This module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in irrigation and debridement, powered and manual drilling, positioning and correctly inserting Schanz screws, and constructing the uniplanar external fixator frame as part of external fixation procedures for open tibial shaft fractures performed in regions without specialist coverage. To maximize patient safety, this module teaches learners to use a powered drill to insert self-drilling Schanz screws through the near cortex and then manually advance Schanz screws into the far cortex to avoid plunging.
Learning Objectives[edit | edit source]
By the end of this module, learners will be able to:
- Conduct a history and physical examination of a patient with an open tibial shaft fracture.
- Review the post-operative anteroposterior and lateral view radiographs of a patient with an open tibial shaft fracture.
- Initially manage a patient with an open tibial shaft fracture.
- Know the indications for uniplanar external fixation for a patient with an open tibial shaft fracture.
- Know the indications for referral of a patient with an open tibial shaft fracture to a tertiary center for specialist care.
It's highly recommended to print off this module, bring it to the emergency room, and file it in the patient's chart to use as a checklist during the assessment of a patient with an open tibial shaft fracture.
History[edit | edit source]
Patient Demographics[edit | edit source]
- Age
- Gender
- Female
- Male
- Occupation
Injury History[edit | edit source]
- Date of Injury
- Time of Injury
- Time of Arrival to Hospital
- Interval From Injury to Arrival at Hospital
- Mechanism of Injury
- Fall
- Gunshot Wound
- Motorcycle Accident
- Motor Vehicle Accident
- Pedestrian-Traffic Injury
- Other
- Environmental Contaminants
- Farmyard Injury
- Saltwater Source
- Freshwater Source
- Fecal Contamination
- Other:___________________
Past Medical History[edit | edit source]
- Diabetes Mellitus
- Human Immunodeficiency Virus (HIV) Positive[1]
- Severe Immunodeficiency
Tetanus Vaccine Status[edit | edit source]
All patients with open fractures should be evaluated for tetanus vaccination status and receive tetanus prophylaxis in accordance with Centers for Disease Control and Prevention guidelines.[1]
- Tetanus Primary Vaccine Series Status
- > 3 Doses of Primary Tetanus Vaccine Series
- < 3 Doses
- Unvaccinated
- Unknown
- Tetanus Booster Status
- Last Dose < 5 years
- Last Dose > 5 years
- Unvaccinated
- Unknown
Allergies[edit | edit source]
- Penicillin
- Other:___________________
- No Known Drug Allergies
Social History[edit | edit source]
- Current Smoker
- Medical Insurance
Physical Examination[edit | edit source]
Neurovascular Exam[edit | edit source]
Vascular Exam[edit | edit source]
Compare both sides when evaluating dorsalis pedis artery pulses.
- Palpable versus Not Palpable
- Symmetric versus Asymmetric
If dorsalis pedis artery pulses are not palpable, check for posterior tibial artery pulses.
If posterior tibial artery pulses are not palpable, check for signs of acute compartment syndrome.
Sensory Testing[edit | edit source]
To test the lateral dorsal cutaneous branch of the sural nerve (S1-2), perform light touch sensation testing on the lateral aspect of the little toe and compare it to the other side.
- Intact versus Not Intact
- Symmetric versus Asymmetric
To test the deep peroneal nerve (L4-5), perform light touch sensation testing on the first dorsal webspace of the foot and compare it to the other side.
- Intact versus Not Intact
- Symmetric versus Asymmetric
To test the superficial peroneal nerve (L4-S1), perform light touch sensation testing on the dorsum of the foot (except the first webspace) and compare it to the other side.
- Intact versus Not Intact
- Symmetric versus Asymmetric
Motor Testing[edit | edit source]
Ask patient to perform ankle dorsiflexion for motor testing of the tibialis anterior muscle. Be sure to compare both sides.
- Able versus Unable
- Symmetric versus Asymmetric
Ask patient to perform ankle plantarflexion for motor testing of the gastrocnemius and soleus muscles. Be sure to compare both sides.
