Surgical Treatment of Patients with Open Tibial Fractures

MAY 1996, VOL 63, NO 5

Home Study Program SURGICAL TREATMENT OF PATIENTS WITH OPEN TlBlAL FRACTURES

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he article “Surgical treatment of patients with open tibial fractures” is the basis for this AORN Journal independent study. The behavioral objectives and examination for this program were prepared by Janet S. West, RN, BSN, CNOR, clinical editor, with consultation from Susan Bakewell, RN, MS(N), professional education specialist, Center for Perioperative Education. A minimum score of 70% on the multiple-choice examination is necessary to earn three contact hours for this independent study. Participants receive feedback on incorrect answers. Each applicant who successfully completes this study will receive a certificate of completion. The deadline for submitting this study is October 3 1, 1996. Send the completed application form, multiple-choice examination, learner evaluation, and appropriate fee to AORN Customer Service c/o Home Study Program 2170 S Parker Rd, Suite 300 Denver, CO 8023 1-571 1

BEHAVIORAL OBJECTIVES

After reading and studying the article on surgical treatment of patients with open tibial fractures, the nurse will be able to discuss the etiology and classification of open tibial fractures, describe the initial emergent care of patients with open tibial fractures, discuss perioperative care for patients undergoing surgical treatment for open tibial fractures, and describe perioperative nurses’ roles when caring for patients undergoing surgical treatment for open tibial fractures.

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Surgical Treatment of Patients with Open Tibia1 Fractures

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rauma is the leading cause of death in people 37 years of age and younger, and every six minutes In the United States someone dies from trauma injuries.' One study estimates that open tibial fractures from motor vehicle collisions (MVCs), farm accidents, falls from heights, and gunshot wounds account for more than 30% of all trauma injuries.2 Other researchers indicate that open libid1 fractures are responsible for approximately 40% of the yearly treatment costs associated with trauma3 The incidence of open tibial fractures has risen dramatically since World War I1 because of the increase in MVCs and the increase in penetrating trauma injuries, such its gunshot wounds. The magnitude of these trauma injuries has increased as well-often with catastrophic consequences for patients."

In one recent study of 63 patients with open tibial fractures, 43 patients ultimately had limb amputat i o n ~ Open .~ tibial fractures with severe soft fissue and neurovascular damage result in high limb amputittion rates. Orthopedic surgical team members' goal in treating such injuries is to provide patients with functionid limbs or ultimately with fitted proitheses for their amputated limbs. If limb amputation procedures lire necessary, they should not be viewed as trauma care failures because delayed limb amputations may cause significant increases in sepsis, death, disabilities, the number of surgical procedures, and hospital costs.6 ETIOLOGY OF OPEN TlBlAL FRACTURES

Most trauma from unintentional causes can bc prevented. The following is a summitry of the most common avoidable causes of open tibial A B S T R A C T Open tibial fractures are true surgical emergencies because of fractures. Motor vehicle collisions. the risk of extensive infection to bone and devitalized soft tissue. The most serious consequence of open tibial fractures is osteomyelitis, Betwcen 1.2 and 1.6 million nonwhich usually can be prevented by prompt surgical intervention within fatal open tibia1 fractures occur six to eight hours after injuries occur. Open tibial fractures often are annually in the IJnited States from the result of trauma from motor vehicle collisions, farm accidents, MVCs. The total cost of medical falls from heights, or gunshot wounds. Initial management of and surgical treatments, rehabilitapatients with multiple trauma injuries focuses on their life-threatening tion, and loss of productivity from injuries before or during orthopedic surgical intervention for open tib- open tibial fractures from MVCs ial fractures. Orthopedic surgeons often work in collaboration with approaches $20 billion annually.' general, vascular, and plastic surgeons and perform multiple surgical Often, open tibial fractures are procedures (eg, fasciotomy procedures for compartment syndromes, caused by acceleration-decelerairrigation and debridement of wounds, application of external fixation tion injuries from MVCs. Drivers devices, placement of intramedullary nails, possible limb amputa- who are not wearing seat belts tions). The type and extent of open tibial fractures and soft tissue usually sustain deceleration-type injuries determine the best treatment options for patients. Periopera- fractures 10 their lower extremity rive nurses should help patients focus on treatment choices for their bones from being propelled foropen tibial fractures that ensure optimal surgical outcomes and main- ward against dashboards. This is especially true for the right lower tain their quality of life. AORN J 63 (May 1996) 875-896. CHRIS BROWN, M D ; SHIRLEY HENDERSON, R N ; SHIRLEY M O O R E , RN

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leg, which often is pressed against the brake pedal at the moment of impact.8 Farm accidents. Each year, more than 200,000 farm residents are disabled from farm machinery (eg. augers, balers, mowers, tractors, shredders, harvesters, grinders, blowers).’ Most often, farm-related tibial injuries result from human error, falls, projectiles thrown from unshielded mechanical parts, or crush injuries. Case study A outlines a typical farmrelated tibial injury often seen by perioperative personnel in small rural hospitals. Falls from heights. Multiple lower extremity fractures often occur from patients’ direct contact with the ground after falls from heights. Open fractures of the calcaneus, talus, or tibial plateau may result from direct blows to the plantar surface of the foot.)()Knowing the mechanism of the injury allows orthopedic surgical team members to decide on the appropriate treatment for open tibial fractures, which may be more extensive than they first appear. Gunshot wounds. Civilian gunshot wounds are classified as low-velocity (ie, pistol) missile injuries, high-velocity (ie, rifle) missile injuries, close-range shotgun injuries, or 9 long-range shotgun injuries.” Low-velocity missile injuries. Low-velocity missile injuries are caused by pistols’ bullets that travel at speeds of 600 to 1,100 f h e c and generally are restricted to pathways created by the bullets as they penetrate bone. The entrance and exit wounds are small. Soft tissue damage is minimal and only patients’ skin edges usually require surgical debridement. These wounds do not require surgical closures and rarely become infected if patients are given prophylactic IV antibiotic therapy. High-velocity missile injuries. High-velocity missile injuries from rifles create small entrance and large exit wounds often resulting in open tibial fractures. Damage to soft tissue and bone is massive, and tissue necrosis is extensive. These open wounds require wide exposure and extensive debridement of devitalized tissues. Surgeons usually leave these wounds open for delayed primary or secondary closures, depending on the type of open tibial fracture.I3 Close-range shotgun injuries. Close-range shotgun injuries can be devastating to patients. Large soft tissue defects are created with extensive damage to bone. In addition, close-range shotgun injuries usually introduce nonopaque foreign material (ie, wadding that is used in the manufacture of shotgun

