Open Tibial Fracture in a Non-Compliant Patient: A Case Report

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1 Journal Functional Morphology Kinesiology Case Report Open Tibial Fracture in a Non-Compliant Patient: A Case Report Samuele Pizzolo, Gianluca Testa * ID, Giacomo Papotto, Giuseppe Mobilia, Giovanni Di Stefano, Giuseppe Sessa Vito Pavone ID Department General Surgery Medical Surgical Specialties, Section Orthopaedics Traumatology, AOU Policlinico-Vittorio Emanuele, University Catania, Via Plebiscito 628, Catania, Italy; samuelepizzolo@gmail.com (S.P.); giacomopapotto@gmail.com (G.P.); mobiliagiuseppe87@gmail.com (G.M.); giovannidistefano86@gmail.com (G.D.S.); giusessa@unict.it (G.S.); vitopavone@hotmail.com (V.P.) * Correspondence: gianpavel@hotmail.com; Tel.: ; Fax: Received: 18 June 2018; Accepted: 10 August 2018; Published: 11 August 2018 Abstract: Open tibial s represent most frequent s long bones, comprising approximately 1.9% all s. Although locked intramedullary nailing is gold stard for treating closed unstable tibia diaphyseal s, for most exposed s, an external fixator can first be used, followed by conversion through an intramedullary nail. The present report describes case a 17-year-old male who presented with a complex multi-segmented displaced tibia, type 42-C3, with exposure IIIB type according to Gustilo Anderson classification, with an attached disrupted peroneal malleolus, type 44-B2. External fixation was preferred treatment method. Before definitive surgical treatment, patient had a second accident that caused re damage to st tissues external fixation system. This prolonged time estimated for conversion from external fixator to intramedullary nail. The reported case shows use various treatment steps with different timelines an intervention with vacuum-assisted closure rapy for st tissue healing as well as subsequent intramedullary nailing in order to reach definitive healing a non-compliant patient. These combined methods achieved an acceptable reduction good stability such a complex. Keywords: open tibial ; Gustilo Anderson classification; compliance; intramedullary nailing; external fixation 1. Introduction Shaft tibial s are relatively common, yet y are complex to manage, due to poor st tissue coverage on antero-medial surface tibia possible alterations alignment stability lower limb. This may result in bone st tissue injuries, leading to exposed s to non-negligible complications, such as infections delayed healing or non-unions [1]. These s ten result from direct, high-energy traumas, such as road, work, or sports injuries. They frequently affect young adults with an average age 37 years. The frequency tibial is approximately s per 100,000 per year, with open being 1.9% all tibial s [2,3]. Cases indirect trauma, such as those due to falling long distances, are less common. The most complete classification diaphyseal tibial s is AO/OTA (Orthopedic Trauma Association) classification, which is based on stard radiographic projections includes site as well as degree type comminution [4]. It distinguishes between simple s (A), compression s (B), complex s (C). Each group is n furr divided into three subgroups (Table 1). Type A s are mono-focal, ir subdivision into various subgroups is based on orientation presence or absence a fibular, J. Funct. Morphol. Kinesiol. 2018, 3, 44; doi: /jfmk

2 J. Funct. Morphol. Kinesiol. 2018, 3, resulting in following categories: spiroid s [A1], oblique s [A2], transverse s [A3]. The suffix (1) is used if re is no associated fibula, (2) is used if peroneal is distant from tibial, (3) is used if it is at same level. In type B s, subdivision is very similar, including spiroid wedge s [B1], flexed wedge s [B2], fragmented wedge s [B3]. Type C s are not divided according to position fibula relative to tibial but are based on severity tibial classified as complex spiroid s [C1], bifocal s [C2], comminuted s [C3]. Table 1. AO classification tibial shaft s. A1 A2 A3 B1 B2 B3 C1 C2 C3 Spiral Oblique Transverse Spiral wedge Oblique wedge Transversal wedge Comminuted Segmental Crush Open s are subdivided according to Gustilo Anderson classification [5]. This classification is based on st tissue damage, grade III considers a variety different s on basis ir morphology, extent contamination, damage to st tissue, or delayed treatment. Grade III sub-categories are identified on basis periosteal damage need for vascular surgery (Table 2). Table 2. Gustilo Anderson Classification open s. I II IIIA IIIB IIIC Open, clean wound, wound <1 cm in length. Open, wound >1 cm but <10 cm in length without extensive st tissue damage, flaps, avulsions. Open with adequate st tissue coverage a d bone despite extensive st tissue laceration or flaps, or high-energy trauma regardless size wound. Open with extensive st tissue loss periosteal stripping bone damage. Usually associated with massive contamination. Will ten need a furr st tissue coverage procedure. Open associated with an arterial injury requiring repair, irrespective degree st tissue injury. Surgical intervention aims to obtain good correction reduction, an adequate axial alignment on sagittal coronal planes, a suitable range motion, restoration correct length limb, as well as good early knee ankle motility. To evaluate clinical radiographic outcomes as well as complex management se s, we report a clinical case an open-shaft tibia with an associated peroneal malleolus in a 17-year-old uncooperative patient. 2. Clinical Case In June 2016, a 17-year-old boy came to our attention after being referred to us following a motorcycle accident. Informed consent from patients was obtained. He immediately appeared non-compliant with healthcare workers. The first clinical evaluation revealed important generalised pain right leg as well as functional impotence, tibial with medial exposure degree IIIB about 10 cm extension at level distal middle third right tibia, contamination same outbreak with material that probably originated from road surface, various lacerated contusion wounds spread around exposure (Figure 1).

