Written by:
Anna Chiara Corriero
Anglia Ruskin Medical School
If you walk into the orthopaedic ward of any hospital in the world, you will get the idea that tibial fractures are extremely feared. The tibia is known for bearing a big proportion of our body weight: it is a very important bone and an injury to it is no laughing matter. Having a fractured tibia means that you won’t be able to make any movements and will need to rest to give the bone enough time to heal.
Due to the subcutaneous nature of the bone (1), tibial fractures often present themselves as open fractures and this will pose a challenge to the physician. Open fractures are characterised by the bone fragments piercing the skin, and thus the wound exposes the bone, making the bone itself and the soft tissue surrounding it more vulnerable to infection and so the muscles, tendons, and ligaments will be at risk (2).
Consequently, when managing a patient with an open tibial fracture, doctors need to consider the possibility of fixating the bone and making sure it can heal properly, as well as preserving the soft tissues by removing possible debris (3) to avoid infection. Luckily, with the medical advancements made in the past century, it has been possible to treat these injuries and in most cases we have been able to avoid sepsis, amputation and death. However, such injuries are still traumatizing to the patient and will perhaps have long-term effects.
Most cases of tibial fracture result from high impact injuries that can happen during sporting activities like skiing, falling from considerable height or as a result of serious road and traffic accidents (4). Due to the aetiology of the fracture, the patients are often in distress, scared and in excruciating pain. Thus, it has been fundamental to standardise the care given to any patient presenting with an open tibial fracture, to holistically deliver the best possible care plan and comfort the patient, as well as saving their limb and avoid any debilitating consequence of open tibial fractures.
However, standardised management plans are imposed more in some countries compared to others; often, lower income countries are provided with less guidelines and directives. This causes more variety in the approach of open tibial fractures. Let’s compare what happens in the United Kingdom as opposed to Latin America.
In the UK, patients with open tibial fractures often present themselves to the local hospitals and clinics. In this setting, patients cannot access the combined care they need from the orthopaedic surgery team as well as the plastic surgery teams (5): this means that often initial debridement happens under the care of the local hospital where the patient is admitted, before being able to reach a centre where soft-tissue reconstruction can happen. Patients who arrive at specialist centres, therefore foregoing the local hospital, are often able to reach better outcomes regarding their injury. It is indeed recognised that transfers between hospitals might delay definite treatment.
In the UK, what has dramatically improved the outcomes of open tibial fractures has been early soft-tissue restoration (6). This has been due to a better knowledge of the cutaneous blood supply of the region as well as surgical advances that have guaranteed a better management of musculocutaneous issues.
Advances in fixation techniques as well as prompt bone grafting have led to a shorter time to union of the fracture. This aspect has contributed to quicker and greater healing, by combining the care of the musculoskeletal injured system and the surrounding soft tissues (7).
Management in the UK therefore involves the following steps:
1Prevention of infection and sepsis from the wound (8) is the primary objective. Numbers suggest that up to 25% of open tibial fracture cases develop some sort of infection, which then poses serious challenges and complications to both the patient and the physician.
Resuscitation: as explained above, patients often present with open tibial fractures after dramatic injuries. Therefore, it will be necessary to assess them with the ABCDE method and ensure that the patient is stable before the start of treatment.
Initial recognition of the extent of injury and thus, administration of adequate analgesia and antibiotics. The literature suggests that exploration of the wound and soft tissue debridement in the emergency department does not lead to any advantage and in some cases, it can be detrimental as it can lead to further dissemination of foreign bodies in the surrounding soft tissues. Concerning antibiotic therapy, guidelines recommend first generation cephalosporins (8). However, sources suggest that due to the link between usage of first generation cephalosporins and the development of C. difficile infections, patients should be offered co-amoxiclav (1.2g / 8 hourly) until the initial debridement procedure has been carried out. Patients with allergies to the beta-lactams can be safely administered clindamycin.
It is also important to note that anti-tetanus therapy must begin in a case of open tibial fractures.
As mentioned above,the prevention of infection and sepsis should start from debridement of the wound as well as irrigation; necrotic tissue should be excised and remaining tissue should be assessed as viable using the C criterion devised by Scully: contractility, colour, consistency and capacity to bleed. This must be accompanied by copious irrigation.
During the initial presentation, rigid stabilisation of the limb is necessary to prevent further injury and avoid complications such as pitting oedema. BOA/BAPRAS guidelines suggest that if external fixators are used, “exchange from spanning external fixation to internal fixation must be done as early as possible” (8), as internal fixation is deemed safer to avoid further exposure to foreign pathogens. Circular fixators can be used on a case to case basis, such as when the bone is fractured at multiple levels or in cases of extensive soft tissue injury.
At the time of definitive management, the patient should be administered gentamicin and vancomycin; these must be stopped after surgery.
It is important, for ease of management and communication between the operating team, to classify the tibial fracture. However, reassessment should be performed after surgery and fixation, in order to reclassify the injury if necessary. Because of habit and simplicity, orthopaedic surgeons around the UK use the Gustilo and Anderson classification.