shells) into these open tibial fracture wounds. Unless the pellet injuries are through and through, the wadding material from shotgun shells causes severe foreign body reactions. Surgeons must find and remove all wadding material before excising devitalized soft tissue. Surgeons usually do not remove all of the lead shot for two reasons: lead shot does not cause foreign body reactions, and attempting to remove it only causes further damage to soft tissues surrounding the open tibial fracture site. Surgeons leave these wounds open and perform surgical closures later.I4 Long-range shotgun injuries. Long-range shotgun injuries consist of multiple low-velocity pellet injuries. Pellets cause widespread soft tissue and bone penetration but generally do not cause as severe damage as close-range shotgun injuries unless the pellets strike major blood vessels in the lower leg. These gunshot wounds are treated like other open tibial fractures with excision of debris and devitalized soft tissue.15 Open tibial fractures from gunshot wounds have a high incidence of nerve transections. For this reason, orthopedic surgeons usually explore these wounds after patients’ other injuries are stabilized. CLASSIFICATION OF OPEN TlBlAL FRACTURES

Open tibial fractures are classified as type I, 11, or 111, with 111 being the most severe and having the highest incidence of complications (ie, osteomyelitis, nonunions).I6 Classification of open tibial fractures depends on the amounts of avascular or devitalized tissue and foreign material associated with the open fracture injuries. Type Zfractures. Type I open tibial fractures are small wounds 1 cm or less in length. These fractures usually are caused by low-velocity trauma (eg lowvelocity bullet passing in and out of the tibia with minimal damage to soft tissue). Type ZZ fractures. Type I1 open tibial fractures are more than 1 cm in length and are associated with moderate soft tissue damage. These fractures have little or no avascular or devitalized soft tissue and contain reIatively little foreign material. Type ZZZ fractures. Type I11 open tibial fractures involve severe soft tissue injuries or loss and can be divided further into three subtypes: subtype IIIA (ie, open tibial fractures with extensive soft tissue injuries but with adequate soft tissue to cover fractured bones), subtype IIIB (ie, open tibial fractures with severe

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soft tissue injuries or tissue loss with periosteal stripping and bone exposures), and subtype IIIC (ie, open tibial fractures associated with neurovascular injuries requiring surgical repairs). This article discusses the most severe open tibial fractures, type 111. INITIAL MANAGEMENT OF PATIENTS WITH OPEN TlBlAL FRACTURES

Patients with open tibial fractures usually enter health care facilities through emergency departments (EDs). Their initial care depends on the type and severity of their trauma injuries. A small percentage (ie, 10% to 17%) of patients with open tibial fractures have associated life-threatening injuries.’* Trauma patients are managed according to an established order of priorities that are used in all EDs. Advanced Trauma Life Support (ATLS) protocols ensure that patients’ most life-threatening injuries are treated f i s t but that less serious injuries are not neglected after patients are stabilized. General ATLS protocols include an initial patient assessment, including history (ie, allergies, medications, previous illnesses, last meal, events surrounding the injury); airway control and establishment of respiration; establishment of venous access and restoration of tissue perfusion; diagnosis of immediately life-threatening injuries, followed by rapid treatment; reassessment of patient’s status; diagnosis of other significant injuries; and definitive treatment (eg, surgery, antibiotics, tetanus prophylaxis). l9 Vascular injuries. Patients with type 111 open tibial fractures are at risk for sudden, life-threatening changes from associated vascular injuries. Blood loss that accompanies open tibial fractures increases the risk of limb loss; therefore, orthopedic trauma surgeons stress the need for ongoing, thorough, and accurate diagnostic evaluations to avoid irreversible tissue damage from rapidly deteriorating circulation. The ED physicians and nurses determine the extent of ischemia in the distal portions of injured extremities by initially assessing for color, turgor, and obvious bleeding. If ED physicians doubt whether vascular integrity exists in injured limbs, they order arteriograms of the affected extremities. Compartment syndromes. Patients with open tibial fractures also are at risk for developing com-

partment syndromes (ie, increased tissue pressure that compromises circulation to muscles and nerves) in their lower extremities. If perfusion to extremities is disrupted, the maximum time that can elapse before irreversible ischemic damage to muscles and other tissues occu~sis six to eight hours.20The ED physicians and nurses, therefore, continuously evaluate these patients’ capillary refills and peripheral pulses for early diagnosis and treatment of compartment syndromes. Cardinal signs of a compartment syndrome include pain with passive stretching of muscles, extremity pallor, lack of palpable pedal pulses, and varying degrees of paresthesia.21 Orthopedic trauma surgeons diagnose compartment syndromes by measuring patients’ intracompartmental pressures with compartment pressure monitors. Pressures that range from 30 to 40 mm Hg indicate the need for fasciotomy procedures.2? Znitial nursing care. Emergency department nurses first assess patients’ vital signs, lung sounds, wounds, and extremity pulses for evidence of possible neurovascular compromises. They insert additional peripheral IV lines and Foley catheters in patients for fluid volume maintenance and urine output measurement. Nurses also arrange for consultations from orthopedic, vascular, and plastic surgeons. Treatment of open tibial fracture wounds. The ED physicians and nurses acutely manage patients’ open tibial fracture wounds by removing gross contaminants, obtaining anaerobic and aerobic wound culture specimens, and meticulously irrigating wounds with sterile normal saline (NS). After irrigating open tibial fracture wounds, ED nurses apply sterile dressings (ie, saline-soaked gauze, gauze rolls, and elastic bandages). Physicians usually do not debride open tibial fracture wounds in EDs. Instead, orthopedic surgeons perform thorough irrigation and debridement procedures on these wounds in the OR, ideally within six to eight hours after injuries occur. Administration of antibiotics. The ED nurses administer prescribed broad-spectrum IV antibiotics: a first-generation cephalosporin (eg, 1 g cephalozin) and an aminoglycoside (eg, gentamicin with dosage determined by body weight). Patients who incur open tibial fractures from farm-related accidents also receive penicillin (ie, with dosage 878