3 J. Funct. Morphol. Kinesiol. 2018, 3, J. Funct. Morphol. Kinesiol. 2018, 3, x 3 10 J. Funct. Morphol. Kinesiol. 2018, 3, x 3 10 Figure Figure Degree Degree exposure exposure st st tissue tissue at at level level right right leg. leg. Figure 1. Degree exposure st tissue at level right leg. The patient showed no apparent deep vascular-nervous deficits reported being a habitual smoker. The After patient appropriate showed no evaluation apparent by deep vascular-nervous general emergency deficits room surgeon reported in order being to a rule habitual out abdominal smoker. After /or appropriate cranial lesions, evaluation patient by was general sent emergency to radiology room to perform surgeon anteroposterior in order to rule out lateral abdominal radiographs, /or cranial which lesions, showed a complex patient multi-segmented was sent to radiology displaced to perform tibia anteroposterior (type 42-C3) with lateral an radiographs, attached disrupted which showed a complex peroneal multi-segmented malleolus, type 44-B2 displaced (Figure tibia 2). (type 42-C3) with an attached disrupted peroneal malleolus, type 44-B2 (Figure 2). 2). Figure 2. Pre-surgical emergency radiographs; anteroposterior (AP) left lateral (LL) projections Figure 2. Pre-surgical emergency radiographs; right anteroposterior leg ankle. (AP) left lateral (LL) projections Figure 2. Pre-surgical emergency radiographs; anteroposterior (AP) left lateral (LL) projections right leg ankle. right leg ankle. The patient was surgically treated with a reduction stabilization with external fixation. The patient The was patient placed was in surgically supine treated position, with a reduction exposure stabilization was debrided with external to remove fixation. The contaminating patient The was patient placed was residues. in surgically Various supine treated bruised position, with a wounds reduction bruises exposure stabilization were thoroughly was debrided with external cleaned. to The remove fixation. The was contaminating patient was reduced by residues. placed mounting Various in supine an external bruised position, fixation wounds implant bruises exposure in a hybrid were configuration thoroughly was debrided cleaned. to with a tibial The remove socket contaminating was three reduced proximal by residues. mounting Various Schanz screws an external bruised three fixation wounds distal implant bruises 2 mm in transverse a hybrid were wires configuration thoroughly cleaned. anchored with to a a The semicircular tibial socket was frame three reduced (Figure proximal by mounting 3). Schanz screws an external fixation three distal implant 2 mm in transverse a hybrid configuration wires anchored with to a tibial a semicircular socket three frame proximal (Figure 3). Schanz screws three distal 2 mm transverse wires anchored to a semicircular frame (Figure 3).

