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 Welcome to

Open Tibial Fractures: Damage

Control and Treatment Options
(An Online Continuing Education Activity)
CONTINUING EDUCATION INSTRUCTIONS
This educational activity is being offered online and may be completed at any time.

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Overview
The tibia is the most common fractured long bone in the body. These fractures, especially
when open, often present with other complex injuries, and it is essential for perioperative
nurses and surgical technologists to have an understanding of tibial fracture management.
This course will provide information on treatment for open tibial fractures. The incidence of
tibial fractures, types, and classifications of tibial fractures will be presented. Approaches
to the immediate management of open tibia injuries will be outlined including: fixation
options, indications, operative positioning, instrumentation, and nursing documentation will
be described.

Objectives
After completing this continuing education activity, the participant should be able to:
1. Describe the various types of open tibial fractures, both proximal and distal. 

2. Discuss the incidence of occurrence. 

3. Identify patient implications. 

4. Discuss emergent external treatment fixations. 

5. Describe internal treatment options. 

6. Outline procedure and instrumentation for internal and external fracture fixation. 


Intended Audience
This continuing education activity is intended for perioperative registered nurses and
surgical technologists involved with the care of orthopedic patients who want to learn more
about the treatment of open tibial fractures.

CREDIT/CREDIT INFORMATION
State Board Approval for Nurses
Pfiedler Enterprises is a provider approved by the California Board of Registered Nursing,
Provider Number CEP14944, for 2.0 contact hours.
Obtaining full credit for this offering depends upon attendance, regardless of circumstances,
from beginning to end. Licensees must provide their license numbers for record keeping
purposes.
The certificate of course completion issued at the conclusion of this course must be
retained in the participant’s records for at least four (4) years as proof of attendance.

Release and Expiration Date:

This continuing education activity was planned and provided in accordance with
accreditation criteria. This material was originally produced in July 2016 and can no longer
be used after July 2018 without being updated; therefore, this continuing education activity
expires July 2018.

3
Disclaimer
Pfiedler Enterprises does not endorse or promote any commercial product that may be
discussed in this activity.

Support
Funds to support this activity have been provided by Smith & Nephew.

Authors/Planning Committee/Reviewer
Julia A. Kneedler, RN, MS, EdD Denver, CO
Program Manager/Planning Committee
Pfiedler Enterprises

Judith I. Pfister, RN, BSN, MBA Denver, CO

Program Manager/Planning Committee
Pfiedler Enterprises

Dondra Tolerson, BS, MA Woodstock, GA

Medical Writer/Author

Melinda T. Whalen, BSN, RN, CEN Denver, CO
Program Manager/Reviewer
Pfiedler Enterprises

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conflict of interest. A commercial interest is any entity producing, marketing, reselling, or
distributing health care goods or services consumed by, or used on, patients.
Activity Authors/ Planning Committee/Reviewer
Julia A. Kneedler, EdD, RN
No conflict of interest

Judith I. Pfister, MBA, RN

No conflict of interest

4
Dondra Tolerson, BS, MA
No conflict of interest

Melinda T. Whalen, BSN, RN, CEN

No conflict of interest

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5
INTRODUCTION
The lower leg is made up of the tibia and fibula bones. The tibia is the larger bone that
supports most of the weight of the body and is an important part of the knee and ankle
joints. Tibial fractures are common long-bone injuries and can fracture in a number of
patterns and locations along the bone; the severity of the fracture typically is dependent
upon the amount of force that caused the break. There are five main categories of
fractures:1
1. Incomplete: the fracture involves only a portion of the cross-section of the bone.
One side breaks; the other usually just bends.
2. Complete: the fracture line involves the entire cross-section of the bone and
fragments are usually displaced.
3. Closed: the fracture does not extend through the skin.
4. Open: bone fragments extend through the muscle and skin.
5. Pathological: the fracture occurs in diseased bone (e.g., cancer, osteoporosis)
with minimal to no trauma
Reports indicate that approximately 492,000 tibial fractures occur in the United States
annually;2 greater than 70,000 hospitalizations, 800,000 office visits, and 500,000 hospital
days have been attributed to tibial fractures.3 The skin and subcutaneous tissue are thin
over the surface of the bone, therefore tibial fractures are frequently open or compound,
which means the broken bone protrudes through the skin or a wound penetrates down to
the broken bone.4 Roughly 25% of tibial shaft fractures are open and represent the most
common open fracture. Open fractures can lead to infection in both the wound and the
bone. Both the broken bone(s) and any soft-tissue injuries must be treated together and
in many cases require surgery to restore strength, motion, and stability to the leg. This
open fractures are particularly serious because, once the skin is broken, infection can
occur in both the wound and the bone. Urgent treatment is required to prevent infection.
Antibiotics, surgical debridement, and internal fixation improve outcomes for open
fractures; however, the underlying principles for treating open fractures-- primary asepsis,
adequate debridement, immobilization, and protection of wounds against disturbance and
reinfection--have not changed in almost a century.

OPEN TIBIAL FRACTURES: TYPES AND CAUSES

Fractures of the tibia can be classified as: proximal tibia, tibial shaft, distal tibia, and pilon
fractures.
The proximal tibia is the upper one-fourth of the tibia and includes epiphysis and
metaphysis. These fractures occur in the upper portion of the bone where it widens (and
forms part of the knee joint) and may or may not involve the knee.

6
Figure 1. Proximal Tibia Fracture

The tibial shaft is the mid-section of the tibia and entirely diaphysis. The most common
open tibial fracture involves the tibial shaft and occurs along the length of the shinbone,
below the knee and above the ankle. In general, it takes a great deal of force to break a
long bone, and other injuries often occur with these types of fractures.4

Figure 2. Tibial Shaft Fracture

The lower one-fourth of the tibia is the distal tibia. If a fracture occurs at the bottom of the
tibia and involves the weight-bearing surface of the ankle joint, it is called a distal tibia
fracture.