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determined by body weight) because these wounds are likely to be contaminated with Clostridium bacteria from soil. Several Cfostridium bacteria species are pathogenic in humans and are the primary causative agents far gas gangrene.23Another combination of antibiotics that may be prescribed for patients with open fractures (ie, particularly patients who have penicillin allergies) is vancomycin and ciprofl~xacin.~~

Neurovascular assessments.

The ED physicians and nurses Figure 1 Trauma OR setup for surgical repairs of open tibial fractures. conduct thorough neurovascular examinations of patients with open tibial fractures by evaluating patients’ peripher- tetanus toxoid booster injections, nurses administer al pulses, capillary refilling, sensation, and motor IM tetanus toxoid and 250 to 500 U of IM tetanus strength in the affected extremities. Nurses monitor immune globuhi.26 patients’ neurovascular statuses every 15 minutes Surgical consents. Whenever possible, surgeons and report changes to physicians. These evaluations obtain informed surgical consents from patients provide physicians important information on posteri- before they perform surgery. Surgeons explain surgior tibial nerve functioning, which is essential cal procedures and possible complications to both because transection of the tibial nerve, and therefore, patients and their family members, depending on a nonfunctioning limb, is a cnterion for primary limb patients’ conditions and family members’ availability. amputation.” Surgeons also have the responsibility to discuss the ~ o s t i evaluations. c Immediate posttrauma possibility of primary limb amputations with their diagnostic evaluations include laboratory tests (ie, patients. Whenever possible, the objective of surgical electrolyte levels, complete blood counts [CBCs], treatment for open tibial fractures is to prevent infection through irrigation and debridearterial blood gases [ABGs], prothrombin [PT] and partial thromboplastin [PTT] times, urinalyses) and ment procedures and IV antibiotic therapy, diagnostic tests including electrocardiograms (ECGs) and chest and spine x-rays. The ED nurses ensure that phlebotomists draw specimens for blood types and cross-matches and blood samples for other laboratory tests appropriate for patients’ immediate conditions. Patients may need two to four units of blood before and during surgery. The ED physicians order anteroposterior and lateral x-rays of injured limbs, including joints above and below the injury sites. If open tibial fractures are severely displaced or angulated, ED physicians reduce and temporarily stabilize Figure 2 Basic orthopedic instruments for soft tissue these fractures with splints before patients are trans- and bone dissection of open tibial fractures (top row, ported to the OR. ffom letr) two straight clamps, two Kocher clamps, two Tetanus prophylaxis. The ED nurses administer curved clamps, one bone clamp, one ronguer; (boflom prescribed tetanus toxoid or antitoxin depending on fow, fron left.. one knife handle with #10 blade, one patients’ tetanus immunization histories. Patients pair of suture scissors, one pair of dissecting scissors, who have been immunized against tetanus in the last two forceps with teeth, two Armyhlavy retractors, two 10 years require booster intramuscular (IM) tetanus sharp rake retractors, two curettes, one periosteal eletoxoid injections. If patients have not received recent vator, one self-retaining retractor. 880 AORN JOURNAL

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Figure 3 The circulating nurse preps the patient‘s surgical extremity with povidone-iodine solution alter the surgeon applies the pneumatic tourniquet. restore normal skeletal alignment and bone length (ie, reduction), maintain bone reduction and stability until healing occurs, and preserve and restore musculoskeletal function for weight bearing.27 PERIOPERATIVE PATIENT CARE

If patients are stable and do not have multiple trauma injuries, they are transported to preoperative holding areas, where circulating nurses introduce themselves and conduct patient assessments. Unsedated patients often are extremely anxious from their pain and discomfort and from knowing there is the possibility of limb amputation. Circulating nurses must offer these patients much reassurance during the preoperative assessments. Whenever possible, nurses should address patients’ questions and concerns before patients receive preoperative sedative medication. In addition to conducting routine chart and surgical consent reviews, circulating nurses also inspect patients for the presence of IV lines and fluids, immobilization devices, dressings, or traction equipment. Surgical preparations. Circulating nurses and

scrub personnel set up ORs before patients’ arrivals because of the emergent nature of open tibial fractures (Figure 1). Most open tibial fractures require irrigation with pulsatile lavage systems and then debridement followed by some type of implant (eg, external fixation devices, plating systems, intermedullary nails) to stabilize fractures. Patients should be placed on radiotranslucent OR beds for continuous radiographic assessments by fluoroscopy during the application of external fixation devices for stabilization of open fractures. Circulating nurses also must anticipate the use of traction devices that provide distraction and reduction of bone fracture sites during surgical procedures. Continuous traction also may be obtained by using specially designed OR beds. Standard equipment generally includes a hand-held electrosurgical device and a monopolar electrosurgical unit, a power drill and saw, and a pneumatic tourniquet. Scrub personnel select sterile surgical instruments (Figure 2), implant systems, and other supplies based on surgeons’ preferences. Intraoperative patient considerations. Circulating nurses must consider the following principles when caring for patients with open tibial fractures. Patients and fracture sites should be handled gently, and patients’ comfort must be considered. Operating room personnel should be ready to treat impending or existing shock or hemorrhage by having appropriate equipment and supplies available. Circulating nurses should position patients to allow adequate circulatory and respiratory functions with sufficient surgical exposures. Aseptic technique must be maintained at all times.28 In addition, type I11 open tibial fractures cause several associated conditions, including secondary hemorrhage, severe damage to soft tissues, damage to blood vessels and nerves, and Volkmann’s contractures (ie, degeneration, contracture, fibrosis, and atrophy of muscle resulting from injury to its blood supply).?y BASIC SURGICAL TREATMENT TECHNIQUES

