Boa Lower Limb 2009

7/30/2019 Boa Lower Limb 2009

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OPEN FRACTURESOF THE LOWER LIMB

Standards or the management o

BritishOrthopaedicAssociation

A SHORT GUIDE


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who should

read this guide?

Standards for the management of open fractures of the lower limb details the optimaltreatment or patients with these challenging injuries. Drawing on an extensivereview o the published evidence and their personal experience, the authors set outeach stage o the management pathway, including what to do i complications arise.

O relevance to pre-hospital, emergency room and hospital clinicians, each chaptercontains key recommendations or the standards o care that should be deliveredand practical advice.

Containing important new guidance or getting the best outcomes, the Standardsare an essential reerence text or orthopaedic, plastic surgery, emergencymedicine, and rehabilitation specialists who treat these injuries as well or thosewho plan and commission trauma care.

Endorsed by the Councils o the British Association o Plastic, Reconstructive andAesthetic Surgeons and the British Orthopaedic Association, the Standards for themanagement of open fractures of the lower limb replace previous guidelines in theUK and will have worldwide relevance.

This short guide contains only the key recommendations rom the Standards.Readers wishing to review the evidence-base behind them should reer to theull Standards publication. Details o how to obtain a copy may be ound on ourwebsites:www.bapras.org.uk and www.boa.ac.uk


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contents

1. Foreword

2. Introduction

3. The working group

4. Principal recommendations

Specialistcentres

Emergencymanagement

Antibioticprophylaxis

Timingofwounddebridement

Softtissuedebridement

Bonedebridement

Deglovinginjuries

Classication Temporarywounddressings

Techniquesofskeletalstabilisation

Timingofsofttissuereconstruction

Typeofsofttissuereconstruction

Compartmentsyndrome

Vascularinjuries

Footandankle

Whenthingsgowrongwithsofttissues Whenthingsgowrongwithbone

Guidelinesforamputation

Outcomemeasures

Managementofsevereopenfracturesinchildren

Acknowledgements

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05

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Back cover


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1

foreword

Lord Darzi

The British Association o Plastic,Reconstructive and Aesthetic Surgeons(BAPRAS) and the British OrthopaedicAssociation (BOA) have been workingto promote the joint care o patientswith severe open ractures o thelower limb by plastic and orthopaedic

surgeons to minimise complicationsand optimise outcomes.

These Standards for the managementof open fractures of the lower limb gobeyond this to provide an evidence-basedapproach to improve the managementoftheseuncommon,difcultinjuries.The authors have built on the previousguidelinestodenethestandardsof

treatment and provide clear guidance ohow these patients should be managed.They have addressed all aspects o thecare o the patient, rom initial assessmentthrough to reconstruction and theindicationsforamputation.Wherethereare no clear data, a balanced view o theavailable evidence is presented, withrecommendations based on principlesand experience. Importantly, they have

also detailed how outcomes can beassessed. I am delighted to note that theintention is or the specialist centres toaudit their outcomes using the evidence-based standards. Oten neglected are

ways to deal with problems when thingsgo wrong, and again the authors haveaddressed this important area.

The recommendation or the patientsto be transerred directly to specialistcentres refects my proposals in the NHS

Next Stage Review or the treatment omajor trauma in specialist centres.

This publication is aimed at improving thequalityoftreatmentthrougheducation.BAPRAS and BOA are to be commendedor making the entire publication availableonline via their websites and ree to downloadinPDFformat,aswellasproducingthisabridged version o the principal guidelines.

The BOAST poster should enable theStandards to be widely publicised.

Our NHS has been at the oreront onumerous innovations and it is hearteningto see that the authors have drawn on awealth o international knowledge to setthe highest standards or patient care.

Proessor, the Lord Darzi o Denham KBE,

HonFREng, FmedSci


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1

foreword

Simon Kay

Plastic surgery is by its nature oneo the most collaborative specialties,orming part o many dierent careteams. No cooperation has been sostrong or productive as that alliancewith orthopaedic and trauma surgery,and this was underlined in the revolution

in the care o the mangled limb, andespecially the open tibial racture.

Whenin1986MarcoGodinademonstratedhow to manage these injuries with the ullbenetoftheemergingeldofmicrovasculartransplantation, he presaged a new era insalvaging limbs. This would not have beenpossible without the advances in racturexation,northeskillsandknowledgein

sot tissue debridement and repair. Butit has been the synergy between thesedisciplines and the remarkable cooperationbetween teams all over the world that haswrought this change most emphatically.

TherstUKguidanceonthejointmanagement o lower limb trauma camerom the BOA and the (then) BAPS in1993andthispresentguidancefollows

in the same tradition. However now, ina contemporary manner, the guidanceismorespecic,morecomprehensive, and evidence-based. These standards

will prove invaluable to teams aroundthe world and the joint working partyis owed a debt o gratitude rom allmanaging trauma and rom all thosepatientswhowillsurelybenetinyearsto come.