4 J. Funct. Morphol. Kinesiol. 2018, 3, J. Funct. Morphol. Kinesiol. 2018, 3, x 4 10 J. Funct. Morphol. Kinesiol. 2018, 3, x 4 10 Figure 3. Post-operative radiographs; AP LL projections right leg ankle. Figure 3. Post-operative radiographs; AP LL projections right leg ankle. Figure 3. Post-operative radiographs; AP LL projections right leg ankle. One month later, patient underwent a clinical radiographic follow-up evaluation, which showed One an month implant later, later, with good patient patient grip underwent underwent a reduction a clinical a clinical radiographic radiographic abutments. follow-up The follow-up patient evaluation, evaluation, underwent which which showed new clinical showed an implant radiographic implant with good with grip checks good two grip a reduction months a reduction three months abutments. after his abutments. surgery The patient (Figure The underwent patient 4). The underwent new multi-fragmentation clinical new radiographic clinical radiographic checks still two showed months checks no two stable three months consolidation months after three during his months surgery se after (Figure controls, his surgery 4). with The (Figure multi-fragmentation poor presence 4). The multi-fragmentation bone callus; conversion still showed to intra-medullary no still stable showed consolidation nailing no stable had during been consolidation planned se controls, during at st tissue se with controls, poor healing. presence with poor bone presence callus; conversion bone callus; to conversion intra-medullary to intra-medullary nailing had nailing been planned had been at planned st tissue at st healing. tissue healing. Figure 4. Radiograph at three-month follow-up evaluation; AP LL projections right leg Figure ankle. 4. Radiograph at three-month follow-up evaluation; AP LL projections right leg ankle. Three months after surgical treatment, patient suffered a new motorcycle accident in which he reported Three months re after surgical decomposition treatment, patient anatomical suffered axis a new motorcycle abutments, accident deformity in which Three months after surgical treatment, patient suffered a new motorcycle accident in which he reported anatomical prile, re damage decomposition to st tissues anatomical external axis fixation system abutments, (Figure deformity 5). reported re decomposition anatomical axis abutments, deformity anatomical prile, damage to st tissues external fixation system (Figure 5). anatomical prile, damage to st tissues external fixation system (Figure 5).

5 J. Funct. Morphol. Kinesiol. 2018, 3, J. Funct. Morphol. Kinesiol. 2018, 3, x 5 10 J. Funct. Morphol. Kinesiol. 2018, 3, x 5 10 Figure 5. Images, st tissue, external fixation implant following new Figure 5. motorcycle Images accident, three months st tissue, after first external one. fixation implant following new motorcycle accident Figure three 5. months Images after, first one. st tissue, external fixation implant following new motorcycle A new surgical accident three treatment months was after performed. first one. The external fixator was removed, abutments were reduced, a long cast with a trans-calcaneal traction was performed. The cast was A new surgical treatment was performed. anteriorly A new open surgical because treatment tibial was performed. focus The was external prominent fixator was level removed, st tissue, abutments encompassing were reduced, trans-calcaneal a long traction cast with bracket a trans-calcaneal (Figure 6). traction was performed. The cast was anteriorly open because tibial focus was prominent at level st tissue, encompassing trans-calcaneal traction bracket (Figure 6). The external fixator was removed, abutments were reduced, a long cast with a trans-calcaneal traction was performed. The cast was anteriorly open because tibial focus was prominent at level st tissue, encompassing trans-calcaneal traction bracket (Figure 6). Figure 6. Radiograph right leg ankle after new treatment performed in October 2016, including removal external fixator packaging pin-femoral-podalic appliance incorporating a trans-calcaneal traction bracket. Figure 6. Radiograph right leg ankle after new treatment performed in October 2016, Figure 6. Radiograph right leg ankle after new treatment performed in October 2016, including removal external fixator packaging pin-femoral-podalic appliance including removal external fixator packaging pin-femoral-podalic appliance incorporating a trans-calcaneal traction bracket. incorporating a trans-calcaneal traction bracket. In following days, vacuum-assisted closure (VAC) rapy was started to allow progressive healing st tissues overlying tibial focus (Figure 7).

