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 ! Long-leg cast

Transverse 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,
l extensive soft tissue injury
IIIa : adequate soft-tissue coverage
IIIb : soft-tissue loss
IIIc : vascular injury
 Open fracture
Ø Grade I

(femur, inside out)

 Open fracture
Ø Grade II

(ankle inner side - pronation)

 Open fracture
Ø Grade III

III/b III/c
Open fractures of the tibia and fibula.

Ø Gustilo Grad I to Grad III :

Ø 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 amputation versus limb salvage

l 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 leg : composed of four compartments:

l anterior, lateral, superficial and deep posterior
l one or double incision technique
l Closure: 5-10 days primary? or skin grafting
 Septic complications
Ø infection:
the most serious complication for
both the patient and the doctor!

• Contamination • Infection
bacteria on site signs of bacterial inf.
* devitalized tissue * rubor
* temperature * tumor
drain-cultures * calor
germs > * dolor
immune status < * 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 Ø deep
* skin necrosis * subfascial
* epifascial supp. * intraarticular
* tendovaginal
good prognosis! * body cavity
* peri-implant
bad prognosis!
 Superficial infection

Ø Diagnostics Ø Therapy
* inspection * conservative/kryoth.
* palpation * operative
* Ultrasound (revision,
* lab results debridement, perhaps
drainage)
 Deep infection

Subfascial, extra/intraarticular
haematoma, tissue damage

Ø Diagnostics Ø Therapy
* inspection * immediate revision,
* palpation debridement
* Ultrasound * suction drainage
* punction * Septopal chain
* labs
 Diagnostic methods

Ø Laboratory Ø Instrumental
* WBC diagnostics
* qualitative bloods * US (punction)
* We (ESR) * x-ray (gas, fluid)
* CRP * CT/contrast
* procalcitonin * MRI/contrast
* TNF * scintigraphy
* thermography (?)
 The best way of therapy:
PRAEVENTION

„conservative or revision?”
therapy…

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 factors: immobilization !,
l fractures : pelvic, lower extremity
l spinal cord injury
l surgical procedures (orthopedic, >2h)
l blood transfusion, high ISS >9, extensive soft-tissue trauma

Ø Prophylaxis: 1. LMWHs
l 2. Vitamin K antagonists (e.g.warfarin) - INR: 2,5
l 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
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