Proessor Simon KayPresident, BAPRAS


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1

foreword

Clare Marx

I am delighted to see the publicationo Standards for the managementof open fractures of the lower limb.This is an excellent example ohow the two Specialist Associations,BAPRAS and BOA, can work togetherto set standards and give practical

guidance to surgeons dealing withthese complex injuries.

I would encourage all orthopaedicsurgeons involved in trauma care toensure that the BOAST and the jointbooklet are seen by as wide an audienceas possible to ensure that standards ocare are improved and assured or theuture. The BOA also recommends those

wishing to have more detailed inormationto purchase the excellent book to bepublishedbytheJointWorkingParty.

Clare MarxPresident, BOA


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The frst meeting between the British Orthopaedic Association (BOA) and the BritishAssociation o Plastic, Reconstructive and Aesthetic Surgeons (BAPRAS) was convenedin 1991 to oster closer working between the specialties or the management o patientswith open tibial ractures.

Therewasaclearconsensusthattheyshouldbemanagedjointlyandin1993andagainin1997,representativesfrombothassociationspublishedguidelinesforthemanagementofopentibial ractures. The main aims were to promote cooperation between orthopaedic and plasticsurgeons, improve the understanding o these uncommon but complex injuries and encourage

their treatment in specialist centres. However, the publication went beyond these, providingan algorithmic approach to the management o the injuries and guidance on how to do it.Atasubsequentmeetingofthetwoassociationsin2003,itwasclearthereweredifcultiesin ollowing the guidelines owing to geographical constraints, lack o resources and remainingareas o clinical controversy.

In2007,theBOAandtheBAPRASnominatedrepresentativestoupdatetheguidelines.Anincreasing awareness o the complexity o these injuries and an appreciation o limitationsofpreviousclassicationstopredictoutcomepromptedtheworkinggrouptoexaminethepublished literature in all areas pertaining to the management o open ractures o the lower

limb with a particular ocus on injuries below the knee. As in other areas o surgery, there wereew randomised trials and an approach based purely on levels o evidence would not havebeen possible. However, we have been able to draw on a wealth o excellent publications andendeavouredtoputtheavailableevidenceincontext.Wherethereisnoclearconsensus,wehave drawn on data rom associated areas and on our experience. I no clear choice betweenavailable alternatives or management was present, we have tried to provide a balanced viewthrough highlighting the relative merits and drawbacks o each. The evidence-base upon whichwehavedrawnispublicationsinEnglish.WearedelightedthattheBritishInfectionSocietyandtheAssociationofMedicalMicrobiologistshavereviewedtheguidelinesforantibioticprophylaxis.The ormat is designed to give the reader easy access to the principal recommendations. Details

on how they were derived and a bibliography o the relevant literature can be ound in the ullStandards publication.

Finally,thispublicationreectsthecurrentevidence-baseforourrecommendationsandwe are unanimous in the view that these are the standards o care every patient with theseinjuriesshouldreceive.TheserecommendationsshouldndapplicationbeyondtheUK.

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introduction


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BAPRAS and BOA established a working group with experienced clinicians to defne thestandards or the management o open ractures o the lower limb. The authors are allpracticing specialists in the UK with a particular interest in the evidence-based managemento open ractures o the lower limb, rom an orthopaedic, plastic surgery and inectioncontrol viewpoint.

Authors:

Jagdeep Nanchahal

Proessor o Hand, Plastic & Reconstructive Surgery, London

Selvadurai NayagamConsultant Orthopaedic Surgeon, LiverpoolUmraz KhanConsultant Plastic Surgeon, Bristol

Christopher MoranProessor o Trauma & Orthopaedic Surgery, Nottingham

Stephen BarrettConsultantinMedicalMicrobiology,Southend

Frances SandersonConsultant in Inectious Diseases, London

Ian PallisterReader in Trauma & Orthopaedic surgery, Swansea

Managing editor:

Hamish LaingConsultant Plastic Surgeon, Swansea

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the working group


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The recommendations that ollow are a summary o the main standards publication Standardsfor the management of open fractures of the lower limb. Each section heading below correspondsto a chapter within the ull standards publication.

1. Specialist centres

Principal recommendations

Amultidisciplinaryteam,includingorthopaedicandplasticsurgeonswithappropriateexperience,isrequiredforthetreatmentofcomplexopenfractures.

Hospitalswhichlackateamwithrequisiteexpertisetotreatcomplexopenfractureshavearrangements or immediate reerral to the nearest specialist centre.

