Treatment Of Open Tibial Fracture With Internal Fixation

Open fracture is a common injury in human life. The same feature is open fracture combined with soft tissue injured. Different degrees of stains was always accompanied with open fracture. Because of the probabilities of pyogenic and anaerobic infection, which make the fracture healing complicated. How to prevent infection, promoting the fracture to heal successfully, and recovering the limb function utmostly became the first problem for our orthopedist to solve.Treatment of open tibial fracture is more complicated than others. As the tibia's especial anatomic structure, the complic- ations of open tibial fracture is appeared to be more frequently. There are many methods in the stabilization of fracture. Exter- nal fixation was ever the main method to stabilized fracture, but it asked for high compliance of the patients and maked the postoperative treatment complicated. Orthopedist began to use internal fixation for fracture stabilization. Internal fixation was usually thought to be liable to increase the infection rate, which was bad for the fracture healing. In this study, We randomly collected 50 cases of open tibial fracture and retrospectively analyzed the clinical effect treated with immediately open or closed reduction and internal fixation between Jan 2005 and Aug 2007. According to Gustilo-Anderson classification with type I 7 cases, type II 20 cases, type IIIa 12 cases, type IIIB 5 cases, type IIIC 6 cases. We follow up these cases range 6– 32 months, and the assessment of the results was through evaluat- ing the radiological result, limb function and the morbidity of complication. All the cases were treated with broad-spectrum antibiotics in emergency room, and accepted operation within 8 hours after injury. The fracture stabilization was done after rigorous debridement. Treatment of antibiotics was given for 3 days at least after operation。All these cases had a satisfactory result in radiology. 40 of 50 cases could walk alone without aids, feel painless of the injured limb, and engage in daily activities successfully. Deep infection didn't occur in type I and type II fractures. The necrosis of skin around wound was seen in 25 cases of type II and type III fractures. Osteomyelitis was found in 5 cases of type III fractures, and limb amputation was done in 2 cases of type IIIC fractures because of persistent severe infection.These cases appeared to obtain satisfactory results. Only 5 of 50 cases occurred osteomyelitis,2 cases of type IIIC needed extremity amputation because of severe persistent infection, the infection rate was 14%(7/50). Osteomyelitis was found in 2 of 39 cases of type I, type II and type IIIa fractures. The infection rate was 5.1%(2/39). When the wound and fracture were managed in time and correctly, accompany with appropriate antibiotic treatment, internal fixation indicated to be safe and effective. The choice of intrameddulary nailing or plate fixation determined the characteristic of fracture. Antibiotic was necessary, used to be given for 7 days after operation. Plate fixation will aggravate soft tissue injury and destroy the blood supply of periosteum, there for, we prefer to intramedullary nailing for open tibial fracture. Metaphysis fractures which intramedullary nail is not adapt to can stabilized by plate and screw. In these cases, a high superfic infection rate was found and the necrosis of skin around wound was seen in 25 cases of type II and type III fractures. The infection rate achieved to 50%(25/50). The reason for this is that a single debridement can not eliminate the inanimate tissues and the focus of infection, for another way the extremity swells obviously after injury, which causes enormous surface tension lead to ischemia and necrosis of skin if primary closure was done. There for, we suggested delayed wound closure were more reasonable for type II and type III fracture. Soft tissue transplantation used to be needed for type IIIB and type IIIC fracture, should be done properly. Vascularized soft tissue transplantation was thought to be more effective which either could close the wound, or provided the new blood supply.Osteomyelitis appeared in 4 of 11 cases type IIIB and type IIIC fractures. Extremity amputation was needed in 2 cases of type IIIC fracture because of persistent severe infection. A bad result was found in type IIIB and type IIIC fracture treated with internal fixation. We suggest external fixation prefer to be more suitable considering its simple procedure and limited soft tissue injury. Further external fixation can spare much more time for other surgical procedures.We think initial management of open fracture is especially critical. Internal fixation is safe and effective for the treatment of type I, type II, and type IIIa fractures. Metaphysis fractures which intramedullary nail is not adapt to can stabilized by plate and screw. Delayed wound closure is suitable for type II and type III fractures because of high superficial infection rate. Reasonable soft tissue transplantation is good for infection prevention,and can promote the fracture healing. External fixation is still suggested for type IIIB and type IIIC fractures.