Severe open – Gustilo type III – tibial fracture treated by external fixation and primary soft-tissue coverage. A Case Report

Sasa Milenkovic[1], Ljiljana Paunkovic[2], Sasa Karalejic[1]
[1]Orthopaedic & Traumatology Clinic Nis, Serbia and Montenegro
[2]Department of Plastic surgery, Surgical Clinic Nis, Serbia and Montenegro

 

ABSTRACT
Introduction: High-energy trauma of the lower extremity is a treatment challenge for the orthopaedic and plastic surgeons. External fixation and primary soft-tissue coverage play an important part in severe injury treatment. External fixator allows additional fracture corrections and secondary reconstructive procedures, essential in such severe injuries.
Results: A case of a 38-year-old female patient with distal tibial open fracture and extensive soft-tissue injury is presented. After thorough wound irrigation and debridement, external fracture fixation, primary soft-tissue coverage with local skin flaps and free skin flaps by Wolffe were performed. Because of partial flaps necrosis in the anteromedial part of the lower limb, secondary skin free flaps by Thiersch was done. After soft-tissue healing, 6 weeks after the surgery, external fixator transformation and fracture refixation were done. The external fixator was removed 23 weeks after the injury, and the pins remained for two more weeks. The patient walked with full weight-bearing. After two weeks, the pins were removed and functional cast was placed for 4 more weeks. One year after the injury, the patient walks without crutches, has antalgic gait and foot and ankle swelling after long standing and walking. Ankle joint movements are limited dorsiflexion (5 degrees) and plantar flexion (30 degrees).
Conclusion External fixation and primary soft-tissue coverage allow fracture healing and reduce the possibility of postoperative complications, such as osteomyelitis, nonunion and infection.

Key words: External fixation, open tibial fracture, soft-tissue injury, primary coverage.

INTRODUCTION
Severe open tibial fractures are the result of high energy injury[1]. High-energy injuries of the lower leg include a traumatic amputation, a Gustilo type III tibial fracture, a disvascular limb after knee dislocation, a closed tibial fracture, or a penetrating wound requiring vascular repair, a major soft-tissue injury of the tibia, and a severe ankle and foot injury[2]. One of the most important goals in the treatment of severe injury of the tibia is to obtain adequate soft-tissue coverage. Soft-tissue coverage procedures are performed to provide a closed wound, to promote revascularization of the injured bone and soft tissue, and to prevent infection and nonunion that may occur secundary to persistent bone ischemia[3,4,5]. The treatment of open tibial fractures with severe soft-tissue injuries are managed with radical wound debridement, external or internal fixation and immediate or very early soft-tissue coverage[6]. The type of flap used for soft-tissue coveage of a soft-tissue defect is generally chosen on the basis of anatomical considerations, specifically the location of the defect on the leg, the size of the defect, and the availability of local tissues for coverage[7].

Figure 1. The appearance of the injured lower limb after hospitalization.



Figure 2. The injured lower limb after external fixation and primary soft-tissue coverage.


Figure 3. Radiographs after surgery shows valgus position.

Figure 4. Partial flaps necrosis after primary soft- tissue coverage.