- Able versus Unable
- Symmetric versus Asymmetric
Acute Compartment Syndrome[edit | edit source]
Evaluate for symptoms of acute compartment syndrome.[2]
- Pain disproportionate to injury and intensified with passive stretch (i.e., flexion and extension of the toes)
- Pallor
- Paresthesias
- Paralysis
- Pulselessness
- Compartment pressure greater than 30-40 mmHg in an unconscious or paralyzed patient
Pre-Operative Open Fracture Classification[edit | edit source]
| Gustilo Type I: | An open fracture with a wound less than 1 cm long and clean. |
| Gustilo Type II: | An open fracture with a laceration more than 1 cm long without extensive soft tissue damage, flaps, or avulsions. |
| Gustilo Type IIIA: | Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound. |
| Gustilo Type IIIB: | Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination. |
| Gustilo Type IIIC: | Open fracture associated with arterial injury requiring repair. |
A patient with Gustilo Type IIIB or IIIC injury should be referred to a tertiary center with specialist care. A Gustilo Type IIIC injury is a surgical emergency.
Photo Documentation of Injured Extremity[edit | edit source]
Take images of the soft tissue wound(s) of the injured extremity including the joint above and below for orientation and with a ruler added for scale.
After the wound is examined and photographed, cover it with a sterile dressing.[2]
Temporarily splint the extremity by immobilizing the joint above and below the fracture site using locally available materials.
Preoperative Radiographic Findings[edit | edit source]
- Anteroposterior and Lateral Views
Extremity Side[edit | edit source]
- Left
- Right
Fracture Site[edit | edit source]
- Diaphysis (Shaft)
- Metaphysis
- Epiphysis
Fracture Location[edit | edit source]
- Proximal 1/3
- Middle 1/3
- Distal 1/3
Fracture Pattern[edit | edit source]
- Transverse
- Oblique
- Spiral
- Comminuted (> 2 fragments)
- Segmental
- Other:___________________
Bone Apposition[edit | edit source]
- > 50% Bone Apposition[5]
- < 50% Bone Apposition
Angulation[edit | edit source]
Angulation can be assessed in the coronal or sagittal plane. The anteroposterior view shows the coronal plane and the lateral view shows the sagittal plane.
Fibular Fracture[edit | edit source]
- Diaphysis (Shaft)
- Metaphysis
- Epiphysis
A distal fibular fracture near or involving the ankle joint requires referral to an orthopedic specialist.
Other Imaging Findings[edit | edit source]
Note any clinically significant radiographic findings.
Fracture Management Plan[edit | edit source]
Advanced Trauma Life Support[edit | edit source]
Any patient with a fracture should be initially managed as a trauma patient using Advanced Trauma Life Support protocols (life-threatening conditions treated first).
Tetanus Prophylaxis[edit | edit source]
All patients with open fractures should receive tetanus prophylaxis in accordance with Centers for Disease Control and Prevention guidelines.[1]
- Tetanus Toxoid Booster; or
- Tetanus Toxoid Primary Series; or
- 250 IU Tetanus Immune Globulin IM; or
- Not Required
Antibiotic Therapy[edit | edit source]
All patients will be managed with intravenous antibiotics immediately at the time of presentation to the emergency department.[9][10][11] Antibiotics may be changed, added or extended depending on subsequent clinical findings. Doses will be adjusted based on patient weight when indicated.
Recommended Antibiotic Therapies for Open Fractures*
| Injury Characteristics | Systemic Antibiotic Regimen | Penicillin Allergy |
|---|---|---|
| Gustilo Type I and II | Cefazolin 2 g IV immediately and q8 hours for a total of 3 doses[9][10][11] | Clindamycin 900 mg IV immediately and q8 hours for a total of 3 doses |
| Gustilo Type III |
|
|
| Farm or fecal
contamination |
Add Penicillin G IV (e.g., 5 million-10 million units/24 hours)[9][10] | Add Metronidazole IV |
| Freshwater or
saltwater contamination |
Add Levofloxacin IV or Ciprofloxacin IV[11] | Add Levofloxacin IV or Ciprofloxacin IV[11] |
These therapies may vary due to regional differences in antibiotic regimens for open fractures.