7
Figure 3. Distal Tibia Fracture

Fractures of the distal articular surface of the tibia are called plafond fractures or pilon
fractures. A pilon fracture is a break that occurs at the bottom of the tibia and involves the
weight-bearing surface of the ankle joint. With pilon fractures, the bone is often shattered
into several pieces due to the high-energy impact that caused the injury.

Figure 4. Pilon Fracture

When injuries to the tibia result in open fractures, other bones (fibula) and soft tissues
(skin, muscle, nerves, blood vessels, and ligaments) may be injured at the time of the
fracture. In most cases, surgery is needed to restore the damaged bone to its normal
position.

Fracture Patterns5
In certain types of tibial fractures, the bone breaks but its pieces still line up correctly. In
other types of fractures, the injury moves the bone fragments out of alignment. The most
common types of tibial shaft fractures include:1

8
Transverse fracture. In this type of fracture, the break is a straight horizontal line across
the femoral shaft.

Oblique fracture. This type of fracture has an angled line across the shaft.

Spiral fracture. The fracture line encircles the shaft like the stripes on a candy cane. A
twisting force to the lower leg causes this type of fracture.

Comminuted fracture. In this type of fracture, the bone has broken into three or more
pieces. In most cases, the number of bone fragments directly correlates with the amount
of force required to break the bone, thus the higher the number of bone fragments, the
greater the amount of force involved in causing the fracture.

Figure 6. Types of Fractures

Open fracture. If a bone breaks in such a way that bone fragments pierce through the
skin or a wound penetrates down to the broken bone, the fracture is called an open
or compound fracture. Open fractures often involve more extensive damage to the
surrounding muscles, tendons, and ligaments. They have a higher risk for complications
— especially infections— and take a longer time to heal.

Figure 7. Open fracture of tibia

Causes
Open fractures tend to be caused by more severe trauma than closed fractures. They
typically occur due to mechanisms involving high-energy injuries (eg, motor vehicle

9
collisions [MVCs], skiing accidents, and high-energy falls), or penetrating injuries (eg,
gunshot wounds).6 However, fractures due to low-energy, indirect, torsional trauma can
penetrate the skin from within, particularly in locations where the bone lies close to the
skin and is not protected by a muscular envelope such as the tibia. For pediatric patients
with open tibial fractures, a high index of suspicion for child abuse should be maintained
especially if there is a history of multiple long bone fractures or fractures in non-ambulatory
children.7

When an individual presents with an open tibial fracture, maintaining a functional limb is the
goal. The surgeon endeavors to save the patient’s limb and life by realigning the fracture
and preventing infection. Exposure of bone and deep tissue to the environment leads to
increased risk of infection, wound complications, and non-union of the fracture.8, 9, 10

CLASSIFICATION SYSTEMS
A classification system is a tool utilized to assist physicians and nurses with methodically
and accurately describing similar injuries or conditions.11 Open fractures often involve much
more damage to the surrounding muscles, tendons, and ligaments; they have a higher
risk for complications and take longer to heal.5 The variable outcomes among different
patterns and severities of open fractures prompted the development of classification
systems11 based on the extent of the associated soft tissue injuries and serve as a guide
for treatment, estimated prognosis, communication, and research. The classification
systems offer decision support to surgeons for making clinical judgments on the most
appropriate management of fractures and aims to prevent treatment errors that may lead to
complications.

Gustilo-Anderson Classification
The Gustilo-Anderson classification for open fractures is most commonly used.11Although
it has limitations, the Gustilo-Anderson classification system has proven to be a good
prognostic indicator and originated as a refinement of the Veliskakis grading system.12,
13
Through their research on infection prevention in open long bone fractures, Gustilo et
al outlined the general principles of management of open fractures and helped define
the current methodology for treating open fractures. Decades of research correlating the
Gustilo-Anderson grade with infection risk have helped refine surgical protocols, change
antibiotic recommendations, and determine appropriate timing for interventions.14, 15 The
system categorizes open injuries into three primary categories based on wound size, level
of contamination, and osseous injury; the higher grades of injury are commonly associated
with infection and nonunion (Table 1).

10
Table 1. Gustilo-Anderson Classification System13, 16, 17

Gustilo and Anderson initially recommended surgical debridement and irrigation for all
open fractures, with primary closure for Types I and II fractures, and secondary closure
for Type III fractures. Gustilo et al later modified these recommendations to include
fixation devices for Type III fractures that have more extensive soft tissue injuries16

Tscherne Classification
In the 1980’s Oestern and Tscherne18 initially developed a classification for closed limb
fractures. Later, they developed a grading system for open fractures and soft-tissue
injuries. The Tscherne classification system includes soft tissue damage, fracture
severity, contamination, and amputation as assessment parameters for open fractures.

11
Table 2. Tscherne Classification of Open Soft-Tissue Injuries18, 19

SEVERITY SOFT FRACTURE ADDITIONAL

GRADE CONTAMINATION
TISSUE DAMAGE SEVERITY CRITERIA

O-1 Mild Mild to moderate None to mild

O-2 Moderate Mild to severe Moderate
O-3 Severe Mild to severe Severe Impending
compartment
syndrome
O-4 Severe Mild to severe Mild to severe Amputation,
subtotal or total;
Compartment
syndrome

Within the orthopedic industry it is felt that the aforementioned classifications have poor
interobserver agreement;20 however, they do serve as good general guides. Results of
contemporary research indicate that these classification systems may not be sufficient in
meeting modern objectives. As a result, a more robust grading system has been made
available in the AO Soft Tissue grading system.21

AO Classification Systems
The AO classification system was developed by the AO Foundation, which originated
from the research study group, Arbeitsgemeinschaft für Osteosynthesefragenis. The
AO Foundation specializes in research and treatment of trauma and disorders of the
musculoskeletal system and is guided by an extensive network of international surgeons,
operating room personnel, and scientists.22, 23

The system identifies injuries to the different anatomical structures: skin, muscles and
tendons, and neurovascular system (Tables 3 - 5). The injuries to these anatomical
structures are then graded based on specific criteria as shown (Tables 3 - 5). Fractures
are separately classified using a detailed and comprehensive set of criteria according
to the AO classification of fractures.1 The AO classification of long bone fractures is
descriptive and grounded in identifying the pattern of the primary fracture and counting
the number of fragments.24 When used in a large database for research, its alphanumeric
classification allows for precise comparison of injury types; however, its intricacy renders
it somewhat impractical for daily clinical practice and there is no conclusive evidence
that this classification is superiorly helpful in clinical decision-making.25 The classification
system is illustrated in a 10-page publication from AO Trauma and can be found at:
https://www.aofoundation.org/Documents/mueller_ao_class.pdf.