Theprimarysurgicaltreatment(wounddebridement/excisionandskeletalstabilisation)o these complex injuries takes place at the specialist centre whenever possible.

Specialistcentresforthemanagementofsevereopenfracturesareorganisedon a regional basis as part o a regional trauma system. Usually these centres also providethe regional service or major trauma.

The characteristics o open injuries that should prompt reerral to a specialist centre are

based on:

1. Fracture patterns:

(a)Transverseorshortobliquetibialfractureswithbularfracturesatasimilarlevel

(b)Tibialfractureswithcomminution/butteryfragmentswithbularfracturesatasimilarlevel

(c) Segmental tibial ractures

(d)Fractureswithboneloss,eitherfromextrusionatthetimeofinjuryorafterdebridement.

2. Sot tissue injury patterns:

(a) Skin loss such that direct tension-ree closure is not possible ollowing wound excision

(b) Degloving

(c)Injurytothemuscleswhichrequiresexcisionofdevitalisedmuscleviawoundextensions

(d) Injury to one or more o the major arteries o the leg.

The specialist centre will need to:

Includeorthopaedictraumasurgery,withspecialexpertiseincomplextibialfracturesand bone reconstruction.

Includeplasticandmicrovascularsurgery,withexpertiseinvascularreconstruction.

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Principalrecommendations


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Providefacilitiesforsimultaneousdebridementbyorthopaedicandplasticsurgicalteams.

Ensureorthopaedicandplasticsurgicalplanningofmanagementstrategytoavoidmultipleepisodesoftreatment,therebyensuringefcientandoptimalpatientcare.

Providededicatedtheatresessionsforthecombinedorthoplasticmanagementofthepatientsduring the normal working day.

Includemicrobiologyandinfectiousdiseaseconsultantswithexpertiseinmusculoskeletalinection.

Includefacilitiesforemergencymusculoskeletalimaging,withangiographyandinterventional

radiology.

Provideaservicefor,orhaveaccessto,articiallimbttingandrehabilitationor amputees.

Haveaccesstophysicalandpsychosocialrehabilitationservices.

Includeauditofoutcomeaspartofthecarepathway.

Aimtoreachathroughputof30suchcasesperannumtomaintainappropriateskillandexperience levels.

Providecombinedorthoplasticclinicsandmultidisciplinarywardrounds.

Possessintensivecareandothertraumafacilitiesforthemultiplyinjuredpatient.

2. Primary management in the emergency department

Principal recommendations Initialassessmentandtreatmentofthepatientoccurssimultaneouslyandinaccordance

with Advanced Trauma Lie Support (ATLS) principles.

Assessmentoftheopentibialinjuryissystematic,carefulandrepeatedinordertoidentifyestablished or evolving limb-threatening conditions and to document limb status prior tomanipulation or surgery.

Haemorrhagecontrolisthroughdirectpressureor,asalastresort,applicationofatourniquet.

Woundsarehandledonlyto

a. Remove gross contaminants

b. Photograph or record

c. Seal rom the environment.

Woundsarenotprovisionallycleanedeitherby:

a. exploration

b. irrigation.

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LimbsplintageisthemostappropriatemeansofimmobilisationavailableintheEmergencyDepartment.Provisionalexternalxatorsarenotapplied.

Antibioticandanti-tetanusprophylaxisisgiven.

Inadditiontotwoorthogonalviewsofthetibia,radiographicassessmentincludesthekneeand ankle joints.

3. Antibiotic prophylaxis

Principal recommendations Antibioticsshouldbeadministeredassoonaspossibleaftertheinjury,andcertainlywithin

three hours.

Theantibioticofchoiceisco-amoxiclav(1.2g8hourly),oracephalosporin(egcefuroxime1.5g8hourly),andthisshouldbecontinueduntilrstdebridement(excision).

Atthetimeofrstdebridement,co-amoxiclav(1.2g)oracephalosporin(suchascefuroxime1.5g)andgentamicin(1.5mg/kg)shouldbeadministeredandco-amoxiclav/cephalosporincontinueduntilsofttissueclosureorforamaximumof72hours,whicheverissooner.

Gentamicin1.5mg/kgandeithervancomycin1gorteicoplanin800mgshouldbeadministered

oninductionofanaesthesiaatthetimeofskeletalstabilisationanddenitivesofttissueclosure. These should not be continued post-operatively. The vancomycin inusion shouldbestartedatleast90minutespriortosurgery.

Patientswithanaphylaxistopenicillinshouldreceiveclindamycin(600mgivpre-op/qds)inplaceofco-amoxiclav/cephalosporin.Forthosewithlesserallergicreactionsacephalosporinis considered to be sae and is the agent o choice.

4. Timing o wound excision in open ractures


Broadspectrumantibioticsareadministeredassoonaftertheinjuryaspossible.