The following is a general description of the initial surgical management of open tibial fractures. Detailed perioperative nursing care is presented in the “Sample general perioperative care plan for adult surgical patients” on pages 869 and 870 in this issue. b

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Pneumatic tourniquet application. After the patient is positioned properly and undergoes induction under general anesthesia, the surgeon applies a pneumatic tourniquet to the upper thigh of the surgical leg; however, the tourniquet is inflated only if the patient has massive bleeding that cannot be controlled. Otherwise, the pneumatic tourniquet remains deflated, because tourniquet compression can cause further tissue damage. In addition, anoxic tissue that results from tourniquet inflation may interfere with the surgeon’s assessment of viable tissue. The circulating nurse preps the patient’s surgical extremity with povidone-iodine solution or chlorhexidine solution (ie, if the patient is sensitive to iodine) after the surgeon applies the pneumatic tourniquet (Figure 3 ) . Irrigation and debridement of open wounds. The surgeon initially imgates the open tibial fracture site with 2 L of sterile NS through a pulsatile lavage system. Use of this powered lavage system minimizes pressure placed on tissues while allowing the surgeon to thoroughly irrigate gross contaminants from the wound. Beginning with the skin and subcutaneous fat, the surgeon initiates a layer-by-layer debridement of the wound. He or she conservatively excises the skin edges of the wound (ie, approximately 1 to 2 mm). More extensive excision is indicated if the skin is clearly avascular or crushed. The surgeon does not detach the skin from underlying soft tissue because detached skin devascularizes and dies. Soft tissue also will devascularize and die if it is removed from the bone; therefore, the surgeon tries to preserve the intactness of these tissue layers. The surgeon excises devitalized fascia and muscle tissue because necrotic tissue is an excellent culture medium for bacterial growth. The surgeon preserves viable muscle tissue by determining muscle viability (ie, viable muscle tissue vigorously retreats from the incising edge of a scalpel, persistent oozing from capillaries demonstrates adequate local perfusion). The surgeon also carefully preserves tendons and their surrounding fibrous sheaths during the imgation and debridement procedure. The viability of bone tissue is difficult to determine. The surgeon initialIy performs conservative bone debridement that permits subsequent debridements. He or she removes small bits of cortical bone not attached to soft tissues unless the tissue is grossly contaminated. The surgeon retains larger portions of cortical bone with soft tissue attachments. He or she makes an attempt to leave the periosteum attached to bones.

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The surgeon removes foreign bodies he or she encounters and ligates or cauterizes small arterial and venous capillaries with an electrosurgical device. The surgeon clamps larger vessels to control bleeding until vascular repairs can be performed. He or she examines the open tibial fracture site for possible transection of the posterior tibial nerve, which necessitates a primary limb amputation of the aflected extremity to decrease the occurrence of nonhealing leg ulcers and infectians, After the surgeon decides that the wound has been debrided completely, he or she irrigates the open tibial fracture site with an additional 8 L of sterile NS and then obtains repeat anaerobic and aerobic wound culture specimens. The circulating nurse adds antibiotics (eg, 500,000U polymyxin B, 50,000 U bacitracin/500 mL of imgation solution) to the last 2 L of sterile NS imgation solution after the surgeon has obtained the wound cultures. Application of external fixation devices. The surgeon stabilizes the open tibial fracture to facilitate bone and soft tissue healing and vascular repairs. External fixation devices allow these wounds to heal and best meet the requirements of adequate bone stability with minimal soft tissue exposure and damage. The surgeon uses a unilateral external fixation device with 5-mm, prestamless steel surgical half pins that enter the tibia through minimal disruption of soft tissue. He or she uses fluoroscopy to determine the correct placement of pins. After the surgical pins have been placed properly and the external fixation device applied, the surgeon incises the skin edges around the pin sites to release them from the metal pins. Vascular injury repairs. Vascular surgeons may assist orthopedic surgeons in repairing damage to large vessels. Vein grafts from contralateral lower extremities may be harvested for vascular injury repairs. After surgeons complete vascular repairs, they irrigate the open fracture wounds with sterile NS and perform fasciotomy procedures to treat compartment syndromes. Scrub personnel apply wet-to-dry dressings or povidone-iodine-impregnated gauze dressings, depending Qn surgeons’ preferences. POSTOPERATIVE PATIENT CARE

Surgical team members (ie, surgeon, anesthesia care provider, circulating nurse) transfer patients to postanesthesia care units (PACUs) or to intensive care units (ICUs), depending on patients’ injuries and postoperative conditions. The PACU and ICU