12
Table 3. AO Soft-tissue Classification: Open Skin Lesions.21
Table 3. AO Soft-tissue Classification: Open Skin Lesions.21
GRADE
Table CRITERIA
3. AO Soft-tissue Classification: Open Skin Lesions.21
GRADE CRITERIA
IO 1 Skin breakage from inside out
Table
IO 3. AO Soft-tissue Classification: Open Skin Lesions. 21
IO 21 Skin
Skin breakage from
breakage from outside in <5 cm, contused edges
inside out
GRADE
IO 23 CRITERIA
Skin
IO Skin breakage
breakage from
from outside in <5
outside in >5cm,
cm,increased
contused contusion,
edges devitalized edges
IO
IO 43 Considerable,
Skin breakage full-thickness
from outside contusion,
in >5cm, abrasion,contusion,
increased extensivedevitalized
open degloving,
edgesskin loss
IO
IO 15 Skin breakage
Extensive from inside out
degloving
IO
IO 42 Considerable,
Skin breakage full-thickness contusion,
from outside in abrasion,edges
<5 cm, contused extensive open degloving, skin loss
IO 35
IO Extensive
Skin degloving
breakage from outside in >5cm, increased contusion, devitalized edges
Table
IO 4 4.4.AO
Table Soft-tissue
AO Soft-tissue Classification:
Considerable, Muscles Muscles
full-thickness
Classification: and
andcontusion,
Tendons. 21 Tendons.
abrasion, extensive
21 open degloving, skin loss
IO 5
GRADE Extensive degloving
CRITERIA
Table 4. AO Soft-tissue Classification: Muscles and Tendons.21
GRADE CRITERIA
MT 1 No muscle injury
Table 4. AO Soft-tissue
MT Classification:muscleMuscles and oneTendons. 21
MT 21 Circumscribed
No muscle injury injury, compartment only
GRADE
MT 23 CRITERIA
Considerable muscle
MT Circumscribed muscleinjury,injury,two onecompartments
compartment only
MT
MT 34 Muscle defect,muscle
Considerable tendoninjury,
laceration,two extensive muscle contusion
compartments
MT
MT 15 No muscle injury
Compartment
MT
MT 24 Muscle defect,syndrome/crush
Circumscribed tendon laceration,
muscle
syndrome with
injury, one extensive
compartment
wide injury
muscle zone
onlycontusion
MT
MT 5
3 5. AO Soft-tissue Compartment
Considerable syndrome/crush
muscle syndrome
injury, twoSystem.compartments with wide injury zone
Table Classification: Neurovascular 21
MT
GRADE 4 Muscle
CRITERIA defect, tendon laceration, extensive muscle contusion
Table 5. AO Soft-tissue Classification: Neurovascular System.21
MT 5 Compartment syndrome/crush syndrome with wide injury zone
Table
GRADE
NV 1
5. AO Soft-tissue Classification: Neurovascular System.21
CRITERIA
No neuromuscular injury
Table
NV 12 5. AO Soft-tissue Classification:
Isolated nerve injuryNeurovascular System.21
NV No neuromuscular injury
GRADE
NV
NV 2 3 CRITERIA
Localized
Isolated nerve injuryinjury
vascular
NV
NV 34 Extensive segmental
Localized vascular vascular injury
injury
NV
NV 154 No neuromuscular
Combine
Extensive ofsegmental injury
neurovascular vascular injury, including total or total amputation
injury
NV
NV 52 Isolated
Combinenerve injury
of neurovascular injury, including total or total amputation
NV
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12

Fractures

and Injuries: The bone(s) can be broken vertically, horizontally, and/or in 12
several pieces. The pieces of the fractured bone can be very sharp and tear through soft
tissue from within. When the bone shatters there may be a multiple fragments, which

13
may lacerate surrounding neurovascular and soft tissues. Patients with Type III fractures
are at significant risk for life-threatening hemorrhage from associated vascular injuries.
Not all severely damaged limbs can be salvaged and amputation may be required.

Contamination: The environment the fracture is exposed to affects the degree of

contamination. Dirt, broken glass, or fabric can be driven into a wound. Due to the
contaminated nature of Type III open fractures, initial treatment is often external fixation,
although some surgeons advocate use of intramedullary nails.

Infection: Open fractures are associated with a significantly higher rate of infection
than closed fractures. However, the degree of infection depends on many variables. In
general, the more extensive the damage to the bone, soft tissues, nerves, and blood
vessels, the higher the corresponding risk for infection. A bone infection can be difficult
to eliminate and may necessitate long-term antibiotic treatment and multiple surgical
procedures. In some severe cases, amputation of the infected limb is the only way to
effectively treat the infection.

Wound Healing: Normally, as a wound heals, new skin cells are formed and added to
the edges and base of the wound and this process continues until the wound is closed.
Wounds associated with open tibial fractures, do not heal normally and the wounds fail
to close. Clinical research into non-healing wounds has highlighted several barriers to
healing that include infection, non-viable or dead tissue, and an imbalance of moisture
levels in the wound. Use of evidence-based treatment protocols help promote wound
healing. An effective wound measurement system should be utilized to track the progress
of wound closure and the effectiveness of prescribed treatment.