Theonlyreasonsforimmediatesurgicalexplorationarethepresenceof:

a.Grosscontaminationofthewound

b. Compartment syndrome

c. A devascularised limb

d. A multiply injured patient.

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Intheabsenceofthesecriteria,thewound,softtissueandboneexcision(debridement)is perormed by senior plastic and orthopaedic surgeons working together on scheduledtraumaoperatinglistswithinnormalworkinghoursandwithin24hoursoftheinjuryunlessthereismarine,agriculturalorsewagecontamination.The6hourruledoesnotapplyforsolitary open ractures.

5. Guidelines or wound debridement (excision)


Early,accuratedebridementofthetraumaticwoundisthemostimportantsurgicalprocedurein the management o open tibial ractures.

Debridementmeansexcisionofalldevitalisedtissue(exceptneurovascularbundles).

Traumaticwoundsareexcisedcomprehensivelyandsystematicallyandthefollowingsequenceisfollowedinallcases:

Initially,thelimbiswashedwithasoapysolutionandatourniquetisapplied

The limb is then prepped with an alcoholic chlorhexidine solution, avoiding contact o theantisepticwiththeopenwoundandpoolingunderthetourniquet

Softtissuedebridement/excisionissafelyperformedundertourniquetcontrol,especiallyincasesofextensivedegloving.Thisallowsidenticationofkeystructuressuchasneurovascular bundles, which may be displaced, and permits accurate examinationo tissues by avoiding blood-staining

Visualisationofthedeeperstructuresisfacilitatedbywoundextensionsalongthefasciotomylines,describedinsection13,page17

Thetissuesareassessedsystematicallyinturn,fromsupercialtodeep(skin,fat,muscle,bone) and rom the periphery to the centre o the wound. Non-viable skin, at, muscle andbone is excised

Atthisstagetheinjurycanbeclassiedanddenitivereconstructionplannedjointlybythesenior members o the orthopaedic and plastic surgical team

Ifdenitiveskeletalandsofttissuereconstructionisnottobeundertakeninasinglestage,thenavacuumfoamdressing(orantibioticbeadpouchifsignicantsegmentalbonehasbeenlost)isapplieduntildenitivesurgeryisperformed.

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6. Bone exposure, decontamination and preservation: debridement


Extensionofthetraumaticwoundisalongthenearestfasciotomyincision(seesection13,page17).

Whilstabloodlesseldduringsofttissuedebridementmaybehelpful,deatingthetourniquetbeforebonedebridementallowssatisfactoryconrmationofacapacityoftheboneendstobleed. This is probably the most useul determinant o bone viability.

Carefulsurgicaldeliveryofboneendsthroughthewoundextensionaidscircumferentialassessment.

Particulateforeignmatterisremovedwithperiodicirrigationtokeepclearvisibilityofthesurgicaleld.

Loosefragmentsofbonewhichfailthetugtestareremoved.

Fractureendsandlargerfragmentswhichfailtodemonstratesignsofviabilityareremoved.

Majorarticularfragmentsarepreservedaslongastheycanbereducedandxedwithabsolute stability.

Lavagefollows,onceacleanwoundisobtainedbyameticulouszone-by-zonedebridement.

Highpressurepulsatilelavageisnotrecommended.

7. Degloving


Deglovingofthelimboccursintheplanesupercialtothedeepfasciaandtheextentofinjuryis oten underestimated.

Thrombosisofthesubcutaneousveinsusuallyindicatestheneedtoexcisetheoverlyingskin.

Circumferentialdeglovingoftenindicatesthattheinvolvedskinisnotviable.

Insevereinjuries,multi-planardeglovingcanoccurwithvariableinvolvementofindividualmuscles, and these may be stripped rom the bone. Under these circumstances, a second lookmaybenecessarytoensurethatallthenon-viabletissueshavebeenexcisedpriortodenitivereconstruction within seven days.

8. Classifcation o open ractures


Accurate,simpleandreproduciblesystemsforclassicationoflowerlimbinjuriesfacilitate

communication between health care proessionals, assist transer o appropriate cases tospecialist centres and should lead to a treatment plan.

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Theyprovideaplatformforconductingdetailedauditofcaretoensureoptimalmanagemento these patients.

TheGustiloandAndersongradingiswidelyusedandisrelativelysimple,buthaspoorinter-observer reliability and is best applied ater wound excision.

Others,suchastheAOsystem,arecomprehensivesystemsbestusedforauditanddatacollection o outcomes.

9. Temporary wound dressings


Negativepressuredressingsmayreducebacterialingressandtissuedesiccationaswellas avoid pooling o serous fuid.

Negativepressuredressingsarenotusedasasubstituteformeticuloussurgicalwoundexcision.