CASE REPORT
A 38-year-old female was accidentally injured while working at the press, in the Textile Factory. She was hospitalized in the Orthopaedic and Traumatology Clinic of Nis, two hours after the injury (figure 1). Surgery under general anesthesia was perfomed immediately after she was admitted in the hospital. Although she had a severe lower limb injury, no neurovascular injuries were noted. Clinical examination confirmed distal tibia fracture. Wound swab was taken for culture and sensitivity of possible germ growth. After wound irrigation and debridement, external fixation of distal tibia fracture was performed by placing the unilateral fixator with 2 pins proximally, 1 pin in the distal tibial fragment and 2 pins in the foot (one in the calcaneus and 1 in the first metatarsal bone). After external fixation, primary soft-tissue coverage with local post-tinjury skin flaps and free skin flaps by Wolffe was done (figure 2). Free skin flaps were taken from ishemic skin parts of the lower limb. The patient received tetanus immunization, cefuroxim and metronidazol, for 7 days, to prevent infection. Low-molecular-weight heparin was given subcutaneously, daily, until the patient was mobilized. Several days after the surgery, the patient was mobilized to walk non-weight bearing with crutches. Postsurgery radiographs show valgus position (figure 3). Culture showed Acinetobacter ssp. and, therefore, antibiotic prophylaxis was changed into Ciprofloxacin and Trimethoprim. Three weeks after primary surgery, clear partial flaps necrosis appears on the anteromedial part of the lower limb (figure 4). Another surgery was performed - flaps necrosis debridement and skin coverage with free flaps by Thiersch (figure 5). Six weeks after the injury, a third surgery was performed aimed at releasing the foot and the ankle. On that occasion, refixation of the tibial fracture (figure 6) and valgus correction (figure 7) were done. During the treatment, the patient walked with crutches. Altogether, the hospitalization lasted 45 days. Full weight-bearing was allowed 10 weeks after the injury (figure 8). The external fixator frame was removed from the tibia 23 weeks after the application.The external fixatior pins remained 15 more days (figures 9, 10), to test fracture healing. After pin removal, functional cast was applied for 4 more weeks. The patient’s condition 6 months after the injury is shown in figures 11 and 12. One year after the injury, the patient walks without crutches, has antalgic gait, chronic swelling in the foot and ankle which increases in longer walking and standing, has a limited dorsiflexion (5 degrees) and plantar flexion (30 degrees)(figures 13, 14). Regardless of the outcome, the patient expressed pleasure at having retained her leg. She returned to work 20 months after the injury.

Figure 5. The appearance after secundary free flaps coverage.


Figure 6. The appearance of the injured lower leg after foot and ankle releasing and tibial fracture refixation.

Figure 7. Radiographs after valgus correction and tibial fracture refixation.

Figure 8. The injured leg 2 months after the injury.

Figure 9. Radiographs after the removal of the external fixator frame.

DISCUSSION
An open fracture is contaminated and results from a high-energy injury. The question of amputation or salvage for more severe injuries still generates heated debate[8,9,10]. While limb salvage is the initial aim, medium and long-term problems with soft-tissue cover, infection and union are too common and result in serious disability[11,12,13]. A number of investigators have mentioned the crucial role that soft-tissue reconstruction plays in the healing of a severe injured lower extremity[3,13]. The operative management is complex. It includes a thorough irrigation and a radical wound debridement, fracture stabilization and primary soft-tissue coverage[14,15,16,17,18,19,20]. After the surgery on the leg, early mobilization and joint motion were encouraged. Weight-bearing was increased as soon as possible, depending on the stability of the fracture and the signs of its healing. Primary soft-tissue coverage reduces a possibility of serious complications such as osteomyelitis, wound infection, wound necrosis, flap loss, nonunion, and sometimes, unfortunatelly, amputation[3,16]. Many authors agree that primary soft-tissue coverage is an important determinant of wound complications[21,22]. The majority of authors recommend internal fixation to stabilize fractures[1,6,16]. Another group of authors recommends external fixation in the treatment of severe open fractures[5,11,12,17,18]. We have not had any experience with the internal fixation of severe open tibial fractures. All open fractures are treated with external fixation method. Our opinion is that the method of unilateral external fixation is workable and relativerly easily applied; it also allows additional fracture corrections and additional reconstructive operations, often essential in such severe fractures[23].

Figure 10. The appearance of the injured leg after the removal of the external fixator frame.


Figure 11. Radiographs 6 months after the injury.


Figure 12. The appearance of the injured leg 6 months after the injury.


Figure 13. Radiographs 12 months after the injury.


Figure 14. The appearance of the injured leg 12 months after the injury.

CONCLUSION
Open tibial fractures with extensive soft-tissue injuries are severe traumas, which should be treated urgently. Radical debridement, external fixation and primary soft-tissue coverage save the injured limb, reduce a possibility of complications and allow fracture healing.

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Mailing address:
Sasa Milenkovic
Orthopaedic and Traumatology Clinic Nis
B.Taskovic 48
18000, Nis, Serbia and Montenegro
E-mail: sasa65@bankerinter.net