Compartment Syndrome: Acute compartment syndrome may develop in an open

tibial fracture and is a medical emergency. The condition can be extremely painful
for the patient and occurs when the tissue pressure within the muscles exceeds the
tissue perfusion pressures. This results in lack of oxygenated blood to the tissue and
accumulation of waste products in the tissue resulting in ischemia to the muscles and
nerves. Peripheral sensation decreases secondary to nerve irritation and damage,
and late manifestations include: absence of distal pulses, paresthesia and hypothesia,
and extremity paralysis. If the elevated pressure in the compartment is not relieved
quickly by fasciotomy, permanent disability due to loss of function of the limb may result.
Compartment syndrome should be diagnosed based on clinical findings such as: 27, 28
• Pain and increased pain with passive toe stretch
• Neurological changes (eg, paresthesia, hypothesia, paralysis)
• Swelling of the muscle compartments
• Compartment pressure measurement with intra-compartment pressure
monitoring device

Compartment syndrome is more common in closed tibial fractures; however, it can

also be associated with open fractures so it cannot be assumed that the open wound

14
decompresses the compartment. Blick et al from the Adam Cowley Shock Trauma Centre
reported a 9% rate of compartment syndrome in patients with open tibial fractures.29
Recent studies show that in diaphyseal tibial fractures, the rate of associated compartment
syndrome may be as high as 11.5 %.27 In particular, pediatric patients have a significantly
increased risk of developing compartment syndrome with open fractures.27, 30, 31 In some
cases of open fractures, blood clot formation can impede effective decompression and the
muscle or fascial layers can close like trap door causing the pressure to increase in the
muscle compartment.

MANAGEMENT OF OPEN TIBIAL FRACTURES

The majority of open fractures require urgent irrigation and debridement. Antibiotics are
essential in preventing infection. Timely wound therapy and closure after all necrotic tissue
has been debrided also decreases complications. Lastly, fixation of the patient’s broken
bone to restore it to normal alignment must be performed. This section will discuss the
most common principles in managing fractures.

Radiographic Evaluation
Radiographic evaluation (x-rays) of tibial fractures allow for assessment of displacement,
translation, shortening and angulation. As a standard, anterior-posterior and lateral
radiographs of the injured bone along with x-rays of the adjacent knee and ankle joint are
recommended. Computer tomography (CT) scans of the tibial plateau or ankle may be
required in order to identify and depict fracture lines extending into the tibial plafond as well
as associated non-contiguous ankle injuries.32, 33

Antibiotic Therapy
Open fractures are associated with a significantly higher rate of infection and preventing
infection is the focus of early treatment. Many variables impact the degree of infection
such as the amount of damage is to the bone, soft tissues, nerves, and blood vessels. The
environment the fracture is exposed to – shards of glass, dirt, and fabric – also affects the
degree of contamination.34 Experts, such as the Surgical Infection Society, recommend that
antibiotics be started as soon as possible in open fractures.35, 36 There is also evidence that
antibiotic regimens as short as one day are as effective as regimens of three to five days.37
Osteomyelitis, or infection of the bone, can be difficult to treat and often results in long-term
antibiotic therapy and multiple surgeries. In severe cases, amputating the infected limb is
the only way to eliminate the infection.

A Canadian study published in 2014 evaluated the association between time to surgery,
antibiotic administration, Gustilo grade, fracture location, and development of deep infection
in open fractures. There were a total of 736 participants with tibia and fibula fractures being
the most common. The overall infection rate among participants was 6% with a median
time to surgery of nine hours for patients without infection and seven hours for those
with infection. The significant finding in the study was infection after open fracture was
associated with increasing Gustilo grade, but not time to surgery or antibiotics.38

15
An observational study published in 2015 analyzed the association between antibiotic
timing and deep infection of type III open tibia fractures. Outcomes revealed that the
time from injury to antibiotic administration and to wound coverage independently predict
infection of these fractures. Predictors for infection were greater than five days from
injury to wound coverage and more than 66 minutes from time of injury to administer
antibiotics to patients. Immediate antibiotics and wound coverage within less than five
days of the initial injury limited infection rates to 2.8%. However, with a delay in one of the
factors--antibiotic administration or wound coverage—infection rates were 10.2% and the
infection rate rose to 40.5% in cases with a delay in both factors.39

Debridement and Irrigation

Patients should be scheduled for debridement and irrigation promptly as to not increase
the risk of infection.40 A recent study explored the relationship between delayed surgical
debridement and deep infection and found a statistically significant increase in the rate
of deep infection per hour of delay in high grade and substantially contaminated open
fractures.41

Tissue Viability
Wound assessment begins with evaluating tissue viability. Viable tissue is granulating
(red) or epithelializing (pink), while non-viable tissue may be necrotic (black) or sloughy
(yellow). Slough (Figure 1) can be soft or firm and is comprised of fibrinous material,
pus, and proteins. Necrotic tissue (Figure 2) presents as a black or dark brown scab
that may cover all or part of the wound. Non-viable tissue creates an environment that is
conducive to infection and bacterial growth.

Figure 8. Representation of Sloughy Figure 9. Representation of Necrotic

Tissue42 Tissue42

Necrotic and sloughy tissue can be removed from the wound through debridement after
vascular supply is established. Wound debridement can be performed surgically or
by manual methods, such as irrigating with a solution or autolytic debridement where
antimicrobial or hydrogel dressings are used to separate dead tissue from healthy tissue.

During debridement, all dirt, foreign bodies, and unhealthy, contaminated skin, muscle,
and other soft tissue are removed. The bone is also cleaned and any unattached pieces
of bone are removed. Surgical debridement is performed in a methodical manner starting
with each layer of the skin around the circumference of the wound and down to the level
of the bone. Necrotic tissue is removed and only viable tissue is salvaged. The exception

16
is skin, where no skin is removed unless obviously necrotic. The quality of the muscle
tissue is also evaluated for color, consistency, circulation, and contractility. The bone
ends are inspected, the fractured edges are curetted to remove fibrous tissue and debris,
and all dirt and non-viable bone are removed.

