Management of Open Shaft of Tibial Fracture

 

       Open Fractures of Tibia Diaphysis 

(Daniel N. Segina, Robert V. Cantus, David Templeman )

How do you manage such a case ?

    ATLS review. R/o life threatening and more urgent issues.

    Examine wound, photograph it, cover it with a saline soaked gauze.

    Analgesia

    Splinting    

    Antibiotics

    Tetanus Toxoid

    Obtain AP and Lateral radigraphs

    transfer to theatre 

    Initial wash /scrub for gross contamination

    Thorough debridement of skin, fat, fascia, muscle, bone    

     Fracture stabilization before further wash out.

    Dressing, splint leg with physical examination    

    make a plan for further management.

    continue ex-fixator or remove the ex-fixator ,      back slab and convert to IMIL after few.               weeks  when pin tracts heal

What is the biggest concern post-operatively ?

     With high energy trauma, particularly tibial        fractures may lead to compartment.                      syndrome.

    Regular observations

    Invasive procedure for those who have a           reduced level of consciousness

Techniques of fasciotomy

       Two incision technique - advised by British Orthopaedic Association

            Ist long incision- medial to postero-                        medial border of tibia, allows posterior              compartment  decompression

            2nd Incision-      2 cm lateral to anterior                                              border of tibia

                                       - access to anterior.                                                        border of tibia 

                                      -  access to anterior and                                                 lateral compartment

How soon to get soft tissue to cover ? recommendation - within 5 days of initial injury

          soft tissue coverage based on                                    reconstruction ladder.

         most complex - free flap

          involves taking a distant muscle with its.             vascular supply and revascularizing it.                 with a healthy vessel close to recipient site.

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