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Grade IIIB Open Tibial Frx

- See: Tibia Fracture Menu and Gustilo Classification

- Discussion:
    - is frx in which there has been extensive stripping of soft tissues and periosteum from bone & where devitalization or loss of soft tissues usually
           requires plastic reconstructive procedures for closure;
           - extensive soft tissue loss with periosteal stripping and sig. wound contamination;
    - segmental defects measuring, on average, 10 cm were managed by:

- Initial Treatment and Timing of Surgery:
    - 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 a lower incidence prevalence of nephrotoxicity;
                  - note that the most frequently identified organisms in open tibial fractures are Staph aureus and nocosomial organisms;
           - tetanus prophylaxis if appropriate;
    - references:
           - Outcomes in open tibia fractures: relationship between delay in treatment and infection.
           - Efficacy of primary wound cultures in long bone open extremity fractures: are they of any value?
           - Efficacy of cultures in the management of open fractures.

- Soft Tissue Defects:
    - initial wound care 
    - pressure irrigation 
    - debridement and wound closure: / wound closure and dressing
          - consider debriding the wound with a separate set of surgical instruments / drapes
          - in most cases, the surgeon will close surgical incisions made during the case but to leave the traumatic wound open with wound VAC;
                 - leaving the wound open maximizes drainage and wound tension (which is frequently present w/ primary closure);
                 - at 2nd look debridement (at 48-36 hrs), the edema will have diminished and the  wound can be closed w/ less tension;
          - references:
                 - Primary or delayed closure for open tibial fractures.
                 - Timing of closure of open fractures. 
                 - Immediate primary skin closure in type-III A and B open fractures: results after a minimum of five years.    
                 - Early versus delayed closure of open fractures
    - wound dressings: (see wound VAC);
           - references:
                 - The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap. 
                 - Use of vacuum-assisted closure and a dermal regeneration template as an alternative to flap reconstruction in pediatric grade IIIB open lower-extremity injuries.              
                 - Routine use of wound vacuum-assisted closure does not allow coverage delay for open tibia fractures.
    - antibiotic bead pouch:
          - as noted by Keating, et al (1996), bead pouches help reduce the infection rate in open tibia frx from 16% to 4%;
          - add 2.4 gm of tobramycin and 4 gm of Vancomycin 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? 
    - 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
                 - Early microsurgical reconstruction of complex trauma of the extremities.
                 - Primary versus delayed soft tissue coverage for severe open tibial fractures. A comparison of results.
                 - The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap.

- Fracture Management:
    - external fixation:
           - some prefer the external fixator, adding limited internal fixation when required to improve joint surface congruity;
           - w/ an open frx, external fixation should include the foot to prevent soft tissue motion over the fracture;
           - exchange IM nailing may be preferable once soft tissue reconstructive surgery has been performed; 
           - in the study by Webb, et al (2007), the authors determined that:
                   - patients treated with an ex fix  had more surgical procedures, took longer to achieve full wt-bearing status, and had more
                             infections and nonunions (compared to IM nailing group);
                   - worst functional results were found in patients treated with ex fix and muscle flap (had worst outcomes than BKA)
           - references:
                   - Open grade III “floating ankle” injuries: a report of eight cases with review of literature
Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures  
    - intramedullary nailing
           - references:
                  - Reamed nailing of Gustilo grade-IIIB tibial fractures.
                  - Open tibial fractures: faster union after unreamed nailing than external fixation.
                  - Emergency management of type IIIB open tibial fractures.
                  - [[Clinical results of primary intramedullary osteosynthesis with the unreamed AO/ASIF tibial intramedullary nail of open tibial shaft fractures].]
                  - Local or free muscle flaps and unreamed interlocked nails for open tibial fractures.
                  - Treatment of type II, IIIA, and IIIB open fractures of the tibial shaft: a prospective comparison of unreamed interlocking IM nails and half-pin external fixators.
                  - Nonreamed locking intramedullary nailing for open fractures of the tibia.
                  - Reamed interlocking intramedullary nailing of open fractures of the tibia.
                  - Locking intramedullary nailing with and without reaming for open fractures of the tibial shaft. A prospective, randomized study.
                  - Contaminated fractures of the tibia: a comparison of treatment modalities in an animal model.
                  - The treatment of open tibial shaft fractures using an interlocked intramedullary nail without reaming.
    - soft tissue management:
           - filling of osseous defect w/ ATB-impregnated cement beads & coverage of soft-tissue defect by local myoplasty or free muscle transfer;
           - by definition soft tissue coverage is usually required;
    - bone grafting:
           - elevation of the flap after about four to six weeks and packing of the osseous defect with large amounts of autogenous
                      cancellous bone graft from the iliac crest

Open type IIIB and IIIC fractures treated by an orthopaedic microsurgical team.

Reconstruction of large diaphyseal defects, without free fibular transfer, in Grade-IIIB tibial fractures.

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.

Treatment of grade-IIIb open tibial fractures. A prospective randomised comparison of external fixation and non-reamed locked nailing. 

The use of a subatmospheric pressure dressing to salvage a Gustilo grade IIIB open tibial fracture with concomitant osteomyelitis to avert a free flap.

Analysis of Surgeon-Controlled Variables in the Treatment of Limb-Threatening Type-III Open Tibial Diaphyseal Fractures.

Primary shortening with secondary limb lengthening for Gustilo IIIB open tibial fractures: a report of six cases.

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