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nurses maintain patients’ IV fluid infusions, perform dressing changes, and assess patients for the stabilization of all body systems. After patients are stable, they are transferred to orthopedic observation or postsurgical units. Elderly patients with other surgical needs, additional fractures, or medical complications may need to be in ICUs for their initial postoperative care. Postoperative patient placements may be in PACUs or ICUs with subsequent transfers to postsurgical units, depending on institutions’ policies and procedures or available services. Patients with multisystem injuries stay in ICUs for approximately 36 ta 48 hours awaiting their next surgical procedures. The ICU nurses focus on the neurologic and circulatory functions of patients’ affected extremities and assess patients’ cardiovascular functions with the use of ECG telemetry monitoring. The ICU nurses frequently check patients’ vital signs, monitor their pulmonary statuses, and provide chest physiotherapy (eg, hourly incentive spirometry). Patients remain on antibiotic therapy for a minimum of 10 to 14 days after surgery. The ICU nurses monitor patients’ IV replacement fluids (eg, 5% dextrose in 0.45% NS at 80 to 100 m L M and continue to monitor patients’ postoperative laboratory data (eg, PTs, PTTs, CBCs, ABGs, electrolytes), especially for patients placed on anticoagulant therapy after vascular repairs. Nurses also observe patients’ nutritional statuses and urinary outputs with the knowledge that patients with myonecrosis may develop acute dtaxicity related to extensive t i w e damage from their open tibia1 fracture injuries. Patients usually progress from clear liquids to regular diets as tolerated. Slow wound and fracture healing may occur in these patients if their dietary protein intakes are not sufficient. SUBSEaUENT SURGICAL PROCEDURES

Patients with type I11 open tibial fractures return to the OR for repeat imgation and debridement procedures 36 to 48 hours after their primary imgation and debridement procedures. Circulating nurses use povidone-iodine to prep patients’ legs and external fixation devices. If patients are sensitive to iodine, nurses use chlorhexidine prep solutions. After scrub personnel drape patients’ affected extremities, surgeons imgate patients’ open wounds with sterile NS, remove necrotic soft tissue and bone, and obtain specimens for anaerobic and aerobic wound cultures. Pkcement of antibiotic beads. If large amounts

of bone loss occur, surgeons implant antibiotic beads made out of tobramycin (ie, 3.26 mg per bead) and methylmethacryIate bone cement into wounds to temporarily fill defects. Surgeons mix tobramycin and methylmethacrylate bone cement together to form soft cement cylinders that are approximately 1 cm in &meter. They use o m t o m e s to make indentations in the preformed soft cement cylinders and place antibiotic-bead chains (ie, approximately 25 beads per chain) within these indentations so that the antibiotic beads lie separately from each other within wound defects. Surgeons position the soft cement cylinders into wounds with #5 polyester sutures or stainless steel surgical wires. Circulating nurses document the number of implanted antibiotic beads on patients’ OR records for future reference. Surgeons remove antibiotic beads four to six weeks after implantation because antibiotic beads lose their effectiveness and can cause foreign body reactions in wounds. At the time of removal, circulating nurses should refer to patients’ previous OR records for the number of beads placed. Circulating nurses also should ensure that plastic surgeons who will be performing soft-tissue coverage procedures are present to inspect patients’ wounds when the beads are removed. If surgeons do not perform closures or soft-tissue coverage procedures at this time, scrub personnel apply wet-to-dry gauze dressings to the wounds. Skin gra& and muscleflaps. Macerated or partially amputated lower extremities may require multiple surgical procedures to repair extensive trauma injuries. Various methods of covering open tibial fracture sites are available after these wounds develop viable, vascularized soft tissue (ie, usually within five to 10 days after the initial injury). Extensive soft-tissue loss requires the use of muscle flaps followed by split-thickness skin graks. The flaps may be IocaI fascia1 cutaneous or muscle flaps, local muscle or remote pedicle flaps, or free microvascularized muscle flaps, all of which provide adequate coverage to extensive open tibial fracture wounds.30 Bone grafts. When free or pedicle muscle flaps are used, s w g e e f f s d e b bum grafting procedures for approximately six weeks to allow for healing of muscle flaps. Cancellous grafts are used for short bone defects, and larger bone defects are reconstructed with vascnlarized bone grafts (eg, iliac or fibula bones). Intramedullary nails. After the initial wound healing of open tibial fracture sites, other forms of

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Figure 4 Preoperative view of Mr L's partially amputated left foot from a farming-related auger accident. MI L's posterior heel and calcaneus bones are viable but his talus and forefoot bones have been severed.

Figure 5 lntrooperative view of Mr L's left foot amputation along a well-delineated line where the blood supply was absent and a partially closed, open tibial fracture wound with external fixation device attached.

bony fixation may be required. Patients may undergo additional surgical procedures to remove external fixation devices and have intramedullary nails implanted into the shafts of the tibial bones to stabilize their fractures. One possible complication of this type of surgical procedure is chronic draining osteomyelitis caused by staphylucoccus or streptococcus infections. If patients develop these infections, they may require repeated irrigation and debridement procedures along with chronic suppressive oral antibiotic therapy. Patients who develop gas gangrene may receive hyperbaric oxygen treatments as an adjunct therapy to irrigation and debridement procedures and oral antibiotic therapy. Postoperative cure. Patients reenter the PACU for initial postoperative monitoring and stabilization and then are transferred to the postsurgical unit. Postoperative IV antibiotics (ie, 1 g cephazolin, gentamicin and penicillin with dosages determined by body weight) are continued. Orthopedic surgeons perform sterile dressing changes on postoperative day two after nurses administer adequate analgesic medications (ie, IV, IM, or PO narcotics). Pin cure. Postsurgical unit nurses perform pin care on patients' external fixation devices every shift using sterile cotton-tip applicators (ie, one applicator per pin site) soaked in half-strength hydrogen peroxide or N S . Nurses use the applicators to push patients' skin down around pins and cleanse crusts from pin insertion sites to prevent infection around pin sites. While cleansing pin sites, nurses check for signs of infection (ie, redness, pain, tenderness) or skin tension. Skin tension around pins is a source of pain and not only interferes with thorough cleansing, but also may result in small areas of skin necrosis. Postsurgical unit nurses report their observations to

surgeons who may need to incise infected skin around pin sites. DISCHARGE PLANNING