Negativepressuredressingsarenotasubstituteforcoverageofexposedfractureswithvascularised faps.

Antibioticimpregnatedbonecementbeadsunderasemi-permeablemembraneare

associated with reduced inection rates. Thesebeadsaremostapplicableinpatientswithsegmentalboneloss,grosscontamination

or established inection, perhaps in combination with negative pressure dressings.

10. Techniques or skeletal stabilisation in open tibial ractures


Spanningexternalxationisrecommendedwhendenitivefracturestabilisationandimmediate wound cover is not carried out at the time o primary debridement.

Fracturepatternsandbonelossdeterminethemostappropriateformofdenitiveskeletal stabilisation.

Exchangefromspanningexternalxationtointernalxationisdoneasearlyaspossible.

Internalxationissafeifthereisminimalcontaminationandsofttissuecoverageisachievedat the same time as insertion o the implant.

Modernmultiplanarandcircularxatorsareusedifthereissignicantcontamination,bone loss and multilevel ractures o the tibia.

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4


Segment 1

Segment 2

Segment 3

Safe corridors for pin

placement in the tibia

The tibia can be conveniently dividedinto three segments in which the saecorridors are relatively constant.

Figure 1In segment one, the posterior tibial

neurovascular bundle lies close tothe midline and directly behind theposteriorcortex.Obliquely-directedscrews avoid accidental injury.

In segment two, a buer o the deepposterior compartment muscles liesbetween the posterior cortex o the tibiaand the posterior tibial neurovascularbundle. Although anteromedial

placement is popular, anterior toposterior screws are sae as long ascare is taken to avoid over-penetration.These sagittal plane screws are useulas they give good access or plasticsurgical procedures on either sideo the sagittal plane o the limb.

In segment three, the anterior toposterior screw is inserted through

a small incision and the plane betweenthe lateral edge o tibialis anteriorand extensor hallucis longus ound.An anteromedial screw is also useulbut attention needs to be paid toavoid tethering the medial skin in theevent a distally-based asciocutaneousfap is needed or racture cover.

Figure 1


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Figure 2aPinsinsertedabout1cmmedialtothetibial crest and directed posteriorly allowasimplesagittalplanespanningxatortobe constructed. This provides good accessor most plastic surgical procedures.

Figure 2bThe tibial pins are inserted in the sagittal

planeapproximately1cmmedialtothecrest.Two coronal plane pins are inserted in the oscalcis and neck o talus on the medial side.This arrangement provides good control o thedistal tibia by eliminating hindoot movement.Alternative pin placement includes the baseoftherstandfthmetatarsalsbutsmallerdiameter pins should be used in these areas.

Figure 2c

Access to the medial aspect o the distal tibiaor plastic surgical procedures is acilitated byalteringthepositionoftheobliqueposteriorconnecting rod as shown. The rod is returnedto its original position ater the procedure orthespanningxatorreplacedbydenitivestabilisation.

Figure 2dControl o knee movement (which occurs in

the sagittal plane) and access to the ront andrearoftheproximaltibiaaretworequisitesofthespanningxatorinopenproximaltibialfractures.Therstisachievedbyusingsagittal plane pins in both tibia and emur;an additional anterolateral pin in the distalfemursignicantlyimprovesthestabilityofthe construct. The second is met by keepingthe tibial pins distal to the junction o proximaland middle tibia, thereby permitting easy

access or potential sot tissue reconstructionusing either local or ree vascularised tissue.

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Figure 2a

Figure 2b

Figure 2c

Figure 2d


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11. Timing o sot tissue reconstruction


Localapsaresafelyperformedatthesametimeasskeletalxation.Internalxationis only undertaken i sot tissue coverage can be perormed at the same time.

Freeapreconstructionisbestperformedonscheduledtraumalistsbyexperienced,dedicatedseniorsurgicalteamsfollowingadequatepreparationofthepatient,includingimaging such as angiography or CT scanning o comminuted ractures. This should beundertaken in a specialist centre.

Thereislittleevidencefortheve-dayrule.Microsurgeryisbestperformedbeforethe vesselsbecomefriableorbrosedandthisbecomesincreasinglylikelyaftertherstweek.Werecommendthatdenitivesofttissuereconstructionbeundertakenwithintherstsevendays ater injury.

12. Type o sot tissue reconstruction

Principal recommendations Allopenfracturesarecoveredwithvascularisedsofttissue.

Dressingssuchasthoseusingfoamwithnegativepressurecantemporisefollowingwoundexcision,butarenottobeusedasasubstitutefordenitiveapcoverage.

Relativelylowenergytibialfracturesarecoveredbylocalfasciocutaneousapssolongasthevascularityhasnotbeencompromisedbythezoneofinjuryanddegloving.