Record the interval from injury to initiation of intravenous antibiotic delivery in the patient's chart.
Indications for Uniplanar External Fixation[edit | edit source]
After completing the entire module, learners should be able to perform uniplanar external fixation of open tibial shaft fractures with the following features:
- Able to directly visualize fracture through the open wound or intraoperative extension of the wound; and
- Gustilo Type II or Gustilo Type IIIA open tibial fracture; and
- Non-comminuted, tibial shaft (extra-articular) fracture; and
- With or without a fibular shaft (extra-articular) fracture
Indications for Referral to a Tertiary Center for Specialist Care[edit | edit source]
- Unable to directly visualize fracture through the open wound or intraoperative extension of the wound
- Non-palpable pedal pulse
- Symptoms consistent with acute compartment syndrome
- Gustilo Type IIIB or Gustilo Type IIIC open tibial fracture
- Comminuted or segmental tibial fracture
- Bilateral tibia fractures
- Metaphyseal tibial fracture with intra-articular extension
- Concomitant distal fibular fracture near or involving the ankle joint
- Concomitant ipsilateral or contralateral femoral fracture
- Severe traumatic brain injury (Glasgow Coma Scale <12)
- Severe spinal cord injury (lower extremity paresis/paralysis)
- Severe burns (involving >10% of the total body surface area or >5% of the total body surface area with full-thickness or circumferential injury)
Acknowledgements[edit | edit source]
This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.
References[edit | edit source]
- ↑ 1.0 1.1 1.2 https://www.cdc.gov/tetanus/clinicians.html
- ↑ 2.0 2.1 Berg, E.E. and Murnaghan, J.J. Orthopedic Surgery: Diseases of the Musculoskeletal System. Essentials of surgical specialties, 2nd Edition. Edited by Peter F Lawrence. 514 pages, illustrated. Philadelphia: Lippincott Williams & Wilkins, 2000.
- ↑ Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976 Jun;58(4):453-8. PMID:773941.
- ↑ Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma.1984 Aug;24(8):742-6. doi: 10.1097/00005373-198408000-00009. PMID:6471139.
- ↑ https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures
- ↑ Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br. 1964 Aug;46:373-87.
- ↑ Haonga BT, Liu M, Albright P, Challa ST, Ali SH, Lazar AA, Eliezer EN, Shearer DW, Morshed S. Intramedullary Nailing Versus External Fixation in the Treatment of Open Tibial Fractures in Tanzania: Results of a Randomized Clinical Trial. J Bone Joint Surg Am. 2020 May 20;102(10):896-905. doi: 10.2106/JBJS.19.00563. PMID: 32028315; PMCID: PMC7508278.
- ↑ Merchant TC, Dietz FR. Long-term follow-up after fractures of the tibial and fibular shafts. J Bone Joint Surg Am. 1989 Apr;71(4):599-606. PMID: 2703519.
- ↑ 9.0 9.1 9.2 Garner MR, Sethuraman SA, Schade MA, Boateng H. Antibiotic Prophylaxis in Open Fractures: Evidence, Evolving Issues, and Recommendations. J Am Acad Orthop Surg. 2020 Apr 15;28(8):309-315. doi: 10.5435/JAAOS-D-18-00193. PMID: 31851021.
- ↑ 10.0 10.1 10.2 https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/further-reading/principles-of-management-of-open-fractures?searchurl=%2fSearchResults#principles-of-surgical-care-for-open-fractures
- ↑ 11.0 11.1 11.2 11.3 Zhu H, Li X, Zheng X. A Descriptive Study of Open Fractures Contaminated by Seawater: Infection, Pathogens, and Antibiotic Resistance. Biomed Res Int. 2017;2017:2796054. doi: 10.1155/2017/2796054. Epub 2017 Feb 20. PMID: 28303249; PMCID: PMC5337837.