Fracture of the leg -- Surgical Management

Before the surgery, the patient is assessed under general anesthetic…

Open fracture: Tibial shaft fracture is associated with a break in the skin

For successful treatment of contaminated open tibial fractures, patient undergoes
1.Radical debridement of necrotic tissue (within 6 hours of injury)
2.Pulsed lavage of the area to remove bacteria
3.Prophylactic intravenous antibiotics (Often, Aminoglycosides + Cephalosporin. For low-grade open fractures, antibiotics such as first-generation cephalosporins are used. For higher-grade injuries with dirty wounds & infection, penicillin + aminoglycosides used)

Repeat debridements (every 24 h, as needed) are often used in
-Injuries with extensive soft tissue injury
-Severely contaminated wounds
-Wounds with vascular compromise in which additional necrotic tissue may present itself.
Soft tissue is usually covered (using sterile technique) within 1 week of injury

A splint should be used for stabilization. The splint usually remains intact until the patient is prepared in the operating room.

Intramedullary (IM) Rodding [Preferred treatment]

Intrameduallary rodding is a procedure to place a medal rod down the center of the tibia to hold the alignment ofthe bone. - A tibial rodding is a surgical procedure that lasts about an hour and half
- Usually done under general anaesthetic
1.Patients will have an incision over the knee joint, and small incisions below the knee and above the ankle. In addition, some fractures may require an incision near the fracture to realign the bones.
2.IM rods are secured within the bone by screws both above and below the fracture.
3.The metal screws and the rod can be removed if they cause problems, but can also be left in place for life.

Tibial rodding provides excellent fixation and alignment of the bones
-Most common risk of surgery is knee pain
-Most common complication is infection  Infection of the rod may require removal of the rod in order to cure the infection

Plates and Screws

Plates and screws are less commonly used, but are helpful in some fracture types, especially those closer to the knee or ankle joints.
Most surgeons choose an IM rod for tibial shaft fractures unless the fracture is too close to the joint to allow for placement of the IM rod  In fractures close to the joint surface, a plate and screws may be the ideal method of fixation.

External Fixator

External fixators tend to be used in more severe fractures, especially open fractures with associated lacerations and soft-tissue damage
-Placement of IM rods or plates may not be possible because of soft-tissue injury
-When there is significant soft-tissue injury, the external fixator may provide excellent immobilization while allowing monitoring and treatment of the surrounding soft tissues

Amputation

Amputation is uncommon but is sometimes indicated for severe tibial fractures, especially those with large soft tissue injury or those in patients with vascular compromise, such as in diabetic patients.

Amputation for grades I and II fractures is rare, but the rate of amputation is increased for grade III fractures. In fact, fractures requiring revascularization (type IIIc fractures) have a corresponding amputation rate of greater than 20%.

The Mangled Extremity Severity Score is a tool that has been developed to help the surgeon decide whether or not amputation is indicated, but it is only part of the equation. Surgical expertise and patient communication are of vital importance when making amputation decisions.

http://www.emedicine.com/orthoped/TOPIC340.HTM
http://www.emedicine.com/orthoped/topic336.htm
http://orthopedics.about.com/od/brokenbones/a/tibia.htm