Strongclinicalevidencetosupporttheuseofoneformofsofttissuecoveroveranotherinopen tibial shat ractures is absent. However, available experimental data would suggest thatdiaphyseal tibial ractures with periosteal stripping are best covered by muscle faps insteado asciocutaneous faps.

Metaphysealfractures,especiallythosearoundtheankle,arebestcoveredbyfasciocutaneous

faps, including ree faps.

13. Compartment syndrome


Compartmentsyndromeisasurgicalemergencyandmustbediagnosedpromptlyandtreated.

Theearlysignsareparaesthesiainthedistributionofthesensorynervespassingthroughthe aected compartment and disproportionate pain, especially on passive stretch o theaected muscles.

Theseimportantsignsmaybeaffectedbythepreviousadministrationofperipheralnerveblocks and regional anaesthesia, as well as by the presence o nerve injury.

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Posteromedial

incision

Anterial tibialartery and

vein and deepperoneal nerve

Peronealartery and veins

Anterolateral incision

Posterior tibialartery and veinand tibial nerve

Subcutaneoustibial border

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Figure 3

Compartmentsyndromedoesnotusuallyresultinthelossofperipheralpulses.Absentpulses should alert the surgeon to the possibility o vascular injury.

Intra-compartmentpressuremeasurementisperformedmostreliablyusingdevicesdesignedspecicallyforthispurpose.Adifferenceof30mmHgorlessbetweenthemeasuredpressureand the diastolic blood pressure is a reasonable threshold or decompression.

Everyeffortismadetoachieveanaccuratediagnosisbecauseinappropriatefasciotomycanbeassociatedwithsignicantmorbidity.

Thetwoincisiontechniqueprovidesoptimalaccessforfourcompartmentdecompression.

The medial incision does not compromise the availability o available local asciocutaneousfaps. It can also be used to extend pre-existing traumatic lacerations to achieve access ordebridement as well as provide an approach to the posterior tibial vessels as recipientvessels or ree faps.

Allnon-viablemuscleisexcisedandfasciotomywoundseitherclosedwithsplitskingraftsor directly, i possible, once the swelling has reduced.

Alatediagnosisofcompartmentsyndromeisamanagementdilemma.Oncethemuscleis no longer viable, compartment release will predispose to inection, and may result incompartmentectomy or amputation o the limb.

Figure 3 Recommended approach to the our compartments o the leg

Anterior compartment

Peroneal compartment

Deep posterior compartment

Supercialposteriorcompartment


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Figure 4 Landmarks, major vessels and their perorators to be preserved

Recommended incisions for fasciotomy and wound extensions.(a)Marginsofsubcutaneousborder o tibia marked in green, asciotomy incisions in blue and the perorators on the medialside arising rom the posterior tibial vessels in red. (b) line drawing depicting the location o theperforators.(c)montageofanarteriogram.The10cmperforatoronthemedialsideisusuallythe largest and most reliable or distally-based asciocutaneous faps. In this patient, theanterior tibial artery had been disrupted ollowing an open dislocation o the ankle; hence thepoorowevidentinthisvesselinthedistal1/3oftheleg.Thedistancesoftheperforatorsfrom

the tip o the medial malleolus are approximate and vary between patients. It is essential topreserve the perorators and avoid incisions crossing the line between them.

14. Vascular injuries


Devascularisedlimbsareasurgicalemergency.Theyarerecognisedimmediatelyandrequireurgent surgical exploration. The aim is to restore circulation within three to our hours o theinjury, ater which muscle death begins. The maximum acceptable delay is six hours o warmischaemia time.

Capillaryrellinthetoescanbemisleadingand,ifthecirculationisnotnormalcomparedto the contralateral limb, there is a low threshold or exploration.

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5cm 5cm5cm

10cm

15cm

10cm 10cm 10cm

Peronealartery

Anteriortibial artery

Peronealartery

Anteriortibial artery

Posterior

tibial artery

Posterior

tibial artery

Figure 4a Figure 4b Figure 4c


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Absentperipheralpulsesarenotattributedtovascularspasmorcompartmentsyndrome.A major vascular injury is always considered and senior surgical opinion is sought.

Preoperativeangiographyinthedevascularisedlimbwastesvaluabletime.Itispossibletodenethelevelofinjuryfromthefracturecongurationandanysiteofdislocation.

Shuntingsignicantlyreducesthemorbidityassociatedwiththeseinjuriesbyreducingtheischaemictime.Musclesuffersirreversibleischaemicdamagewithinthreetofourhourso complete ischaemia. Nerves are also susceptible to ischaemic injury.

Oncethecirculationisrestored,thelimbisreassessedwithregardtothepotentialforsalvage.

Theskeletonisthenstabilisedbeforereplacingtheshuntswithreversedveingrafts.

