Post-Operative Management

This module allows medical officers and surgeons who are not orthopedic specialists to become confident and competent in irrigation and debridement, powered and manual drilling, positioning and correctly inserting Schanz screws, and constructing the uniplanar external fixator frame as part of external fixation procedures for open tibial shaft fractures performed in regions without specialist coverage. To maximize patient safety, this module teaches learners to use a powered drill to insert self-drilling Schanz screws through the near cortex and then manually advance Schanz screws into the far cortex to avoid plunging.

Learning Objectives

By the end of this module, learners will be able to:

1. Conduct a history and physical examination of a patient following uniplanar external fixation of an open tibial shaft fracture.
2. Review the post-operative anteroposterior and lateral view radiographs of a patient following uniplanar external fixation of an open tibial shaft fracture.
3. Provide post-operative care for a patient following uniplanar external fixation of an open tibial shaft fracture.
4. Know the indications for adjusting the uniplanar external fixator for a patient with an open, simple tibial shaft fracture.
5. Know the indications for referral of a patient with an open tibial shaft fracture to a tertiary center for specialist care.

Postoperative Clinical Assessment

Physical Examination

Neurovascular Exam

Sensory Testing

Motor Testing

If patient is unable to dorsiflex and plantarflex their ankle, ask the patient to move their toes.

Vascular Exam

If posterior tibial artery pulses are not palpable, check for signs of acute compartment syndrome.

Acute Compartment Syndrome

Rule out acute compartment syndrome:^[4]

Pain disproportionate to injury and intensified with passive stretch (i.e., flexion and extension of the toes)

Pallor

Paresthesias

Paralysis

Pulselessness

Compartment pressure greater than 30-40 mmHg in an unconscious or paralyzed patient

No signs of compartment syndrome

Acute compartment syndrome is a surgical emergency and must be treated with a fasciotomy. If the patient has signs of acute compartment syndrome, the patient should be referred to a tertiary center for specialist care.

Hardware Inspection

Other Clinical Findings

Please describe any other relevant clinical findings:______________________________________

Photo Documentation of Injured Extremity

Take images of the soft tissue wound(s) of the injured extremity including the joint above and below for orientation.

After the wound is examined and photographed, re-dress it with a sterile dressing.

Post-Operative Radiographic Findings

Review anteroposterior (AP) and lateral views and note any clinically significant radiographic findings.^[7] The AP view shows the coronal plane and the lateral view shows the sagittal plane.

Post-Operative Management Plan

Wound Care

Soft tissue wounds are cleaned with sterile normal saline and dressed with povidone iodine gauze dressing.

The frequency of dressing changings will vary according to the amount of wound contamination:

If the wound is highly contaminated, dressings are changed twice daily.

If the wound is clean, dressings can be changed once daily or every other day.

Antibiotic Therapy

Antibiotics may be changed, added or extended depending on clinical findings.^[11][12][13] Doses will be adjusted based on patient weight when indicated.

Recommended Antibiotic Therapies for Open Fractures

These therapies may vary due to regional differences in antibiotic regimens for open fractures.

Venous Thromboembolism Prophylaxis

Contraindications for venous thromboembolism (VTE) chemoprophylaxis are:^[14]

active bleeding in the last 48–72 hours

hypertensive crisis

coagulopathy

platelet count < 25,000

used recombinant tissue plasminogen activator against stroke within 24 hours

recent head trauma with central nervous system hemorrhage

multiple trauma with high bleeding risk, such as solid organ injury (suspected) peri-spinal hematoma, or

at high risk for bleeding according to clinical judgment

if no contraindications for VTE chemoprophylaxis, give enoxaparin (low molecular weight heparin) 40 mg every 24 h

Early Mobilization

On post-operative day #2, the patient can be non-weightbearing and mobilized on axillary crutches.

Additional Surgical Procedures

If required, additional procedures can be performed 48 to 72 hours later for further debridement (a "second look") if the wound is still contaminated, suture-based skin closure of a clean, small (< 4 cm) soft tissue wound, and/or to adjust or replace the uniplanar external fixator hardware.

Post-operative AP and lateral radiographs will be obtained and reviewed.

Antibiotics may be changed, added or extended depending on clinical findings.

Discharge Instructions

When the wound appears clean enough for dressing changes twice a week, patients will remain non-weight-bearing, and can be discharged typically within 48 hours on crutches with wound and pin care instructions.

The patient or caregiver should apply the following wound and pin care instructions until the uniplanar external fixator is removed:

• Clean soft tissue wounds should be dressed with a non-adherent gauze dressing (like Sofra-Tulle) twice a week.
• The pin insertion sites normally do not have to be dressed. However, if a clean environment and hygiene cannot be maintained after discharge, then gauze soaked in povidone iodine can be used to dress the pin insertion sites.
• The pin insertion sites should be kept clean. If crust or exudate is present, then the pin insertion site can be cleaned with normal saline and disinfected with alcohol.
• Pin insertion sites need not be protected for showering or bathing with clean water.^[15]

Follow-up Care

After discharge, patients can be followed up in the clinic at 2 weeks, 4 weeks, 6 weeks, 8 weeks, 12 weeks, 6 months, and 1 year or as per local practices.

Acknowledgements

This work is funded by a grant from the Intuitive Foundation. Any research, findings, conclusions, or recommendations expressed in this work are those of the author(s), and not of the Intuitive Foundation.

References