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Medical course data
Parent Tibial Fracture Fixation
Required
time
2 hours

Modular External Fixation for an Open Tibial Shaft Transverse Fracture

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 rod-to-rod modular frame as part of external fixation procedures for open tibial shaft fractures performed in regions without specialist coverage.

Learning Objectives[edit | edit source]

By the end of this module, learners will:

  1. Know the blood supply to the tibia
  2. Know the nerves that supply the tibia
  3. Know the safe zones in the tibia for pin insertion
  4. Know how to apply the Gustilo Open Fracture Classification to open tibial shaft fractures
  5. Understand how the Gustilo Open Fracture Classification impacts the selection of antibiotic therapy for open tibial shaft fractures
  6. Know the principles of surgical care and management for open tibial shaft fractures
  7. Know the indications for modular external fixation for a patient with an open tibial shaft fracture
  8. Know the indications for referral of a patient with an open tibial shaft fracture to a tertiary center for specialist care
  9. Know the acceptable parameters for reduction of open tibial shaft fractures

Anatomy Review[edit | edit source]

The tibia is dependent on the soft tissue envelope for its blood supply.[1] Stripping of soft tissues may render the bone avascular.
The drill trajectory angles for the safe zones of the tibia are between 20°-60° relative to the tibial crest for the proximal fragment and between 30°-90° relative to the tibial crest for the distal fragment.[2]

Gustilo Open Fracture Classification[edit | edit source]

Gustilo Open Fracture Classification[3][4]
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.

The Gustilo Open-Fracture Classification impacts the selection of antibiotic therapy for open tibial shaft fractures:

Antibiotic Therapy[edit | edit source]

All patients should be managed with intravenous antibiotics immediately at the time of presentation to the emergency department.[5][6][7] Antibiotics may be changed, added or extended depending on 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[5][6][7] Clindamycin 900 mg IV immediately and q8 hours for a total of 3 doses
Gustilo Type III
  • Ceftriaxone 2 g IV immediately for a total of 1 dose, and
  • Vancomycin 1 g IV immediately and q12 hours for a total of 2 doses
  • Aztreonam 2 g IV immediately and q8 hours for a total of 3 doses, and
  • Vancomycin 1 g IV immediately and q12 hours for a total of 2 doses
Farm or fecal

contamination

Add Penicillin G IV (e.g., 5 million-10 million units/24 hours)[5][6] Add Metronidazole IV
Freshwater or

saltwater

contamination

Add Levofloxacin IV or Ciprofloxacin IV[7] Add Levofloxacin IV or Ciprofloxacin IV[7]
These therapies may vary due to regional differences in antibiotic regimens for open fractures.

Principles of Management of Open Tibial Shaft Fractures[edit | edit source]

Indications for Modular External Fixation for an Open Tibial Shaft Fracture[edit | edit source]

After completing the entire module, learners should be able to perform modular external fixation of open tibial shaft fractures with the following features:

  • 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]

  • 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)

Reduction Parameters for an Open Tibial Shaft Fracture[edit | edit source]

The acceptable reduction parameters for open tibial shaft fractures are:

  • Bone apposition > 50%
  • Rotation < 10 degrees[8]
  • Angulation < 10 degrees in any plane[8]
  • Length discrepancy < 2 cm shortening[8]
  • No distraction (lengthening)[1][8][9][10][11]

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. 1.0 1.1 https://www.wheelessonline.com/bones/x-rays-for-tibial-frx/
  2. https://surgeryreference.aofoundation.org/orthopedic-trauma/adult-trauma/tibial-shaft/approach/safe-zones-of-the-tibia-for-pin-insertion
  3. 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.
  4. 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.
  5. 5.0 5.1 5.2 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.
  6. 6.0 6.1 6.2 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
  7. 7.0 7.1 7.2 7.3 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.
  8. 8.0 8.1 8.2 8.3 Nicoll EA. Fractures of the tibial shaft. A survey of 705 cases. J Bone Joint Surg Br. 1964 Aug;46:373-87.
  9. https://www.orthobullets.com/trauma/1045/tibial-shaft-fractures
  10. 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.
  11. 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.
Page data
Type Medical course
Authors Medical Makers
Published 2022
License CC-BY-SA-4.0
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