Proximaltothelevelofthetrifurcation,anydeepvenousinjuryisalsoreconstructed.

Accessincisionsforvascularrepairtakeintoaccountthenecessityforapcoverandthepresence o adjacent ractures.

Fasciotomyisperformedifindicatedbythepresenceofraisedintra-compartmentalpressurescompared to the diastolic blood pressure. However, it is important that these measurementsare perormed repeatedly, as muscle swelling may not develop until several hours aterrevascularisation(seesection13).

Thepresenceofasinglepatentarterytothefootisnotacontraindicationtofreeapreconstruction using end-to-side anastomoses. In this situation, reconstruction o theinjured vessels is considered, especially the posterior tibial artery.

15. Open ractures o the oot and ankle


Theseareparticularlychallenginginjuriesowingtothelimitedlocalsofttissueapoptions,likelihood o injury to the neurovascular bundles, intra-articular ractures predisposing topoorlongtermfunction,anddifcultyinstabilisingthefractures.

Amputationisconsideredwhenthenalfunctionaloutcomefollowingreconstructionislikelyto be inerior to a trans-tibial amputation. This is especially likely to be the case or a foatingankle injury or crush injuries with an open mid- and oreoot.

Initialskeletalstabilisationisachievedwithaspanningexternalxator,avoidingbularplating.Thereareinherentdifcultiesinstabilisingthesefracturesastheanchorpointsformostspanningexternalxatorsrelyonanintactoscalcis/talus/metatarsals.

Denitiveskeletalxationisperformedatthetimeofsofttissuecoverage.Theexactcongurationwilldependonthefracturepattern,withintra-articularfracturesusuallybestmanagedbyinternalxation.Internalxationisnotrecommendedintheabsenceof

adequatesofttissuecover,asthismaybeassociatedwithanincreasedriskofdeepsepsis. Deglovedplantarskin:

a. I supraascial, is deatted and replaced as ull-thickness grat

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b. I subascial and proximally based, is sutured back without tensionc. I subascial and distally based, is considered or revascularisation.

Plantarsofttissuelossisbestmanagedusingfasciocutaneousaps,andreinnervationmayconer some protection against the development o neuropathic ulceration. Dorsal skin losscan be managed by split skin grats or thin, ree asciocutaneous faps.

Openpilonfracturesarestabilisedwithaspanningexternalxator.Iftheplanneddenitivetreatmentisinternalxationofthetibialplafond,andprovidedthesofttissuespermit,openreductionandinternalxationofthebulaatprimarysurgerymayhelptoassistmaintainthe

limb out to length. Sot-tissue cover should be by way o thin, pliable asciocutaneous faps. Injuriestotheposteriortibialnerveareaccuratelyassessedandconsiderationisgivento

reconstruction o segmental deects o the posterior tibial artery with autologous vasculargrat. End-to-end anastomoses to avulsed vessels are perormed with care as it can bedifculttoassesstheextentofintimaldamage.

Openhind-footinjuriesaremanagedasforadiaphysealinjurywhenonlyonearticularsurfaceisinvolved.Whenthereisgreaterdisruptionofthehind-foot,atrans-tibialamputationisconsidered.

Isolatedopenmid-footinjuriesareoftencausedbyheavyobjectsfallingonthefoot.These

resultinsignicantpost-operativestiffnessandpainduetoligamentousdisruptionandagain,amputation is considered.

Openforefootinjuriesinvolvingtherstmetatarsalaretreatedasaggressivelyasopendiaphysealinjuries.Whentheothermetatarsalsareinjuredinisolation,arayamputationresults in a reasonable return to ambulation.

16. When things go wrong with sot tissues


Necrosisofalocalapoverthefracturesiteismanagedbyearlyreturntotheatreand

revision surgery to achieve healthy sot tissue coverage.

Limitedtipcongestionmayrespondtoleechtherapy.

Somelocalfasciocutaneousapsmaybemorepronetodevelopcomplicationsinpatientswith co-morbidities.

Freeapcomplicationsarereducedbypatientpreparation,carefulplanningandperformingtheanastomosesoutsidethezoneofinjury,ideallyproximally.

Thereisalowthresholdforimmediatere-explorationofafreeapwithsuspectedcirculatorycompromise.

Deepinfectionrequiresareturntofracturesiteexploration,debridement,deadspacemanagementandantibiotictherapy.Fracturexationmayneedrevision.

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17. When things go wrong with bone


Earlycomplicationswithboneoccurasaconsequenceoftheoriginalinjuryorfromsurgery.

Problemsthatpresentare:

a. wound leakage

b. sepsis

c. loss o alignment.