Infection and Inflammation43, 44

Wound healing is delayed when harmful bacteria in the wound cause infection or worsen
inflammation. If untreated, life-threatening, systemic infection can result. Localized areas
of infection can be removed from a wound by debridement or by utilizing antiseptic or
antimicrobial products to reduce bacterial counts and accelerate healing time. Causative
agents of infected wounds can be confirmed with a wound culture and typically display
the characteristics indicated below:
• Redness
• Inflammation
• Exudate
• Increased odor
• Increased tenderness
• Irregular tissue that bleeds easily

Moisture Management
As part of the healing process, wounds release fluid called exudate which is mainly
comprised of water but also contains electrolytes, proteins, and various types of cells.
Although the skin layers of moist wounds heal faster and scar less than dry wounds, too
much (maceration) or too little (desiccation) exudate can interfere with wound healing.
Therefore, it is important to properly assess exudate levels and select a suitable dressing
that will either remove excess fluid or add hydration (i.e., hydrogels) to the wound in
order to improve wound healing.

Wound Coverage
Open fractures accompanied by complex wounds where substantial soft tissue has been
lost (Type IIIB) can create a wound that is too large to be closed. This may be a result
of the injury itself or from delayed wound necrosis. In these complex wounds, temporary
coverage of the fracture must be established to decrease the risk of infection and
promote healing. Adequate debridement and close monitoring of the soft-tissue defect
are necessary so that definitive soft-tissue coverage can be achieved within the first one
to two weeks.45

The extent of damage to the soft tissue determines the method of wound coverage.
The surgeon may elect to conduct a local flap procedure where the muscle tissue from
the involved limb is rotated to cover the fracture. A skin graft is then performed, which
involves removing skin from another area of the body, and is placed over the exposed
muscle. With a free flap procedure, a complete transfer of full-thickness skin and muscle
is taken from a donor site such as the patient’s back, opposite leg, or abdomen. This

17
procedure usually requires the assistance of a microvascular surgeon to ensure the
blood vessels connect and circulation is established. It is recommended that the time to
flap coverage not exceed seven days because the odds of flap contamination and other
flap-related adverse outcomes increase significantly beyond that time.46

For complex open wounds, many types of dressings can be used. Sometimes the
wound is sealed with a semipermeable material until the soft-tissue closure procedure
can be completed. Antibiotic beads are often placed into the wound bed before sealing
to provide high concentrations of antibiotics directly to the site of the injury. Vacuum
assisted closures (VACs) are negative pressure wound dressings that can provide
temporary coverage of an open wound. These dressings help reduce bacterial counts in
wounds, remove excess fluid and exudate, help diminish wounds, and promote growth
of granulation tissue. VACs may allow definitive closure with the subsequent use of split-
thickness skin grafts, instead of more complex flap procedures. Debate continues over
timing and type of definitive wound coverage. Ideally, VAC usage should not extend
beyond seven days to avoid higher infection rates and amputation risks.47

Fracture Stabilization and Fixation Devices

It is essential to stabilize the broken bone(s) as soon as possible to prevent further
soft tissue damage, reduce bleeding, and help relieve pain. There are multiple external
and internal fixation options for surgical bone stabilization. Average time to union for
severe open tibial fractures can be up to a year, and delay or failure of bone healing is
a common risk with open tibial fractures. Failure to unite may require additional surgical
procedures, such as bone grafting and/or revised fixation. Stimulation of bone healing
remains a developing field.48

Internal Treatment Options49, 50

For less severe open tibial fractures with minimal contamination, the fracture can be
stabilized with internal fixation after the wound has been thoroughly debrided. The
stabilization procedure is called an Open Reduction Internal Fixation (ORIF) and
prevents the bones from healing abnormally. During the procedure, bone fragments
are first reduced (repositioned) into proper alignment. Appropriate alignment must be
maintained throughout internal fixation placement. Special screws or plates are placed on
the outer surface of the bone for alignment. Insertion of metal rods through the marrow
space in the center of the bone can also hold bone fragments together. Most patients
who have an ORIF do very well and complications are rare. The risk of complication
varies according to age, anatomy of the fracture, and other medical conditions. For
example, smokers and individuals with diabetes or low bone mass may be at greater risk
of complications.

Intramedullary Nails
Intramedullary nails (IM) are specially designed titanium alloy rods used to treat fractures
of the long bones by inserting them into the medullary cavity of a bone. They are solid
or hollow (cannulated), come in a variety of sizes, and have locking screw holes close
to both ends. Contemporary IM nails permit placement of locking screws through bone

18
 conditions.
of locking For example,
screws through smokers
boneand and individuals
nail to with diabetes
improve or low bone
fixation bothmass may be atand
proximally greater risk of to a
distally,
complications.
fixation, and to control length, rotation and alignment. They are suitable for the mid diaphysi
newer nail designs
Intramedullary
and nail to Nails and consideration of technique has extended the procedure to include tr
improve fixation both proximally and distally, to allow secure fixation, and to
fractures in the
Intramedullary proximal
nails (IM) are
control length, rotation and distal
specially
and third of
designed
alignment. theare
titanium
They tibia. Thefor
alloy rods
suitable nails
used to also provideofhowever,
treat fractures
the mid diaphysis; suitable biomech
the long bones
by inserting them into the medullary cavity of a bone. They are solid or hollow (cannulated), come in a
stabilization
varietynewer
and
of sizes,
acts
nailand as aandweight-sharing
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have locking consideration of device
screw holes close technique often leading
has extended
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IM nails permit placement
mobiliz
advantage of
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of nails
fracturesis inthat
the they
proximal require
and minimal
distal third surgical
of the tibia. dissection
The nails
of locking screws through bone and nail to improve fixation both proximally and distally, to allow secure with
also appropriate
provide pr
blood supply to the fracture. Reamers can also be used with the IM nail to enlarge the med
suitable
fixation, and to biomechanical
control length, fracture
51
rotation andstabilization
alignment. and
They acts
are as a weight-sharing
suitable for the mid device
diaphysis; often
however,
newer
larger leading
diameter tonails
nail designs early postoperative
andand produceofmobilization.
consideration technique
no Anextended
has
differences advantage theof
in healing the IM nails
procedure
rate, is thattreatment
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surgery,of implant
fractures in theminimal
require proximalsurgical
and distal third of 52
dissection the tibia.
with The nails also
appropriate provide suitable
preservation of bloodbiomechanical
supply to thefracture
compartment syndrome,
stabilization and or infection.
51 acts as a weight-sharing device often leading to early postoperative mobilization. An
fracture. Reamers can also be used with the IM nail to enlarge the medullary canal
advantage of the IM nails is that they require minimal surgical dissection with appropriate preservation of
for larger diameter nails and produce no differences in healing rate, secondary surgery,
bloodFigure
supply to10.
the Examples
fracture.51 Reamers
of IM can also be used with the IM
Nails nail to enlarge the medullary
Figure canal for of IM
11. Example
implant failure rate, compartment syndrome,
larger diameter nails and produce no differences or infection.
in healing
52
rate, secondary surgery, implant failure rate,
compartment syndrome, or infection.52
Figure 10. Examples of IM Nails Figure 11. Example of IM Nails
Figure 10. Examples of IM Nails Figure 11. Example of IM Nails

