Instructional Course Lectures, The American Academy of Orthopaedic Surgeons - Open Fractures of the Tibial Shaft. Current Treatment*†

The tibial shaft is one of the most common sites of an open fracture18, a fracture that involves a break in the skin with soft tissues communicating with the fracture or its hematoma, or both. The specific methods of skeletal stabilization and soft-tissue treatment of open and closed fractures continue to be topics of debate in orthopaedic traumatology. The type of treatment selected for open tibial fractures depends on the individual characteristics of the fracture and the concomitant soft-tissue injury, making experience and clinical judgment an important part of the over-all treatment13,42. Most orthopaedists treat only a few of these injuries each year; however, there are increasing expectations for surgeons to understand and apply the techniques of treatment of open fractures, such as the use of flap coverage and bone transplant techniques, to help patients to obtain an optimum functional outcome13. In the emergency room, initial attention should be given to resuscitation and assessment of the patient according to the guidelines of Advanced Trauma Life Support 1. Specific assessment of the extremities other than to control active hemorrhage should be part of a secondary survey. The orthopaedist must be aware of other injuries because severe pulmonary, intra-abdominal, or head injuries may limit the extent of initial debridement and stabilization that can be performed acutely for the open tibial fracture18. Concomitant fractures of the long bones and unstable fractures of the posterior part of the pelvic ring associated with hemodynamic instability should be stabilized within the first twenty-four hours after the injury whenever possible. The physical examination should include a thorough inspection and palpation of the extremities18. Occult open fractures may be missed if the examining physician does not elevate the extremity and inspect it circumferentially. The initial …