Commoncausesincludeinadequatedebridement,haematomaformation,inappropriateordelayedsofttissuecoverandunstablexation.Eachcauseissoughtandremediedpromptly.

Anexpectantapproachisseldomfruitfuland,ifadopted,shouldbeforalimitedperiodonly.

Adecisiontointerveneistakenifthereisfailuretoimprove.

Earlyproblemscanexertanundueinuenceonthenaloutcomeunlessweighedfortheirsignicanceandacteduponappropriatelyandpromptly.

Discussionofthecasewiththenearestspecialistcentreisencouragedandgivestheopportunity to correct the problem at the earliest opportunity.

18. Guidelines or primary amputation


Aprimaryamputationisperformedasadamagecontrolprocedureifthereisuncontrollablehaemorrhagefromtheopentibialinjury(usuallyfrommultiplelevelsofarterial/venousdamage in blast injuries), or or crush injuries exceeding a warm ischaemic period o six hours.

Primaryamputationisalsoneededforincompletetraumaticamputationswherethedistalremnantissignicantlyinjured.

Aprimaryamputationisconsideredanoptionwheninjurycharacteristicsincludeoneorseveral o the ollowing:

avascular limbs exceeding a our to six hour threshold o warm ischaemia

segmental muscle loss aecting more than two compartments

segmental bone loss greater than one third the length o the tibia.

Absentorreducedplantarsensationatinitialpresentationisnotanindicationforamputation.

Amputationlevelsarepreferablytrans-tibialortrans-femoral(ifsalvageofthekneeisnotpossible). Through-the-knee amputations are not recommended or adults.

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Thedecisiontoamputateprimarilyshouldbetakenbytwoconsultantsurgeonswith,i possible, patient and amily involvement.

Discussionwiththenearestspecialistcentreisadvisedwhenthereisuncertaintyordisagreementbetweensurgeonrecommendationsandpatient/familywishes.

19. Outcome measures


PatienthealthstatusquestionnairessuchasSicknessImpactProleandMedicalOutcomes

StudyShortForm-36(SF-36)provideavaluableoverallassessmentofthepatient.

Uniontimeofdiaphysealfracturescanbedifculttoassessbutisanacceptedoutcomemeasure.

Ratesofsignicantcomplicationssuchasdeepinfection,apfailureandsecondaryamputation are recorded.

LimbfunctionscoressuchastheEnnekingScore,whichisexpressedasapercentageo the contralateral uninjured limb, are recommended.

Peri-articularinjuriesideallyshouldincludemeasuresoftheaffectedjoints.

20. Management o severe open ractures in children


Thewoundforopenchildrensfracturesisdebrided(excised)asrecommendedforadults.There is no evidence to suggest that tissues with compromised viability are more likely torecover in children compared to adults.

Skeletalxationisdeterminedbythefractureconguration.Theuseofintramedullarydevicesmay be limited by the presence o growth plates.

Theavailableevidencesuggeststhatchildrenundertheageoftwelveyears(prepubertal)

are likely to have shorter union times.

Softtissuereconstructionforopenfracturesinchildrenofallagesreliesonvascularisedfaps, as it does or adults.

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BAPRAS

BAPRAS, the British Association o Plastic, Reconstructive andAesthetic Surgeons, is the voice o plastic surgery in the UK. It aimsto increase the understanding o the proessional specialty andscope o plastic surgery, promoting innovation in teaching, learningandresearch.Foundedin1946(originallyastheBritishAssociationofPlasticSurgeons),todayBAPRAShasover800membersandis

the proessional representative body or reconstructive and aestheticplastic surgeons providing services to patients on the NHS andprivately in the UK.

The British Association o Plastic, Reconstructiveand Aesthetic Surgeons (BAPRAS)35-43LincolnsInnFields,LondonWC2A3PE,Telephone:02078315161,Fax:02078314041 www.bapras.org.uk

BOAThe BOA is the proessional association or trauma and orthopaedicsurgeons in the UK and those abroad who have had orthopaedictraining in the UK or who show a continuing interest in the aairs o theAssociation.Foundedin1918,ourmissionistobringrelieftopeoplesuering rom injury or musculoskeletal disorder by advancing thescience, art and practice o orthopaedic surgery. The BOA currentlyhasabout4000membersintheUKandoverseas,themajorityofthese are UK consultant and trainee orthopaedic surgeons.

The British Orthopaedic Association (BOA)

35-43LincolnsInnFields,LondonWC2A3PE,Telephone:02074056507,Fax:02078312676 www.boa.ac.uk

BritishOrthopaedicAssociation

ACKNOWLEDGEMENTS

Wearegratefulthatthepublicationofthesestandardshasbeensupportedwitheducationalgrantsfrom:DePuy,Orthox,Smith& Nephew and Synthes.

Documents

Boa Lower Limb 2009