The The
technique
technique for
The techniquefor insertion
insertion of nails
for insertion
of IM IMof nails
IM begins
nails
begins begins
with with
with application
applicationapplication of
of the
of suction to suction
suction
entry to
tooltheto the entry
to entry
assist tool to a
in blood
evacuation and minimize aerosolization of blood. The reamer is inserted
evacuation and minimize aerosolization of blood. The reamer is inserted over the guide wire
tool to assist in blood evacuation and minimize aerosolization over
of the
blood.guide
The wire
reamerand into
is the
proximal portionover
inserted of the
thetibia.
guideOnce it is
wire and confirmed thethat the reamer hasofadvanced toOnce
the medullary canal of
proximal portion
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it is removed tibia.
and Once
the fracture it into
is reduced.
proximal
is confirmed portion
that
The appropriatethesizethe tibia.has
reamer it is confirmed
advanced
nails are selected to the medu
and positioned
that the reamer has advanced to the medullary canal of the tibia, it is removed and the
the tibia, it is into
and locked removed andposition
place. Final the fracture is reduced.
of the fracture Theviaappropriate
is confirmed x-ray. size nails are selected a
fracture is reduced. The appropriate size nails are selected and positioned and locked
and locked into place. Final position of the fracture
into place. Final position of the fracture is confirmed via x-ray. is confirmed via x-ray.
Despite its popularity, IM nail fixation of displaced tibial shaft fractures remains challenging and is
associated with multiple potential pitfalls. Union rates vary among different studies. According to
Despite its popularity,
Despite IM nail
its popularity, fixation
IM nail of ofdisplaced
fixation displaced tibial shaftfractures
tibial shaft fractures remains challenging a
remains
associated with multiple
challenging potential with
and is associated pitfalls. Union
multiple ratespitfalls.
potential vary among different
Union rates studies. Accordin
vary among
different studies. According to contemporary studies, union rates are 90% or higher with 17
contemporary implants and appropriate surgical techniques.53, 54, 55 Tibial shaft fractures
that fail to heal following IM nail fixation typically respond well to exchange reamed

nailing procedures.56 IM nails yield excellent results for Type I open fractures. In Type II
and Type IIIB fractures they yield an average time to union of 24 to 27 weeks and a deep
infection rate of 3.5%. Complications increase with Type IIIB fractures with an average
time to union of 50 weeks and infection rate of 23%.57

It has been documented that patients have long-term, functional deficits following
repair of tibial shaft fractures with IM nail fixation. Outcome evaluations at one year
post-surgical repair demonstrated that as many as 44 % of patients continued to have
functional limitations with regard to their injured leg58 and as many as 47 % of patients
reported work-related disability.59 Additional follow-up studies indicated that nearly 20%

19
of patients do not return to their previous occupation at two years post-intramedullary
nail fixation 30 % do not return to their previous level of recreation.60 A review of patients
14 years post- procedure found that 73.2 % of patients complained moderate knee pain
and 33.9 % voiced concerns with swelling. The physical examination revealed decreased
range of motion (ROM) of the ankle joint in 42.4 % of patients while 93.9 % of patients
demonstrated full range of motion of the knee joint. X-rays of the knee and ankle showed
osteoarthritis in 35.4 % of patients although misalignment was not present in the films.61

Plates and Screws

The primary indication for the use of plates and screws is a fractured tibia involving
the knee or ankle, and they are also utilized to treat malunions. A variety of locking
and conventional tibial plates are available. Locking plates do not rely on plate-to-bone
compression or friction forces to obtain stability which preserves the local blood supply
to the bone. In theory, this allows for more rapid bone healing, decreased incidence
of delayed or non-union, evades stress shielding below the plate, and prevents bone
necrosis and infection.62, 63, 64

Distal Locking Plates: Anterior and posterior distal tibia locking plates are scalloped and
permit lag screw placement without compromising plate position, and the contour of the
plates facilitate an anterior approach to distal tibia fractures in the coronal plane. The
plates are left and right-side specific and has consistent 1.5mm thickness. Medial distal
tibia locking plates are smooth and feature a tabless distal tip which minimizes soft tissue
irritation over the medial malleolus. These plates are also right and left-specific and the
shape enables a medial approach to distal tibia fractures in the sagittal plane.

Figure 13. Distal Locking Plates and Screws

Proximal Locking Plates: Proximal tibial locking plates offer the advantage of locked
plating with the flexibility and benefits of traditional plating. These plates offer a construct
that resists angular collapse while simultaneously acting as an effective aid to fracture

20
reduction. The pre-contour of this plate provides an excellent fit against the surface of
the bone and the scalloped proximal end allow easy placement of lag screws outside the
plate for fixation of articular fractures.

Figure 12. Proximal Locking Plate with Screw

The length of locking plates should be selected using a proximal or distal template prior
to surgery--longer plates allow for better mechanical advantage over short plates. During
the procedure, the fracture is reduced and then the locking screws placed. The plate is
inserted and positioned to the lateral proximal tibia.