Patients and their family members must be able to perform pin care, and patients must be able to ambulate before discharge. As patients near discharge, dietitians perform calorie counts to determine patients' need for additional parenteral or enteric supplements. If patients are discharged with external fixation devices o r intramedullary nail implants, physicians refer them to home health care nurses who monitor the patients' wounds and pin sites for early signs of infection. Home health care nurses also monitor patients' tolerances to ambulation and their adjustments to limitations imposed by their wounded extremities. These nurses teach patients meticulous skin care and progressive exercises to improve patients' ambulation abilities. They also stress the importance of return visits to the orthopedic surgeons for close monitoring to prevent potential limb amputations. CASE STUDIES

The following case studies are illustrative of patients who undergo surgical procedures for treatment of open tibial fractures. Case A . Mr L was a 43-year-old farmer who caught his left foot in an auger. He was seen in the ED of a small rural hospital, where physicians and nurses noted that he had a mangled foot that was near amputation but retained a laterally based flap of soft tissue (Figure 4). The ED nurses obtained specimens for anaerobic and aerobic wound cultures from Mr L's left foot, irrigated his wound with 2 L of sterile NS, and covered the open fracture wound with 889

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Figure 6 Preoperative x-ray of Mr L‘s left partial foot amputation of his talus and four forefoot bones from a farming-related auger accident.

Figure 7 Postoperative x-ray of Mr L‘s complete foot amputation and left open tibial fracture with external fixation device.

gauze and elastic bandages. The nurses administered prescribed IV antibiotics (ie, 1 g cephazolin, gentamicin and penicillin with dosages determined by body weight) before transferring Mr L to the OR for surgical treatment. The orthopedic surgeon obtained an informed surgical consent from Mr L for an irrigation and debridement and a complete amputation of his left foot. After successful induction of general anesthesia, surgical team members transferred Mr L from the transport gurney to the OR bed and placed him in a supine position. The surgeon placed a deflated tourniquet on Mr L’s left upper thigh, and the circulating nurse placed a safety strap over his abdomen. The circulating nurse prepped Mr L’s left lower extremity with a povidone-iodine solution, and the surgeon and scrub person placed sterile drapes on Mr L’s left lower extremity. The surgeon obtained another set of anaerobic and aerobic wound culture specimens of Mr L’s left open tibial fracture site, and the circulating nurse sent the wound culture specimens to the laboratory. The surgeon performed the initial irrigation and debridement of Mr L’s left open tibial wound using a pulsatile lavage system and 2 L of sterile NS. The anesthesia care provider inflated the tourniquet, and the surgeon began his assessment of Mr L’s trauma injury. The medial aspect of Mr L’s foot

was noted to be completely avascular, and because the ischemic time was greater than eight hours, the orthopedic surgeons amputated Mr L’s left foot along a well-delineated line where the blood supply was absent. The surgeons also removed Mr L’s talus and the remaining forefoot bones (Figures 5 and 6). They noted that Mr L’s posterior heel and calcaneus were viable, and they placed an external fixation device on Mr L’s left tibia (Figure 7). The surgeons irrigated Mr L’s wounds again with a pulsatile lavage system and 6 L of sterile NS. They obtained another set of anaerobic and aerobic wound culture specimens and lavaged Mr L’s open wound with 2 L of sterile NS with antibiotics (ie, 500,000 U polymyxin B sulfate, 50,000 U bacitracin) added. The surgeons brought a plantar lateral flap anteriorly across the open wound and loosely approximated the wound. The scrub person then packed Mr L’s left open tibial fracture wound with antibiotic-soaked gauze. Mr L did well after surgery. The intraoperative cultures of Mr L’s left leg wound grew multiple organisms, including molds and yeasts; therefore, Mr L’s physicians added fluconazole to his postoperative antibiotic regimen. The postsurgical unit nurses taught Mr L to perform proper pin care to his external fixation device. Mr L was discharged in stable condition only a few days after his emergent surgery. 890

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Figures 8 and 9 (leff) lntraoperative fluoroscopic view of an external fixation device placed on Mr M‘s left open tibial fracture and (right) a postoperative x-ray of Mr M‘s complete external fixation device.

He required another surgical procedure to revise the external fixation device because of skin impingement observed on x-ray films. After Mr L’s bones fused naturally, he obtained a left-leg prosthesis, which allowed him to bear weight on his left lower extremity. Case B. Mr M was a malnourished 19-year-old male who was the victim of a motor vehicle/pedestrian accident. He was seen at a Level I trauma center, where ED physicians and nurses discovered bilateral open tibial fractures and various contusions. Mr M became hypotensive in the ED and was emergently intubated by an anesthesia care provider. The ED nurses administered IV lactated Ringer’s solution for fluid volume replacement during Mr M’s resuscitation phase of care. Mr M’s lower extremity injuries consisted of a closed right tibial plateau fracture and a fracture of his proximal tibia and fibula in conjunction with left open distal tibia/fibula fractures. The ED nurses measured an area approximately 5 cm x 8 cm of exposed left tibia with a larger surrounding area of soft tissue damage and skin maceration. Mr M’s left pedal pulses were diminished to palpation, but the ED nurses were able to locate them with the use of a Doppler sound device. The orthopedic surgical resident placed a cast on Mr M’s right lower extremity. The ED nurses imgated Mr M’s left open tibial fracture with two liters of sterile NS and obtained anaerobic and aerobic wound culture specimens. The ED nurses administered an IM tetanus toxoid booster and IV antibiotics (ie, 1 g cephazolin, gentamicin with dose adjusted according to weight). After the orthopedic surgeon obtained a surgical consent from Mr M, the ED nurses transported Mr M to the OR for irrigation and

debridement and placement of an external fixation device on his left open wound. In the OR, the nurses placed Mr M in a supine position and restrained him with a safety strap across his abdomen. After Mr M received a general anesthetic, the orthopedic surgeon excised necrotic tissue and bone and irrigated Mr M’s wound with 6 L of sterile NS, followed by 2 L of a combined antibiotic/sterile NS solution. The surgeon placed an external fixation device on Mr M’s left lower extremity to stabilize his tibial fracture (Figures 8 and 9). The scrub person then applied a sterile wet dressing to the wound and a sterile dressing around the external fixation device. The anesthesia care provider extubated Mr M in the OR, and surgical team members transported Mr M to the PACU. During the initial postoperative period, PACU nurses began chest physiotherapy on Mr M. The

Figure 10 Postoperative view of Mr M s left open tibia1 fracture site after plastic surgeons performed a pedicle medial gastrocnemius flap and split-thickness skin graft.