6 J. Funct. Morphol. Kinesiol. 2018, 3, x 6 10 J. Funct. Kinesiol. 2018, 3, x J. Funct. Morphol. Kinesiol. 2018, 3,days, 44 InMorphol. following vacuum-assisted closure (VAC) rapy was started to allow progressive healing st tissues overlying tibial focus (Figure 7). In following days, vacuum-assisted closure (VAC) rapy was started to allow progressive healing st tissues overlying tibial focus (Figure 7). Figure 7. Condition progressive improvement st tissues following vacuum-assisted closure Figure 7. Condition progressive improvement st tissues following vacuum-assisted closure (VAC) rapy. 7. Condition progressive improvement st tissues following vacuum-assisted closure (VAC)Figure rapy. (VAC) rapy. At visit carried out in November 2016, patient s st tissues had significantly improved, while wasout basically unchanged notpatient s fully healed (Figure 8).had significantly improved, At visit carried in November 2016, st tissues At visit carried out in November 2016, patient s st tissues had significantly improved, whilewhile was basically unchanged not fully healed (Figure was basically unchanged not fully healed (Figure 8).8). Figure 8. Radiograph right leg image st tissue in November Figure 8. Radiograph right leg image st tissue in November After 45 days with a plaster a decision was made a definitive surgical treatment. Figure 8. Radiograph cast, right leg image to perform st tissue in November This involved intramedullary nailing blocked with two proximal screws two distal screws to After 45 days with a plaster cast, a decision was made to perform a definitive surgical treatment. realign reduce tibial peroneal s (Figure 9). After 45 days intramedullary with a plaster nailing cast, a decision was two made to perform a definitive surgical treatment. This involved blocked with proximal screws two distal screws to intramedullary reduce tibial peroneal s 9). This realign involved nailing blocked with(figure two proximal screws two distal screws to realign reduce tibial peroneal s (Figure 9). J. Funct. Morphol. Kinesiol. 2018, 3, x 7 10 Figure 9. Postoperative radiograph right leg performed in December Figure 9. Postoperative radiograph right leg performed in December Subsequent monthly two-monthly clinical-radiographic follow-up evaluations showed progressive healing tibia fibular s improvement functional clinical prognosis (Figure 10).

7 J. Funct. Morphol. Kinesiol. 2018, 3, Figure 9. Postoperative radiograph right leg performed in December Subsequent monthly two-monthly clinical-radiographic follow-up evaluations showed progressive healing Subsequent monthly tibia two-monthly fibular s clinical-radiographic improvement follow-up evaluations functional showed clinical progressive healing tibia fibular s improvement functional clinical prognosis (Figure 10). prognosis (Figure 10). J. Funct. Morphol. Kinesiol. 2018, 3, x 8 10 Post-Operative Care Figure 10. Clinical-radiographic follow up in February Figure 10. Clinical-radiographic follow up in February Such s can lead to a significant loss functionality may limit ability to walk, run, participate in sports work. Progressive loading on lower right limb was possible after about 15 days after surgical nailing operation. This was performed to stimulate bone healing, while remaining compatible with expressed tolerance patient. To evaluate results, we considered both clinical radiological criteria. We performed last accurate objective examination radiographic follow-up evaluation in February 2017, two

8 J. Funct. Morphol. Kinesiol. 2018, 3, Post-Operative Care Such s can lead to a significant loss functionality may limit ability to walk, run, participate in sports work. Progressive loading on lower right limb was possible after about 15 days after surgical nailing operation. This was performed to stimulate bone healing, while remaining compatible with expressed tolerance patient. To evaluate results, we considered both clinical radiological criteria. We performed last accurate objective examination radiographic follow-up evaluation in February 2017, two months after intramedullary nailing surgery, which showed sufficient knee ankle joint motion with an initial consolidation. Physiorapy played an important role in recovering normal joint function. The initiation physiorapy ten varies, depending on type surgery performed severity s damage to st tissues. A rehabilitation consisting passive active muscular mobilisation exercises was carried out to assist functional joint recovery as well as maintenance posture in orthostatism, balance, proprioception, adequate tension, muscular strength. All se were limited did not allow for normal daily activities, following long period immobilization. The muscles were strengned affected lower limb from hip to ankle. In first period (after about 30 days), isometric toning exercises were performed by contracting limb at one-minute intervals. Balance exercises were performed on injured limb, toning exercises were performed using axial compression, flexion exercises were performed by extending foot leg toward thigh. At beginning rehabilitation, use crutches was necessary. In general, with progressive walking balance improvement, patients may only require one crutch before y can move walk freely, according to patient s tolerance. The walking style, amplitude movement, strength, swelling, pain, surgical scars were all taken into consideration. Ice-based rapies, electrical stimulation, heat were applied to reduce pain swelling to allow for earlier bone healing. Swimming cycling helped with muscle recovery. Also, lifting exercises lowering affected leg were performed to assist recovery quadriceps femoris gastrocnemius. Some rehabilitation treatments were performed at home after being introduced by a physiorapist. Massages scar tissue mobilisation were performed. The recovery times vary for each patient can only be approximately calculated. They mostly depend on conditions at start rehabilitation after surgery. Physiorapy for cases similar to present one usually lasts 4 to 10 weeks. In presented case, physiorapy lasted about seven weeks until recovery mobility return to normal activities were safely achieved. Patient compliance is essential for good results,, in this case, patient was tentimes non-compliant. 3. Discussion External fixation is a widely used method to treat exposed tibia s, as it is considered to have a low incidence infections. It does not require placement devices on site is characterised by a lower risk vascular damage. It can also be used as a definitive or temporary fixation. The external fixations allow for use multi-planar mounts with medial lateral bars fixed by screws or by piercing pins in quadrilateral, triangular, or or particular configurations, depending on which method provides best possible stability [6]. Circular external fixators [7] hybrid fixators exhibit highest configuration complexity. Circular fixators are comprised complete rings or semi-rings that are fixed to tibia by tensioned piercing threads. Hybrid fixators are comprised a system both rings with tensioned piercing wires bars with screws. Locked intramedullary nailing is gold stard for treating closed unstable tibial shaft s most exposed s (types I, II, IIIA Gustilo Anderson) [8]. Numerous studies have reported a high percentage consolidation a low incidence incorrect consolidation infections, even in cases exposed s. If re is any doubt about possibility a shaft tibial treatment with an intramedullary nail, it is possible to begin initial treatment with an external

