TREATMENT AND

PROGNOSIS
Main Objectives
1. Limit soft-tissue damage and preserve (or restore, in the
case of open fractures) skin cover

2. Prevent – or at least recognize – a compartment syndrome

3. Obtain and hold fracture alignment

4. Start early weightbearing (loading promotes healing)

5. Start joint movements as soon as possible.

Right Tibia
and Fibula
Open
Fracture
Gustilo’s Classification

Which one is our case ?

What to do?
Uncomminuted, spiral fractures with minimal soft-tissue damage
(Gustilo I)
• Heal with minimum of trouble
• Treat conservatively unless there is a definite indication for
surgery

Fractures associated with severe soft-tissue damage and unstable

fracture patterns
• Need much more careful attention
• Avoid complications
HIGH-ENERGY FRACTURES
• Initially, the most important consideration is the viability of the
damaged soft tissues and underlying bone.
• Tissues around the fracture should be disturbed as little as possible
• Open operations should be avoided unless there is already an open
wound
• For open fractures, the use of internal fixation has to be
accompanied by judicious and expert debridement and prompt
cover of the exposed bone and implant
• External fixation can be safer if these pre-requisites cannot be met.
Fixation
Treatment

A suitable treatment of open tibial fractures:

• antibiotics
• debridement
• stabilization
• prompt soft-tissue cover
• rehabilitation
Antibiotics
• Start immediately.
• Gustilo grades I–IIIA  First- or second-generation cephalosporin
• More severe grades  with Gram-negative cover as well
(aminoglycoside such as gentamicin)
• continued for 24 hours in a grade 1 fracture and 72 hours in more
severe grades
• Delayed closure of open tibial wounds  nosocomial infection 
multiresistant, not covered by standard antibiotics
• Good debridement of the fracture and prompt cover remain the
strongest defense against infection.
Debridement
• Wound should be photographed first in ER, then covered with a
sterile dressing  serve as a record and prevent further
disturbance to the wound.
• Excise as little skin as possible and discuss wound extensions with
a plastic surgeon
• All dead and foreign material is removed, includes bone without
significant soft-tissue attachments
• Tissue of doubtful viability  second look in 48 hours
• Wash the wound and fracture site with large quantities of normal
saline
• Temporary cover of the exposed bone by using antibiotic 
reduce bacterial colonization. The wound should be closed in the
first 3–5 days
Stabilize
• Gustilo I, II and IIIA injuries  locked intramedullary nailing (as
definitive wound cover is possible)
• More severe grades  internal fixation, only at the time of
definitive soft tissue cover. If this is not feasible  stabilized
temporarily with a spanning external fixator
• Exchange of the fixator for an intramedullary nail  when
definitive soft tissue cover is carried out – ideally within 5 days of
the injury
Intramedullary Nailing
Closed intramedullary nailing is
now the preferred treatment
for unstable tibial fractures.

This series of x-rays shows the

fracture before (a) and after
(b,c) nailing. Active
movements and partial
weightbearing were started
soon after operation.
Postoperative management
• Swelling is common after tibial fractures (even after fixation)
• Elevate the limb, frequent check for signs of compartment syndrome
• After intramedullary nailing of a transverse or short oblique fracture,
weightbearing can be started within a few days and increased to full
weight when comfortable
• Comminuted or segmental fracture  almost the entire load will be
taken by the nail initially, only partial weightbearing is permitted until
some callus is seen on x-ray.
• Patients with external fixators can usually weightbear early unless
there is major bone loss
• Weightbearing through the fractured tibia is increased when callus is
visible on x-ray. The fixator is later ‘dynamized’ to allow greater load
transfer through the bone and help the callus bridge to mature
Early Complications
• Vascular injury  damage to popliteal artery (emergency!)
• Compartment Syndrome  due to tissue edema and bleeding
• Infection  treat by antibiotics

Late complications
• Malunion  varus/valgus, more than 7° is unaccpetable
• Delayed Union  by 6 months, consider secondary intervention
• Non-union  due to bone loss, deep infection, faulty treatmet
• Joint Stiffness  due to prolonged immobilization
• Osteoporosis of the distal fragment
Compartment Syndrome : fasciotomy
Late complications

(a) Hypertrophic non-union: the exuberant callus formation and frustrated

healing process are typical. (b) Atrophic non-union: there is very little sign of
biological activity at the fracture site. (c) Malunion: treated, in this case, by
gradual correction in an Ilizarov fixator (d,e).
Prognosis???
• Overall okay, The fracture is
oblique and not
comminuted
• Check for early and late
complications
• Regular check up/control