Management of open fractures. Septic and non-septic complications in Traumatology. Fractures of the tibia and fibula. Semmelweis University Department of Traumatology

Dr. Gál Tamás

Fractures of the Tibia Anatomical characteristics: • Anteromedial surface: thin soft tissue coverage  open fractures (13%) • Osteo-fascial muscle compartments  compartment syndroma (≤ 20%) • Dynamic framework • Tension between tibia and fibula • 1/6th of the load on the fibula • Elastic load absorption

AO Arbeitsgemeinschaft für Osteosynthesefragen

Conservative treatment • Stable, non-dislocated fractures • General condition of the patient Traction for 3 weeks…

Cast: 9-12 weeks

Operative treatment • Intramedullary nailing • Plate synthesis • External Fixator

Indications of intramedullary nailing for the treatment of tibia fractures • Best choice for fractures between the 2/7-6/7th (shaft fractures) if it can be technically carried out • Reamed nailing: monotrauma, patient is allowed to bear weight earlier, good for cases of mal-union or non-union • Unreamed nailing: polytrauma, shorter operation time, Grade lll- types B-, C open fractures, narrow intramedullary canal. • Interlocking: gives rotational stability, static interlocking recommended, dynamisation can be later performed. Mandatory in unreamed nailing.

Reamed Intramedullary Nailing

Unreamed intramedullary nailing – UTN (Unreamed Tibia Nail)

IM nailing post operative care: •if stability of the fracture is in question, then below knee cast immobilization and touch down wt bearing are used until healing •once partial fracture healing has taken place, consider a functional brace or consider a below knee cast.

•active dorsiflexion and plantarflexion stresses the tibia and produces displacements similar to wt bearing; - static locking: most tibial fractures heal in the static locked mode; - dynamization: - removal of proximal or distal screws allows axial loading of tibia - consider at 3 months in axially stable fractures with no callus - axially unstable frx should remain in static mode and should receive bone graft

Indications of plate synthesis • Intraarticular fractures and fractures near the joint (when ORIF is necessary) • Non-union, malunion (with bone graft) • When other methods of treatment are contraindicated (e.g. compartment syndrome)

Plate synthesis Medial plate

Indications for External Fixation • • • •

Severe soft tissue injury (Glll-BC) OPEN FRX In certain cases of polytraumatisation For intermittant limb shortening As a supplementation for minimal synthesis epi-metaphyseal fractures • Joint bridging • Segment transfer, bone lengthening

External fixation device

Ilizarov external fixation device

Compartment syndrome increasing tissue pressure prevents capillary blood flow and produces ischemia in muscle and nerve tissue. The process is progressive and leads to necrosis with permanent loss of function! Surgical Emergency….. Otherwise amputation Intracompartmental pressure > 30 mmHg

Causes • High-energy limb injuries (most often calf area) • Crushing injuries • Burns • Prolonged compression (comatose, unprotected patient) • Abnormal capillary permeability caused by reperfusion after prolonged ischemia. Tight bandages, splints, or casts….Volkmann ischemic contracture

Compartment syndrome • • • •

Edema Pallor Pain „like childbirth” Pain to Passive movement • Local hyp/Paraesthesia FASCIOTOMY !!! • Paresis • Pulselessness

Open fractures – Gustillo and Anderson classification

55 y.o. male pedestrian was hit by an automobile. Patient is HIV positiv. Grade I intraart. open tibia frx

Intraop. imaging

Postop. 12 weeks

-8 weeks non-wt. bearing - week 8-12 phys. ther. (imitation of walking) -12 th week – half wt bearing -pain in the area of the op.

Breakage of the 4 proximal screws

-Another op -7 extra screws -callus formation -postop 24 th week jogging again -fully recovered, metal removal after 2 years

INFECTION: the most serious complication for both the patient and the doctor! • Contamination bacteria on site * bakterial culture * temperature drain-cultures germs ↑ immune status ↓

• Infection signs of bacterial inf. * rubor (hyperemia) * tumor (edema) * calor (warm) * dolor (painful) * functio laesa (loss of function * pus

Causes of infection • Open wounds / fractures • Iatrogenic infections - sterility problem - ultrasterile boxes • Circulation problems, diabetes • Immune status - transplants / steroids - oncologic illness • Operative errors - haematomas, tissue damage

Classification of infections 1. • Acute - early posttraumatic period (1-7 days)

• Subacute - (1 week- 1 month) • Chronic - (after 1 month)

Classification of infections 2. • superficial - skin necrosis - epifascial supp.

good prognosis!

• deep - subfascial - intraarticular - tendovaginal - body cavity - peri-implant bad prognosis!

Superficial infection • Diagnostics - inspection - palpation - Ultrasound - lab results

• Therapy - conservative/kryoth. - operative (revision, debridement, perhaps drainage)

Deep infection Subfascial, extra/intraarticular haematoma, tissue damage

• Diagnostics - inspection - palpation - Ultrasound - aspiration - labs

• Therapy - immediate revision, debridement - suction drainage (vaccum sealing) - perhaps Septopal chain or antibiotic cement

Diagnostic methods • • Laboratory - WBC - qualitative blood - We (Erythrocyte Sedimentation Rate) - CRP - procalcitonin - TNF

Instrumental diagnostics - sonography (punction) - x-ray (gas, fluid) - CT/contrast - MRI/contrast - scintigraphy - thermography (?)

•obtain adequate cultures •Antibiotics should be considered only if the patient is systemically septic prior to wound exploration •Empirical antibiotic treatment is based upon the antibiotics sensitivities of likely infecting organisms • history of previously positive cultures • institutional frequency statistics

Antibiotic beads Locally administered antibiotics may have a supplementary role in the management of musculoskeletal infections. poorly perfused areas, or “dead space”, antibiotic-laden cement is frequently used, both to fill the space and to deliver high doses of local antibiotic with low risk of systemic toxicity. A common technique is the use of antibiotic-laden PMMA beads. Antibiotic-impregnated beads may be purchased in some countries or made by the surgeon more cheaply.

Circulation problem Contraindication

profylaxis: Radical debridement

Pathophysiology

Sequester Area outside of circulation

ANTIBIOTICS parenteral / local

Time factor!

SEPTOPAL-prophylaxis Open fracture prophylaxis Magyar Traumatologia 28:280 (1985)

Local AB-therapy: Protection of osteosynthesis under fracture healing

Local AB-therapy

Local AB-therapy:

Fill area, ASP preparation

Soft tissue-correction

Without debridement local AB-treatment is useless, contraindicated!

Disadvantage: resistency

Intramedullary debridement

Intramedullary debridement gravitational drainage

intermittant removal

Septic complication after femoral neck OS

Early debridement, 2 session TEP implant.

GIRDLESTONE hip

42 éves

chr. alc.

GIRDLESTONE-hip

Limb salvage 9 y.o. girl Brain contusion Rupture of stomach Closed tibia frx (car accident)

„Second look”

Patient fell from a ladder, open distal intraart frx of tibia and fibula

Angular plate synthesis

Osteomyelitis

Local antibiotic cement

Total Knee Replacement – 60 y.o. male farmer

Antibiotic spacer

3 months postop.

7 months postop. Revision TKR

•10 months postop •Signs of loosening again

11 months postop. AB spacer again 15 months postop. Revision surgery again

Non-union -34 year old male was in a fight, and defended himself with his right foremarm -ulna diaphysis fracture

Postoperative x-ray

Postop. 3 months

Bone graft

Thank you for your attention