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Figure 1 1 Postoperative view of antibiotic beads placed in Mr C‘s left open tibial fracture site where his external fixation device is already in place.

Figure 12 Postoperative x-ray of Mr C’s left open tibial fracture site after surgeons substituted an intramedullary rod for his external fixation device.

PACU nurses administered prescribed antibiotics (ie, 1 g IV cephazolin, gentamicin with dose adjusted according to weight) and obtained an angiogram of Mr M’s left lower extremity because of diminished pedal pulses. The angiogram results were normal; however, x-rays showed Mr M’s left tibial fracture had become displaced. Mr M returned to the OR for revision of his external fixation device. At the same time, plastic surgeons performed a pedicle medial gastrocnemius flap and split-thickness skin graft to Mr M’s left lower leg wound (Figure 10). Mr M did well postoperatively, and he was transferred from the PACU to the postsurgical unit. When Mr M was able to tolerate oral fluids, the postsurgical unit nurses gave Mr M protein milk shakes to treat his malnourished state. Nurses monitored Mr M’s laboratory test results, implemented pain management measures, assisted Mr M with ambulation, and taught him pin care. Physical and occupational therapists and social service personnel all contributed to Mr M’s postoperative care. Mr M became physically independent one week after his second surgery, and physicians discharged him to home care.

Case C. Mr C was a 64-year-old male whose left lower leg was crushed between two motor vehicles. He initially was treated at a small, rural Level 111 trauma hospital. The ED physicians noted that Mr C had a diminished left anterior tibial artery pulse and ordered an angiogram. The preoperative angiogram showed that blood flow in Mr C’s left anterior tibial artery was interrupted. The ED nurses transported Mr C to the OR, and vascular and orthopedic surgeons participated in his emergent surgical procedure. The orthopedic surgeons placed an external fixation device on Mr C’s left leg to stabilize his open tibial fracture. Vascular surgeons then performed a primary repair of his left anterior tibial artery. The orthopedic surgeons performed an irrigation and debridement procedure on Mr C’s wound and removed bone fragments that were not attached to soft tissue. The scrub person and circulating nurse applied sterile dressings to Mr C’s external fixation device. The surgeons placed MI C on IV antibiotics (ie, 1 g cephazolin, gentamicin and penicillin with dosages determined by body weight) until he was transferred to a tertiary care facility eight days later. 894

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The orthopedic surgeons at the tertiary care facility performed another irrigation and debridement procedure on Mr C’s left tibial wound. The surgeons discovered that Mr C had significant bone loss, and they placed antibiotic beads in Mr C’s left leg wound (Figure 11). At the same time, plastic surgeons performed a scapular free flap on Mr C’s left leg. Postoperatively, nurses assessed the viability of Mr C’s free flap, monitored his vital signs and laboratory test results, implemented pain management measures, and instructed Mr C on pin care. Mr C did well and physicians discharged him with follow-up by home health care nurses who would assess his skin flap. Four weeks later, the orthopedic surgeons removed the antibiotic beads from Mr C’s left leg, inserted an intramedullary rod into Mr C’s left tibia (Figure 12), and grafted bone to his left tibial wound. SUMMARY

The incidence of open tibial fractures continues to increase from MVCs, farm accidents, falls from heights, and gunshot wounds. The surgical treatment goal for open tibial fractures is to promote fracture and soft tissue healing without wound sepsis and to return patients to their normal activities of daily living whenever possible. To achieve this goal, patients often require multiple surgical procedures, including limb amputations for devitalized tissues. The type of surgical treatment selected depends on the anticipated length of time for fracture and soft tissue healing, patients’ anticipated postoperative activity levels, and patients’ accompanying injuries or disease processes.31 Orthopedic surgery team members must help patients and family members make many complex NOTES 1. National Safety Council, Accident Facts (Chicago: National Safety Council, 1994) 2-3. 2. E J MacKenzie, S Shapiro, J H Siegel, “The economic impact of a vehicular trauma: One year treatment related expenditures,” Product Association of Advance Automotive Medicine 32 no 53 (1988). 3. F J Bondurant et al, “The medical and economic impact of severely injured lower extremities,” Journal of Trauma 28 (August 1988) 12701273; J H Siegel, S Mason-Gonzalez, P C Dischinger, “Causes and costs of injuries in multiple trauma patients

treatment decisions when patients have open tibial fractures. Limb amputations may allow patients to return to more normal, painless lifestyles in shorter periods of time than multiple limb salvage procedures. Limb amputations also protect patients from postoperative complications often associated with repetitive surgical procedures. Patients who undergo limb amputations have their own unique postoperative economic and psychosocial issues that perioperative nurses must address through individualized patient care plans. Care for trauma patients with open tibial fractures requires collaboration among orthopedic surgeons, perioperative nurses, personnel in other hospital units, and other disciplines (eg, ED physicians and nurses, radiology and laboratory department personnel, PACU and postsurgical unit nurses, physical and occupational therapists). In addition, perioperative nurses often work with social workers to assist patients with their financial obligations and use of community resources after discharge. Perioperative nurses also help family members cope with patients’ traumatic losses and changes to ensure favorable patient outcomes and quality of life. A Chris Brown, MD, is a fourth-year orthopedic surgery resident, Washington University School of Medicine, Barnes Hospital, St Louis. Shirley Henderson, RN, BSN, is an orthopedic staff nurse in the OR, Barnes Hospital. St Louis. Shirley Moore, RN, PhD, is an associate professor of nursing, University of Missouri, St Louis.