External Treatment Options

Once used primarily as a last resort method of fracture fixation, external fixation has
evolved into a conventional technique.65 The purpose of the external fixation is to serve
as a bridge between fracture reduction and insertion of an internal fixator such as an
intramedullary nail.66, 67 External fixation involves the use of percutaneously placed pins
and/or wires secured to external frames to provide support to a fractured limb. They are
fixed angle devices and create the ability to provide superior fixation in compromised
bones. Indications for external fixation include:65
• Severe open fractures
• Highly comminuted closed fractures
• Arthrodesis
• Infected joints
• Infected non-unions
• Fracture stabilization to protect arterial or nerve anastomosis
• Major alignment and length deficits

More severe open tibial fractures are often initially stabilized by external fixation. The
external fixator is a frame applied outside of the leg that holds the leg and ankle in proper
position with pins and/or wires until an internal fixation procedure can be tolerated.
External fixators can be rapidly applied (especially in polytrauma cases) and allow for
regular inspection of the soft-tissue of the leg and ankle without frequent splint changes.68

21
The device also allows postoperative adjustability, which is a distinction from internal
plates and IM nails. When limb lengthening or deformity correction is indicated, gradual
manipulation is possible with frame adjustment.65 External fixators can be applied using
either a modular or uniplanar frame technique. While modular frames are more versatile
and the configuration can be individualized to suit the specific application, they are less
rigid than uniplanar fixators due to multiple connections.69

Single Plane External Fixators: This type of external fixator can be used for temporary or
definitive stabilization of pilon fractures of the tibia and as an adjunct to internal fixation
for treatment of tibial fractures. The variety of clamps and bar lengths permits versatility
in assembling the frame. Cartridge clamp design is positive locking, allowing no passive
release of pins or bars. The clamps also provide extra flexibility and the ability to angle pins
to 25 degrees. The ball joint component of the clamps allows linear reduction of fractures,
with true translation of long bone fragment ends.

Figure 14. Single Plane External Fixator

Unilateral External Fixators: This frame is indicated for fracture fixation post-traumatic
joint contracture, which may result in loss of range of motion, and for fractures requiring
distraction. It may also be used for limb lengthening by correction of bony or soft tissue
deformity or infected fractures. This fixator is designed to provide flexibility in frame
construction and ease of use. The clamps permit angulation of pins up to 50 degrees and
allow for rapid application, stability, and single-point tightening. The cartridge clamp design
is positive locking, and the four- and six-hole clamps offer several attachment posts to
maximize construct alternatives.

Figure 15. Unilateral External Fixator

22
Circular Wire Fixators: These external fixators are used for open or closed fractures
requiring distraction, are infected, or in cases of non-union. They offer a single solution
for correcting the most challenging cases allows for post-operative fracture reduction and
alignment correction. The circular construct permits the patient to bear weight almost
immediately, thus accelerating fracture healing and increasing bone strength.70

Figure 16. Circular Wire Fixator

The most common complications with external fixation are pin track infection, increased
rate of malunion and need for secondary procedures,71 nerve or vessel damage, and
loosening or breakage of wires and pins.72,73 On the other hand, external fixation causes
less disruption of the soft tissues, osseus blood supply, and periosteum when compared
with internal plating and IM nailing techniques. External fixators are ideal for soft tissue
management in cases of acute trauma with open wounds, in chronic trauma following
skin grafting and flap procedures, and in patients with poor skin healing potential (ie,
rheumatoid disease, diabetes, peripheral vascular disease).65 Both internal and external
fixation techniques are associated with complications; however, both are equally
acceptable strategies for managing tibial fractures.

Amputation: The Last Resort

There are circumstances where an extremity cannot be salvaged following a severe
tibial fracture. Multiple scoring methodologies have been developed to assist surgeons
with the decision to salvage or amputate a limb, however, they cannot be used as the
sole criterion by which an amputation decision is made. The literature is inconsistent in
the support of the Mangled Extremity Severity Score (MESS) method, although it is the
best-known method for predicting the odds of limb salvage.74 MESS analyzes the velocity
involved in the skeletal and soft tissue injury, limb ischemia, presence and duration of
shock, and the age of patient.

23
The presence of limb ischemia for longer than 6 hours, infrapopliteal vascular injury, and
posterior tibial and/or common peroneal nerve neurotmesis are the strongest indications
for amputation.75 A good MESS indicates that a limb should be considered salvageable;
however, a poor MESS should not automatically prompt amputation. In recent years, new
techniques to attempt limb salvage have been developed and surgeons should be cautious
when interpreting scores and must rely on clinical judgment for decision-making.76, 77

CASE HISTORY
It is also important to note that case history is important to help the surgeon determine the
appropriate method of treatment and timing. Details about when, where, and how the injury
occurred can be critical points of information. For example, an open tibial fracture sustained
in a farming accident would likely have a high risk of infection. Prolonged entrapment in a
vehicle would imply the potential for developing compartment syndrome. Most critical of all,
is information on the amount and direction of the force or energy that caused the injury--the
greater the force, the more serious the damage and sequelae.21

CONSIDERATIONS FOR THE PERIOPERATIVE NURSE

Perioperative nurses and surgical technologists fulfill a variety of roles and functions with
surgical management of open tibial fractures. As with any surgery, the priorities for the
perioperative nurse caring for a patient with an open tibial fracture are safety, avoiding
additional injury, preventing complications, preparing the operating room with appropriate
instruments, and ensuring accurate documentation.

Patient Positioning
The perioperative nurse and surgical technologist should be knowledgeable about ideal
patient positioning for the surgical procedure to be accomplished in addition to intraoperative
factors to consider in positioning the patient, which include the following:78, 79, 80

• Whether asleep or awake, the patient should be in a comfortable position as

possible.
• The operative area must be adequately exposed.
• Vascular supply and nerves should not be obstructed by an awkward position or
undue pressure.
• There should be no interference with the patient’s respiration.
• Patient safety must be observed at all times.
• In case of excitement, the patient may need gentle restraint before induction.

