Surgical Management of Open Fracture

Grading of fractures

Grade I: Small skin laceration by tip of spiral fracture 
Grade II: Small to moderate, well circumscribed wound. No significant tissue necrosis 
Grade IIIA: Longer laceration with significant contused or non-viable tissue. After debridement, delayed suture of split thickness skin graft (STSG) can close wound.
Grade IIIB: Extensive soft tissue wound with crush. Local or free muscle flap required.
Grade IIIC: An open fracture with vascular injury that requires vacular repair to salvage the limb.
Grade IV: Total or subtotal amputation


Pre-operative
Take history
Physical Examination
Complete blood test
Radiographs- anteroposterior and lateral radiographs of the injured leg.
The ipsilateral knee and ankle are also often radiographically imaged. Why?
A CT scan and an MRI may be obtained.
Radical debridement of necrotic tissue, and prophylactic intravenous antibiotics.

Intra-operative
The procedure involves using a large surgical incision, reducing the fracture, placing a metal plate over the fracture, and fixing the plate onto the bone with multiple screws.
Because of the extensive soft-tissue manipulation required, plating can be difficult for the surgeon and damaging to the local vascular supply.
External fixation is a widely used and very successful method for treating some types of tibial shaft fractures.
The procedure involves multiple pins attached to the external rods to maintain length and alignment.

Post-operative & follow-up
Long-term outcomes for tibial shaft fractures generally are good, but a small increase in osteoarthritis of unclear etiology in the knee and ankle has been observed
After surgery, the patient should be monitored in the post-anesthesia care unit until stable.
Depending on the extent of the other injuries, the patient may be transferred to the surgical intensive care unit or to a regular ward bed.
Initially, the patient's vital signs should be monitored repeatedly, with careful attention paid to any abnormalities.
If a complication occurs, early discovery almost always improves the prognosis.
On the first postoperative day, the patient should be examined by the surgical team and a complete blood count should be obtained.
Once the patient has recovered from surgery and is considered safe to leave the hospital, he or she should be discharged to home or to a suitable rehabilitation facility