requiring extrication from motor vehicle collisions,” Journal of Trauma 35 (December 1993) 920-931; T R Miller, N M Pindus, J B Doughs, “Medically related motor vehicle injury costs by body region and severity,” Journal of Trauma 34 (February 1993) 270-275. 4. Ibid. 5. Bondurant et al, “The medical and economic impact of severely injured lower extremities,” 12701273. 6. Ibid. 7. Siegel, Mason-Gonzalez, Dischinger, “Causes and costs of injuries in multiple trauma patients 895 AORN JOURNAL

requiring extrication from motor vehicle collisions,” 920. 8. R E Rosenthal, “Lower extremity fractures and dislocations,” in Trauma, ed K L Mattox (Norwalk, Conn: Appleton & Lange, 1988)588. 9. D H Cordes, D Foster, “Health hazards of farming,”American Family Physician 38 (October 1988) 233243. 10. Rosenthal, “Lower extremity fractures and dislocations,” 588. 11. A H Crenshaw, Campbell’s Operative Orthopaedics: Volume Three, seventh ed (St Louis: The C V Mosby Co, 1987) 1600. 12. Ibid.

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13. C R Peny, J A Elstrom, A M Pankovich, Handbook of Fractures (New York: McGraw-Hill Book Co, 1995) 3. 14. Crenshaw, Campbell‘s Operative Orthopaedics: Volume Three, 1600; J J Vemick, M J Cohen, “Trauma and bums,” in Surgery, second ed, B E Jarrell, R A Carabasi, eds (Baltimore: Williams & Wilkins, 1991) 360. 15. Ihid. 16. Peny, Elstrom, Pankovich, Handbook of Fractures, 3. 17. Ibid; Crenshaw, Campbell’s Operative Orthopaedics: Volume Three, 1598. 18. Bondurant et al, “The medical and economic impact of severely injured lower extremities,” 12701273. 19. Committee on Trauma, American College of Surgeons, “Resuscita-

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tion,” in Resourcesfor Optimal Care of the Injured Patient: 1993 (Chicago: American College of Surgeons, 1993) 14. 20. R N Rosier, “Orthopaedics,” in Principles of Surgery, sixth ed, S I Schwartz, ed (New York: McGrawHill Book Co, 1994) 1902. 21. Ihid. 22. Ihid. 23. M P McAndrew, B A Lantz, “Initial care of massively traumatized lower extremities,” Clinical Orthopaedicsand Related Research 243 (June 1989) 20-29. 24. J Wilkins, M Patzakis, “Choice and duration of antibiotics in open fractures,” Orthopedic Clinics of North America 22 (July 199I ) 433437. 25. R H Lange et al, “Open tibia1 fractures with associated vascular injuries: Prognosis for limb salvage,”

AORN is accredited as a provider of continuing education in nursing by the American Nurses CredentialingCentefs Commission an Accreditation. AORN recognizes this octivity as continuing education for registered nurses. This recognition does not imply that AORN or the American Nurses Credentialing Centefs Commission on Accreditotion approves ar endorses any product included in the octivity. AORN maintains the following provider numbers: Alabama ABNP0075, California BRN00667, Florida 27FO 177, Iowa 103. AORN is approved as a provider of continuing nursing

Journal of Trauma 25 (March 1985) 203-208. 26. M J Patzakis, “Management of open fracture wounds,” Instructional Course Lectures 36 (1987) 367-369. 27. B J Gruendemann, B Femsebner, ComprehensivePerioperative Nursing, Volume Two: Practice (Boston: Jones & Bartlett, 1995) 25 I . 28. M H Meeker, J C Rothrock, Alexander’s Care of the Patient in Surgery, loth ed (St Louis: MosbyYear Book, Inc, 1995) 766. 29. lbid. 30. M Chapman, “Open fractures,” in Rockwood and Green’s Fractures in Adults, third ed (New York: J B Lippincott Co, 199I ) 223-264. 3 1. B Gregory, Moshy’s Perioperative Nursing Series: Orthopedic Surgery (St Louis: Mosby-Year Book, Inc, 1994) 145.

education by the Kansas State Board of Nursing. This course offering is approved for three contact hours. The Kansas State Board of Nursing approved provider number is LTO 1 14-03 16. Professional nurses are invited to submit manuscripts for the Home Study Pragram. Manuscripts or queries should be sent to the Editor, AORN Journal, 2 170 S Parker Rd, Suite 300, Denver, CO 80231-571 1. As with all manuscripts sent to the Journal, papers submiited for Home Study Programs should not have been previously published or submitted simultaneously to any other publication.

Sample General Perioperative Care Plan This month the Journal is publishing a sample genera1 penoperative care plan for adult surgical patients (pages 869-870) as a way of eliminating the repetitive description of general care of surgical patients in articles. By publishing a general care plan, authors can provide more in-depth descriptions of the specialized

care needs of patients in their clinical articles. Do you find this general perioperative care plan helpful? Does it eliminate repetition in Journal articles? Please let the Journal staff members know by sending us your comments by fax to: (303) 7503441, attn: Sample General Perioperative Care Plan.

Americans Need 30 Minutes of Exercise Per Day As reported in the Jan 11, 1996, issue of the Medical Tribune, an independent panel of specialists convened by the National Institutes of Health announced that all Americans-adults and children-should participate in some sort of exercise for at least 30 minutes per day. This activity can be moderate, such as brisk walking or yard work, and

performed in 10-minute spurts throughout the day. One of the panel members relates, “the risk of heartdisease deaths could be reduced in the United States by 10% to 25%.” P fastman, “Americans need 30 minutes of exercise, ‘ Medical Tribune 37 (Jan 1 1, 1996) 1, 8.

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