Clinical Briefing:
Repair and Reconstruction of Type IIIB Open Tibial Fractures
July/August 2008
The prevailing objectives for the management of high-energy
type IIIB open tibial fractures at the Hospital of the University
of Pennsylvania (HUP) include emergent debridement, irrigation,
and temporizing fixation, followed by early soft tissue and
bony reconstruction of the limb, return to function after
healing and long-term limb survival. To optimize the treatment
of these debilitating injuries and minimize their postoperative
complications, HUP has assembled an interdisciplinary team
of specialists in orthopaedic trauma surgery, plastic surgery
and trauma/critical care.
At Penn, patients sustaining high
energy type IIIB open tibial fractures are usually aggressively
resuscitated at presentation to maintain perfusion of their
at-risk limb. After appropriate emergent management, which might include debridement
and irrigation, temporizing orthopaedic stabilization, advanced
radiographic imaging and evaluation of vascular patency in the affected limb,
pre-operative planning for definitive management is initiated through cross-disciplinary
communication between orthopaedic surgery, plastic
surgery and the
division of traumatology and surgical
critical care.
Definitive management includes
reconstruction and stabilization of the tibia using optimal
implant technology to restore length, alignment and rotation
of the limb. After definitive fixation, the plastic surgeons
provide adequate soft tissue coverage with free flaps. If
the patient’s injuries allow, definitive stabilization and
soft coverage is usually performed within seven days to optimize outcomes. In
the immediate postoperative period, a variety of techniques
are incorporated to avoid and prevent deep infection, wound
contamination, osteomyelitis, non-union, and tissue
necrosis.
Case Study
Following a bicycle accident, Ms. A, a 23-year-old woman,
was transferred to the Penn
Orthopaedic Trauma Service with a type IIIB fracture involving the articular surface
of the distal tibia. The wound spanned a six-inch diameter
of the left anteromedial surface of the tibia with gross
contamination.
CT scan demonstrating an open comminuted fracture
of the distal tibia, including the articular
surface.
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At Penn, Ms. A was taken immediately to the
OR, where her wound was aggressively debrided
of devitalized tissue and copiously irrigated.
Her tibia was temporarily stabilized via external
fixation and an antibiotic bead pouch was applied.
Three days later, Ms. A’s wound received
a repeat debridement and irrigation. At this
time, Penn Plastic Surgery performed an intraoperative
consultation for her leg to determine the best
course for soft tissue coverage.
On day six, an open reduction and internal fixation
of the open tibia fracture took place with removal
of the external fixator. Concomitant to this
definitive fixation, a free-flap procedure was
performed to provide soft tissue coverage. Once
the flap healed, Ms. A began aggressive rehabilitation
to regain range of motion in the limb; transition
to weight-bearing occurred as tolerated.
Day Six: Internal fixation of the
pilon fracture following aggressive
debridement of the open wound
and copious irrigation.
Day Six: After open reduction and
internal fixation of the open fracture,
a free flap is placed.
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At this
time, her free flap has healed and she is fully
weight-bearing. No further surgery is required.
Our Team of Faculty
The management of type IIIB open tibial fractures at the Hospital of the
University of Pennsylvania involves a multidisciplinary effort including the
Orthopaedic Trauma Service, Penn Plastic Surgery, and the Division of
Traumatology and Surgical Critical Care.
Orthopaedic Trauma Surgery
Comprised of an integrated
team of surgeons, nurse practitioners, nurses,
social workers, therapists, interventional radiologists,
plastic surgeons, critical care specialists,
vascular surgeons, and rehabilitation specialists,
the Penn Orthopaedic
Trauma Service is committed
to pre-eminent orthopaedic surgery and clinical
research and excellence in the education of orthopaedic trauma surgeons.
Department of Orthopaedic Surgery
Samir
Mehta, MD
Chief, Orthopaedic Trauma Service
Assistant Professor of Orthopaedic
Surgery
Pedro K. Beredjiklian, MD
Associate Professor of Orthopaedic
Surgery
David J. Bozentka, MD
Chief, Hand Surgery
Associate Professor of Orthopaedic
Surgery
John L. Esterhai, MD
Professor of Orthopaedic Surgery
R. Bruce Heppenstall,
MD
Professor of Orthopaedic Surgery
David R. Steinberg,
MD
Associate Professor of Orthopaedic
Surgery
Orthopaedic Trauma Nurse Practitioner
Adele
Hamilton, CRNP
Plastic Surgery
The Penn Plastic Surgery
Service provides a complete range of reconstructive and
cosmetic surgery options, as well as medical services dedicated to the restoration
of function and treatment of appearance. Specialty areas include reconstruction
following tumor resection or trauma, reconstructive microsurgery, breast
reconstruction, craniofacial reconstruction, and the full range of cosmetic
surgery and services.
Joseph M. Serletti, MD, FACS
Chief, Division of Plastic Surgery
Henry Royster-William Maul Measey
Professor in Plastic and Reconstructive
Surgery
Stephen J. Kovach, III, MD
Assistant Professor of Surgery
David W. Low,
MD
Associate Professor of Surgery
Liza C. Wu, MD
Assistant Professor of Surgery
Traumatology and Surgical Critical Care
The trauma
surgeons of the Division of Traumatology
and Surgical Critical Care participate in the evaluation
and resuscitation of all patients with severe
orthopaedic injuries, including open tibial fractures.
C. William Schwab, MD
Chief, Division of Traumatology
and Surgical Critical Care;
Professor of Surgery
Vicente H. Gracias, MD
Associate Professor of Surgery
John P. Pryor,
MD
Assistant Professor of Surgery
Patrick M. Reilly,
MD
Associate Professor of Surgery
Urgent Access
For urgent access, call
800.543.STAR (7827).
The PennSTAR Communications
Center will facilitate any and all
requests.
PennSTAR flight, the 24-hour emergency air medical
transport service of the Division of Traumatology
and
Surgical Critical Care at the University of Pennsylvania
Health System, provides safe, efficient service
from any
hospital within 150 miles of Philadelphia.
Access
Patient appointments are available
at:
Penn Orthopaedic Institute
Hospital of the University
of Pennsylvania
2 Silverstein
3400 Spruce Street
Philadelphia, PA 19104
Penn Orthopaedic Institute
Penn Presbyterian Medical Center
1 Cupp Pavilion
39th and Market Streets
Philadelphia, PA 19104
Penn Plastic Surgery and the
Center for Human Appearance
Hospital of the University
of Pennsylvania
10 Penn Tower
3400 Spruce Street
Philadelphia, PA 19104
To refer a patient and/or consult with
a doctor call 800-789-PENN (7366) or you can also refer
a patient online.
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Referring Physicians: To speak with a Penn physician
or refer a patient, contact PennHealth through the secure online
referral form or by calling
1-800-789-PENN
(7366). |
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