9 J. Funct. Morphol. Kinesiol. 2018, 3, fixation n perform definitive fixation with an intramedullary nail [9]. Contraindications to initial nailing a tibial shaft include pre-existing deformities, open conjugation cartilage, a bone marrow channel less than 8 mm wide, wounds near surgical access, severe contamination, exposed s occurred more than 24 h before treatment, type-iiic Gustilo open s. The reported case demonstrates management a patient with poor compliance that required use various treatment steps adjusted timelines. A second motorcycle accident occurred destroyed external fixation implant, creating a re. Therefore, intervention with VAC rapy for st tissue healing subsequent intramedullary nailing was necessary. A cast combined with VAC rapy enabled st tissue healing. Immediate nailing would not have been a prudent choice because patient s highly critical conditions [10]. This decision allowed functional recovery patient through early mobilisation an appropriate rehabilitation process. This consisted passive active mobilisation exercises muscle strengning for purpose functional joint recovery. It also included orthostatism posture maintenance improvements balance, proprioception, tension, muscle strength, which, following long period immobilisation, were limited hindered normal daily activities. 4. Conclusions The treatment shaft tibial s is generally surgical, re are typically multiple options. The gold stard is intramedullary nailing, which can be performed through various surgical techniques is able to guarantee excellent results with relatively low complication rates. External fixation is a widely used method in exposed tibia s, which has been shown to lead to a lower incidence infections than intramedullary nailing can be used as a temporary treatment method. External fixation was preferred option in this specific case. However, patient s poor compliance altered timing originally estimated for conversion from external fixator to intramedullary nail. This lengned treatment time made st tissue removal necessary using VAC Therapy, following re st tissue injury that subsequently occurred. Functional recovery through physiorapy progressive loading on affected limb post-nailing had an essential role in this complex case. The physiokinetic rapy for similar cases usually lasts 4 to 10 weeks; in this case, it took approximately seven weeks until mobility was recovered, patient was able to return to his normal activities. Author Contributions: G.P. G.T. observed case contributed to acquisition data; S.P., G.D.S., G.M. performed review literature analyzed data; S.P. G.M. wrote paper; G.S. V.P. supervised paper; all authors contributed to revision paper. Funding: This research received no external funding. Conflicts Interest: The authors declare no conflict interest. References 1. Marx, J. Rosen s Emergency Medicine: Concepts Clinical Practice; Mosby: Philadelphia, PA, USA, Court-Brown, C.M.; McBirnie, J. The epidemiology tibial s. J. Bone Jt. Surg. Br. 1995, 77, [CrossRef] 3. Weiss, R.J.; Montgomery, S.M.; Ehlin, A.; Al Dabbagh, Z.; Stark, A.; Jannson, K.A. Decreasing incidence tibial shaft s between : Information based on Swedish inpatients. Acta Orthop. 2008, 77, [CrossRef] [PubMed] 4. Müller, M.E.; Nazarian, S.; Koch, P.; Schatzker, J.; Heim, U. The Comprehensive Classification Fractures Long Bones; Spinger-Verlag: Berlin, Germany, Haas, N.; Krettek, C.; Schelmaier, P.; Frigg, R.; Tscherne, H. A new solid unreamed tibial nail for shaft s with severe st tissue injury. Injury 1993, 24, [CrossRef]

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