Overall, the most important factor in management of open tibial fractures has been found to be early debridement and administration of antibiotics. Early stabilisation is also significant, even if the method varies depending on the fracture pattern, the quantity of bone lost, and the extent of the soft tissue injury. Both factors are cardinal because it is believed that saving a limb without a good function can be more detrimental to the overall health and quality of life of the patient, compared to proceeding with early amputation, physiotherapy and rehabilitation with an artificial limb (9).
Concerning Latin America, it is safe to say that tibial fractures are still considered a burden on the healthcare systems of the continent. With a rise in road traffic accidents, there has been an increase in the incidence of this presentation (10), and despite a stable yet high rate of complication, there does not seem to be a wide, standardised strategy to tackle this injury (11).
Sources report that Latin American surgeons use the same classification method as UK-based surgeons, being the Gustily-Anderson classification of lower limb fractures. However, often the antibiotic therapy (with first or third generation cephalosporins, often joined by aminoglycosides) and the process of debridement are delayed and far from the optimal treatment time (11). When looking at the literature, the common causes identified for these issues are lack of staff or space in the hospital facilities for treatment as well as delayed presentation to the care setting.
Regarding definitive management, internal fixation is preferred to external fixation; the latter is often disregarded to avoid infectious complications and the former is often delayed for the same reason. Moreover, due to the lack of plastic surgeons and surgeon training levels, sources report that up to a third of patients do not undergo soft-tissue coverage procedures (11).
The differences in management of open tibial fractures are evident and can be explained by the socio-economic disparities between the United Kingdom and Latin American countries; the existence of more economical and efficient resources in the United Kingdom have led to the creation of guidelines and standardised management in the UK; in Latin America, a lack of the aforementioned resources, as well as a lack of trained staff, has led to more freedom and diversity in management of the condition.
The available literature shows a significant difference in complication rates between the United Kingdom and Latin American countries; Mexico, for example, has reported a complication rate of 20% for all open fractures, with infection being the most contributing complication (12). Instead, for open tibial fracture cases in the UK, data that infection cases can range from 10% to a maximum of 16% (13).
It will be interesting to see more data comparing the management of open tibial fractures worldwide, describing the differences in treatment plans and procedures in high income countries as opposed to low income countries. Moreover, it would be admirable to see some world-wide imposed guidelines, in order to decrease the differences in care given to patients, regardless of the socio-economic status of their country.
References
Open Tibia Fractures: Practice Essentials, Etiology, Epidemiology. Emedicine.medscape.com. https://emedicine.medscape.com/article/1249761-overview#a1. Accessed November 13, 2020.
Tibia (Shinbone) Shaft Fractures - OrthoInfo - AAOS. Orthoinfo.aaos.org. https://orthoinfo.aaos.org/en/diseases--conditions/tibia-shinbone-shaft-fractures/. Accessed November 13, 2020.
Cross WW 3rd, Swiontkowski MF. Treatment principles in the management of open fractures. Indian J Orthop. 2008;42(4):377-386. doi:10.4103/0019-5413.43373
Anandasivam NS, Russo GS, Swallow MS, et al. Tibial shaft fracture: A large-scale study defining the injured population and associated injuries. J Clin Orthop Trauma. 2017;8(3):225-231. doi:10.1016/j.jcot.2017.07.012
Naique SB, Pearse M, Nanchahal J. Management of severe open tibial fractures: the need for combined orthopaedic and plastic surgical treatment in specialist centres. J Bone Joint Surg Br. 2006;88(3):351-357. doi:10.1302/0301-620X.88B3.17120
Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285-292. doi:10.1097/00006534-198609000-00001
Keating JF, Blachut PA, O'Brien PJ, Court-Brown CM. Reamed nailing of Gustilo grade-IIIB tibial fractures. J Bone Joint Surg Br. 2000;82(8):1113-1116. doi:10.1302/0301-620x.82b8.10566
Open Fractures of the Lower Limb | BAPRAS. Bapras.org.uk. https://www.bapras.org.uk/professionals/clinical-guidance/open-fractures-of-the-lower-limb. Accessed November 13, 2020.
Shanmuganathan R. The utility of scores in the decision to salvage or amputation in severely injured limbs. Indian J Orthop. 2008;42(4):368-376. doi:10.4103/0019-5413.43371
Fraser B. Traffic accidents scar Latin America's roads. Lancet. 2005;366(9487):703-704. doi:10.1016/S0140-6736(05)67158-9
Albright PD, MacKechnie MC, Roberts HJ, et al. Open Tibial Shaft Fractures: Treatment Patterns in Latin America [published online ahead of print, 2020 Sep 4]. J Bone Joint Surg Am. 2020;10.2106/JBJS.20.00292. doi:10.2106/JBJS.20.00292
Orihuela-Fuchs VA, Fuentes-Figueroa S. Incidencia de infección en fracturas expuestas ajustada al grado de exposición [Infection rate in open fractures adjusted for the degree of exposure]. Acta Ortop Mex. 2013;27(5):293-298.
Elniel AR, Giannoudis PV. Open fractures of the lower extremity: Current management and clinical outcomes. EFORT Open Rev. 2018;3(5):316-325. Published 2018 May 21. doi:10.1302/2058-5241.3.170072