Reduction of the tibial fracture for fixation requires careful planning, positioning, and
mechanical aids. The fracture must be reduced before fixation can be accomplished. For
internal fixation with IM nails, the patient should be placed supine on a radiolucent table with
the uninjured leg extended. The injured leg should be placed with the knee flexed at least 90
degrees and the thigh supported with a bolster. The fracture must be reduced before the nail
is placed across it. An external fixator or distractor can be used to hold the fracture reduced
while the foot rests on the table surface.81

24
Figure 17. Supine Positioning for IM Nail Placement

When positioning a patient for external fixation, the patient should be in a supine position
on a radiolucent table. Bolsters should be placed under the patient’s thigh and hindfoot
to suspend the lower leg high enough to have maneuvering space for the rings. Leg
positioning should allow anterior-posterior (AP) and lateral fluoroscopy with the image
intensifier on the opposite side of the operating table. For patient positioning for internal
fixation with plates and screws, gross metaphyseal alignment using manual traction or
skeletal distraction should be achieved.

Figure 18. Positioning for External Fixation

A traction table may be used in some hospitals. Counter traction is provided by well–
padded support under the distal femur.

Figure 19. Positioning with Traction Table

Once the patient is properly positioned for the procedure, confirm all pressure points
are protected and continuously observe the team during the procedure to ensure no
additional pressure has been placed on the patient (ie, Mayo stands).78, 79, 82

25
Documentation
The documentation in the patient’s medical record by the perioperative nurse should
correspond to established guidelines for perioperative nursing care and meet
professional and regulatory compliance requirements. Additionally, specific information
related to the fixation devices used should be recorded.83 Documentation of the following
is critical:
• External Fixation
o Placement of external fixation device
o Manufacturer
o Serial and lot number
o Sterilization of external device

• Internal Fixation
o Type of implant
o Size of implant
o Manufacturer
o Serial and lot numbers
o Sterilization date

Instrumentation
When preparing for an internal or external fixator procedure, one Mayo stand should
be equipped with basic surgical instruments. A second Mayo should be prepared with
appropriate instrumentation specific to the procedure (eg, wrenches, pins, clamps,
drill bits, drill guides, countersink, depth gauge, taps, tap guides, screwdriver, plate
contouring instruments, instruments for removing broken screws, etc). Bone clamps and
forceps should be available.

Cutting, bending, or scratching the surface of components of fixator sets can reduce the
strength and fatigue life of the device. As such, they should be handled with care. Any
components damaged during the course of the surgery should be replaced with items
from the same manufacturer. It is important for nurses and surgical technologists to be
aware that components of sets from different manufacturers should never be mixed.

SUMMARY
Treatment of open tibial fractures continues to be a challenge for orthopedic and trauma
surgeons. The majority of open tibial fractures are contaminated; therefore, early
diagnosis and treatment is critical. Aggressive debridement, prompt and appropriate
antibiotic therapy, fracture stabilization, and appropriate wound closure are the principles
of managment for open tibial fractures. The perioperative nurse and surgical technologist
must have an awareness and understanding of how such injuries should be managed
can greatly impact the patient’s overall functional outcome.

26
Clinical judgment, details regarding the mechanism of injury, and classification of the
fracture and associated wound drive decision-making for individualized treatment.
The circumstances under which the trauma was sustained can give insight to the level
of contamination that might be present. Severity of injuries to soft tissues, bone, and
neurovascular structures must be identified to determine wound coverage and fixation
treatment. Associated arterial injury must be identified and treated urgently in order
to salvage the limb. Once the injury has been fully assessed, an array of internal and
external fixation devices (nails, screws, plates, braces) can be utilized to stabilize the
fracture and aid in promoting fracture healing and restored function.

27
GLOSSARY
Amputation The surgical removal of all or part of a limb or
extremity such as an arm, leg, foot, hand, toe, or
finger.

Aseptic
 Free from infection or septic material; called also

sterile.

Aseptic Technique Methods by which contamination with

microorganisms is prevented frequently
referenced to sterile field during surgery.

Comminuted Fracture Fixation One in which the bone is splintered or crushed.

Debridement The removal of foreign material and devitalized

or contaminated tissue from or adjacent to a
traumatic or infected lesion until surrounding
healthy tissue is exposed.

Desiccation The state of extreme dryness or the process of

extreme drying.

Distal Tibia Lower one-fourth of the tibia.

Epithelializing To form a covering of epithelial cells over a

wound.

Exudate Fluid that filters from the circulatory system into

lesions or areas of inflammation.

Fixation The act or operation of holding, suturing, or

fastening in a fixed position. The condition of
being held in a fixed position.

Fracture The breaking of a part, especially a bone. A break

or rupture in a bone.

Granulating Tissue New connective tissue and microscopic blood

vessels that form on the surfaces of a wound
during the healing process.

Maceration The softening and breaking down of skin resulting

from prolonged exposure to moisture.

28
Mangled extremity severity score A scoring tool developed to discriminate between
salvageable (MESS) and doomed limbs in the
setting of lower extremity trauma.

Necrotic Wound Dead tissue, which usually results from an

inadequate local blood supply.

Open Fracture One in which there is an external wound leading

to the break of the bone. Also called compound
fracture.

Pilon Fracture Comminuted fracture of the inferior articular

surface of the tibia and the malleoli, caused by
axial compression of the ankle joint.

Proximal Tibia Upper one-fourth of the tibia.

Radiolucent Table Image guided surgical tables.

Sloughy Wound Dead yellow or black/yellow tissue, which needs

to be debride

Tibial Shaft Mid-section of the tibia.

X-ray Image Intensifier Converts x-rays into visible light at higher intensity
light to allow low-intensity x-rays to be converted
to a conveniently bright visible light output. This
effect allows the surgical team to more easily see
the structure of the object being imaged.

29
REFERENCES
1. Muller M. Muller AO classification of fractures-long bones. AO Foundation website.
https://www.aofoundation.org/Documents/mueller_ao_class.pdf. Accessed July 5,
2016.
2. Praemer A, Furner S, Rice D. Musculoskeletal conditions in the United States.1992.
3. Schmidt AH, Finkemeier CG, Tornetta P. Treatment of closed tibial fractures. J Bone
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