Fractures of the tibia and fibula. Management of open fractures. Septic and non septic complications in Traumatology Dep. of Traumatology M.Szebeny
Fractures of the tibia and fibula. Proximal : tibial plateau
Shaft fractures - 10-20% open - compartment syndrome
Pilon (tibial plafond) fr.
Fractures of the tibia and fibula. Mechanism of injury: falls, sports, motor veh. - low energy - high energy Examination: soft tissue ? neurovascular assessment compartments ? - reassessment ! Radiographs: ap. and lat. (including knee and ankle)
Fractures of the tibia and fibula. Nonoperative management
Closed ! Transverse
Long-leg cast 10-18 weeks
Fractures of the tibia and fibula Nonoperative management
Sarmiento – below-the-knee cast – PTB (patellar tendon bearing)
Fractures of the tibia and fibula Nonoperative management
for closed unstable fractures: spiral, oblique, comminuted is possible, but …
Sceletal traction for 3 weeks + cast for 8-16 weeks …operative management is preferred.
Fractures of the tibia and fibula Operative management Proximal : tibial plateau
Intraarticular Plate Pilon (tibial plafond) fr.
Tibial shaft fractures Operative management
Ø Intramedullary
nails
reamed or…
Tibial shaft fractures Operative management
Ø …unreamed.
Closed fractures
A03 A01
A02
Ø with
soft tissue damage
Classification of open fractures (Gustilo and Anderson) Ø Grade
I: <1cm wound, inside out Ø Grade II: >1 cm wound <5-10 cm, l
outside in, moderate crushing
Ø Grade
III: >10 cm wound,
extensive soft tissue injury IIIa : adequate soft-tissue coverage IIIb : soft-tissue loss IIIc : vascular injury l
Open fracture Ø Grade
(femur, inside out)
I
Open fracture Ø Grade
II
(ankle inner side - pronation)
Open fracture Ø Grade
III/b
III
III/c
Open fractures of the tibia and fibula.
Ø Ø
Gustilo Grad I to Grad III : Intramedullary nails to external fixation
Open fracture management Ø The
most important is extensive and appropriate debridement Ø Sceletal stabilization Ø Antibiotics (but do not substitute for debridement of necrotic tissues !) Ø Delayed closure of he wounds Ø Redebridement may be necessary Ø Plastic surgeon
Mangled extremity Ø Early l
amputation versus limb salvage
Life before limb
Depends on: skin bone muscles vessels nerves
Lhoce 8561m
Compartment syndrome Ø occurs
when increased tissue pressure within a limited anatomic space (fascial compartment) compromises perfusion
Etiology: vascular – reperfusion crush injury fractures (50%) most common: tibial
Compartment syndrome Ø Symptoms:
PAIN out of proportion… • Paraesthesias • Paralysis - late!
Signs: swollen, tense compartment pain on passive stretching pulslessness – late! Pressure: >30mmHg
Compartment syndrome Treatment: fasciotomy
Ø Lower l l l
leg : composed of four compartments:
anterior, lateral, superficial and deep posterior one or double incision technique Closure: 5-10 days primary? or skin grafting
Septic complications Ø infection:
the most serious complication for both the patient and the doctor! • Contamination bacteria on site * devitalized tissue * temperature drain-cultures germs > immune status <
• Infection signs of bacterial inf. * rubor * tumor * calor * dolor * functio laesa pus
Causes of infection Ø open wound/fracture Ø Iatrogenic infection
* sterility problem * ultrasterile boxes Ø Circulation problems, diabetes Ø Immune status * transplants/steroids * oncologic illness Ø Operative errors * haematomas, tissue damage
Classification of infections 1. Ø Acute
* early posttraumatic period (1-7 days) Ø Subacute * (1 week- 1 month) Ø Chronic * (after 1 month)
Classification of infections 2. Ø superficial
* skin necrosis * epifascial supp. good prognosis!
Ø deep
* subfascial * intraarticular * tendovaginal * body cavity * peri-implant bad prognosis!
Superficial infection
Ø Diagnostics
* inspection * palpation * Ultrasound * lab results
Ø Therapy
* conservative/kryoth. * operative (revision, debridement, perhaps drainage)
Deep infection Subfascial, extra/intraarticular haematoma, tissue damage Ø Diagnostics
* inspection * palpation * Ultrasound * punction * labs
Ø Therapy
* immediate revision, debridement * suction drainage * Septopal chain
Diagnostic methods Ø Laboratory
* WBC * qualitative bloods * We (ESR) * CRP * procalcitonin * TNF
Ø Instrumental
diagnostics * US (punction) * x-ray (gas, fluid) * CT/contrast * MRI/contrast * scintigraphy * thermography (?)
The best way of therapy: PRAEVENTION
„conservative therapy…
or revision?”
When you have a suspicion on postoperative infection… Don’t hesitate!!! Immediate revision is obligatory!!!
Soft tissue infection after Achilles tendon suture
Management: Radical debridement
GIRDLESTONE
42y.
chr. alc.
GIRDLESTONE
Hip prosthesis infection
Secundary wound healing
Intramedullary debridement
Intramedullary debridement gravitational drainage
staged removal
Infected Non Union
Ø Secundary
prosthetic replacement
Venous thromboembolism Ø Deep
venous thrombosis (DVT) Ø Epidemiology Ø Risk factors Ø Location Ø Complications Ø Diagnosis Ø Prophylaxis Ø Treatment
DVT Prophylaxis in Traumatology Ø Risk l l l l
factors: immobilization !,
fractures : pelvic, lower extremity spinal cord injury surgical procedures (orthopedic, >2h) blood transfusion, high ISS >9, extensive soft-tissue trauma
Ø Prophylaxis: l l
1. LMWHs
2. Vitamin K antagonists (e.g.warfarin) - INR: 2,5 3. per os prophylaxis (only hip and knee replacement !) • Xa inhibitor: rivaroxaban • thrombin inhibitor : dabigatran
Reconstructive (plastic ) surgery Ø Soft
tissue reconstruction Ø Bone transplantation Ø Apropriate stabilization
Ø Limb
salvage of a mangled extremity needs a series of heroic surgical attempts, with it’s psychological, functional and morbid effects.
Soft-tissue reconstruction
+ repeated bone transplantation
+++ bone transplantation different ostheosynthesis: EF, plate, nail
2 years !
BJ 92 7 137
