Modern Principles in the Acute Surgical Management of Open Distal Tibial Fractures

Babar Shafiq, MD; Jacques Hacquebord, MD; David J. Wright, MD; Ranjan Gupta, MD

Disclosures

J Am Acad Orthop Surg. 2021;29(11):e536-e547. 

In This Article

Abstract and Introduction

Abstract

Over the past two decades, management of open distal tibial fractures has evolved such that a staged approach, with external fixation and débridement during the index procedure, followed by definitive fixation and wound closure at a later date, is often considered the standard of care. Although definitive treatment of these complex injuries is often done by a multidisciplinary team of surgeons well versed in periarticular fracture repair and soft-tissue coverage in the distal extremity, the on-call orthopaedic surgeon doing the index procedure must understand the principles and rationale of the staged treatment algorithm to avoid compromising definitive treatment options and ensure the best possible patient outcome. The mechanism of injury, neurovascular status, size and location of soft-tissue injury, fracture pattern, and concomitant injuries in the polytraumatized patient should direct the treatment plan and anticipated outcomes. This review focuses on evaluation and management of these complex injuries with an emphasis on early aggressive débridement, principles of initial fracture fixation, and modern options for soft-tissue coverage, including local and free tissue transfer.

Introduction

Open tibial fractures account for 11.2% of all open fractures and represent a significant source of morbidity and economic cost burden.[1] Although basic principles of management have remained constant since Gustilo and Anderson described the importance of early antibiotic administration and aggressive surgical débridement, advances in our understanding of fracture biology, fracture fixation, and microsurgical technique have changed the landscape of both routine management and complex limb salvage over the past 20 years. A staged approach, with the index procedure including external fixation and debridement, followed by definitive fixation and wound closure at a later date, is often considered the standard of care. Although definitive treatment is often done by a multidisciplinary team of surgeons well versed in periarticular fracture repair and soft-tissue coverage in the distal extremity, the on-call orthopaedic surgeon doing the index procedure must understand the principles and rationale of the staged treatment algorithm to avoid compromising definitive treatment options and ensure the best possible patient outcomes. Although this review focuses specifically on the initial management of open distal tibial fractures, many of the principles can also be applied to closed injuries.

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