-infected;
- some recommend bone grafting 5-7 days after debridement;
- some recommend adding powered antibiotic to the cancellous graft;
- posterolateral via virgin approach if possible;
- pure cancellous bone
- occasional indication for free fibular graft;
- ref:
Segmental tibial defects. Comparing conventional and Ilizarov methodologies.
Skeletal defects. A comparison of bone grafting and bone transport for
segmental skeletal defects.
Early prophylactic bone grafting of high-energy tibial fractures.
Management of open fractures with sterilization of large,
contaminated, extruded cortical fragments.
Posterolateral bone graft of the tibia.
The timing of flap coverage, bone grafting, and IM nailing in patients who have a fracture of
the tibial shaft with extensive soft tissue injury.
MD Fischer et al. JBJS 73-A. 1991. p 1316-1322.
Open fractures of the tibia in children.
Plates versus external fixation in severe open tibial shaft
fractures. A randomized trial.
Management of open tibial fractures
Treatment of open fractures of the tibial shaft with the use of
interlocking nailing without reaming.
Locked intramedullary nailing of open tibial fractures.
Plates versus external fixation in severe open tibial shaft
fractures. A randomized trial.
Compartment syndrome in open tibial fractures.
Medial external fixation with lateral plate internal fixation in
metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury.
Team approach to tibial fracture. 37 consecutive type III cases reviewed
after 2-10 years.
Complicated open fractures of the distal tibia treated by secondary
interlocking nailing.
Flexible Medullary Nailing of Acute Tibial Shaft Fractures.
Wiss. Clinical Orthopaedics; 212: 122-132, 1986;
Flexible Medullary Nailing of Tibial Shaft Fractures.
Wiss. et. al. J. Trauma, 26: 1106-1112, 1986;
- See:
- Infections of the Tibia:
- Preoperative Antibiotics;
- therapeutic doses of ancef and tobramycin for 48 hrs are appropriate;
- despite the added cost, tobramycin is more effective against Pseudomons
and has been shown to have lower incidence prevalence of nephrotoxicity;
- tetanus prophylaxis if appropriate;
- Soft Tissue Defects:
- initial wound care:
- debridement:
- consider debriding the wound with a separate set of surgical instruments / drapes
- in most cases, the surgeon will elect to loosely close any incisions made during the case but
to leave the traumatic wound open;
- leaving the wound open maximizes drainage and wound tension (which is frequently present
w/ primary closure);
- at second look debridement (at 48-36 hours), the edema will have diminished and the
wound can be closed w/ less tension;
- references:
Primary or delayed closure for open tibial fractures.
- wound dressings:
- antibiotic bead pouch:
- as noted by Keating et al 1996, bead pouches help reduce the infection rate
in open tibia fractures from 16% to 4%;
- add 2.4 gm of tobramycin per cement package, and fashion small beads attached
to a O silk suture;
- counting the beads and adding methylene blue helps ensure that none
of the beads will be left behind at removal;
- a small drain is left adjacent to the beads and the wound is sealed w/ Opsite;
- references:
Reamed Nailing of Open Tibial Fractures: Does the Antibiotic Bead Pouch
Reduce the Deep Infection Rate?
JF Keating et al. J. Orthop. Trauma. 1996. Vol 10, No 5. p 298-303.
- soft tissue coverage for tibial defects
- note that if a external fixator is being considered, it should be placed in a way
so as not to interfere w/ flap application (eg a medially placed external fixator
might interfere w/ a medial gastrocnemius flap);
- references:
The Timing of Flap Coverage, Bone-Grafting, and Intramedullary
Nailing in Patients Who Have a Fracture of the Tibial Shaft With Extensive Soft-Tissue Injury.
MD Fischer et al. JBJS 73-A. 1991. p 1316-1322.
Early microsurgical reconstruction of complex trauma of the extremities.
Primary versus delayed soft tissue coverage for severe open tibial
fractures. A comparison of results.
- Management Based on Gustillo Classification:
- Grade I Frx:
- generally treated w/ intramedullary nail or a plates
- references:
- Closed intramedullary tibial nailing: its use in closed and type I open fractures.
CM Court-Brown et al. JBJS Vol 73-B. 1991. p 959-964.
- Grade II Frx:
- generally treated w/ intramedullary nail or an external fixator;
- Grade IIIb Frx:
- generally treated w/ intramedullary nail or an external fixator;
- note that if a external fixator is being considered, it should be placed in a way
so as not to interfere w/ flap application (eg a medially placed external fixator
might interfere w/ a medial gastrocnemius flap);
- Grade IIIc Frx: Treatment Options;
- generally treated w/ an external fixator;
- these fractures by definition are associated w/ vascular trauma, and have a
high prevalence of infection:
- its important to assess viability of the limb, both w/ common sense, as well
as w/ objective criteria such as the MESS;
- in many cases amputation is the best option;
- ref:
Classification of type III (severe) open fractures relative to treatment
and results.
Severe open fractures of the tibia
Severe open tibial fractures: a study protocol.
Open tibial fractures with associated vascular injuries: prognosis for
limb salvage.
- Early Bone Grafting:
- bone by history (high energy frx treated with early grafts)
- as soon as soft tissue envelope is closed and non-infected;
- some recommend bone grafting 5-7 days after debridement;
- some recommend adding powered antibiotic to the cancellous graft;
- posterolateral via virgin approach if possible;
- pure cancellous bone
- occasional indication for free fibular graft;
- ref:
Segmental tibial defects. Comparing conventional and Ilizarov methodologies.
Skeletal defects. A comparison of bone grafting and bone transport for
segmental skeletal defects.
Early prophylactic bone grafting of high-energy tibial fractures.
Management of open fractures with sterilization of large,
contaminated, extruded cortical fragments.
Posterolateral bone graft of the tibia.
The timing of flap coverage, bone grafting, and IM nailing in patients who have a fracture of
the tibial shaft with extensive soft tissue injury.
MD Fischer et al. JBJS 73-A. 1991. p 1316-1322.
Open fractures of the tibia in children.
Plates versus external fixation in severe open tibial shaft
fractures. A randomized trial.
Management of open tibial fractures
Treatment of open fractures of the tibial shaft with the use of
interlocking nailing without reaming.
Locked intramedullary nailing of open tibial fractures.
Plates versus external fixation in severe open tibial shaft
fractures. A randomized trial.
Compartment syndrome in open tibial fractures.
Medial external fixation with lateral plate internal fixation in
metaphyseal tibia fractures. A report of eight cases associated with severe soft-tissue injury.
Team approach to tibial fracture. 37 consecutive type III cases reviewed
after 2-10 years.
Complicated open fractures of the distal tibia treated by secondary
interlocking nailing.
Flexible Medullary Nailing of Acute Tibial Shaft Fractures.
Wiss. Clinical Orthopaedics; 212: 122-132, 1986;
Flexible Medullary Nailing of Tibial Shaft Fractures.
Wiss. et. al. J. Trauma, 26: 1106-1112, 1986;