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Open tibia fracture in Tanzania

This case involves a 62-year-old man who sustained an open fracture of the left tibia after a motorbike accident. He was treated in Haydom Lutheran Hospital in Tanzania.

Medical history

The man is a farmer living with two wives and six children. They keep cows and goats.

The household spends approximately two dollars a day. He has never been admitted to a hospital and told us that he had not taken any medication in his life. On the day of the accident he was a passenger on a pikipiki (motorcycle taxi) that hit another pikipiki. They did not wear helmets. He was unconscious after the injury. An ambulance was called and brought him to Haydom Lutheran Hospital (photo 2).

Physical examination

When he arrived at the emergency department he was hemodynamically stable with a GCS of 14 and complaining of a severe headache and pain in the left leg. A displaced open fracture of the left leg was observed with good sensation and circulation of the foot. No other injuries. Full blood panel was normal, Hb 14,8 gr/dl. After applying a backslab, a CT scan and an X-ray of the left leg were requested. The scan revealed a subarachnoid hemorrhage and the X-ray displayed a displaced tibia and fibula fracture of the mid third of the left lower leg. Somehow the x-rays could not be found in the system anymore one year later.

Conservative management

Management at the emergency department

The patient was kept on head elevation, the wound was irrigated and AB treatment IV was started together with pain medication (paracetamol and diclofenac).

Surgery

After stabilization of the patient overnight he was evaluated by the anesthetists and declared fit for surgery: He was planned for surgical debridement, external fixation and a local flap (if needed) under spinal anesthesia (photo 4). 

After surgical debridement it was clear that a flap was needed to close the wound since the defect was too big for primary closure (size of the wound W3xL7cm) (photo 5). 

The surgeons choose to place the pins for the external fixation in a standard way [see how to place a bar to bar external fixation system for the midshaft tibia fracture] before closing the wound with a local flap (photos 4-6).

After stabilization of the patient overnight he was evaluated by the anesthetists and declared fit for surgery: He was planned for surgical debridement, external fixation and a local flap (if needed) under spinal anesthesia (photo 4). 

After surgical debridement it was clear that a flap was needed to close the wound since the defect was too big for primary closure (size of the wound W3xL7cm) (photo 5). 

The surgeons choose to place the pins for the external fixation in a standard way [see how to place a bar to bar external fixation system for the midshaft tibia fracture] before closing the wound with a local flap (photos 7-10).

We choose a proximally based design in this case (photo 11). To determine the distal end of the flap it is needed to check the arc of rotation based on the pivot point of the flap (video 1). The classical transposition flap was further dissected, transposed to the defect (video 2) and sutured in place (photo 12). A split skin graft from the upper leg was used to close the donor site. These images show the final result (photos 13-16).

Postoperative care

We applied vaseline gauzes with tetracycline ointment on the skin graft with a light bandage for 4 days. AB treatment iv for 7 days. The patient was allowed to mobilize with a wheelchair, non weight bearing.

Outcome

Follow up after 4-6 weeks

The patient was mobilizing with two crutches, still experiencing pain on partial weight bearing. A small wound at the end of flap discharging pus otherwise graft was taking well and flap (photos 18-20).

Follow up after 3 months

Still at the hospital. X-rays did not show callus formation yet. External fixation was removed because of pin tract infections and an above knee cast was applied. Patient requested to be discharged, still on oral AB (photos 21-23).

Follow up 6 months

Follow up over a telephone call. The plaster of Paris cast was removed quite quickly after discharge three months before. The patients declared that he was doing well, walking with some pain still but not too much and able to walk approximately 500 meters. He was advised to come to the hospital for follow-up x-ray but he did not come.

Follow up 12 months

Location of follow up at the hospital. Still happy with the outcome. 

Mode of ambulation: walking with crutches. No sinus anymore. No fever or swelling, but still experiencing some pain while walking. X-rays show a non-union of a displaced fracture (photos 24-28).

The team recommended providing more stability with an intramedullary nail, but the patient refused because he was able to perform most of the activities he wanted to. The costs were not the issue because the poor patient fund could support it.   

He will be seen for follow-up again at 18 months.

Lessons learned

  1. The classical transposition flap is a basic but effective technique to cover relatively small mid-tibia soft tissue defects. 
  2. Pay attention to the design of this flap, based on anatomy knowledge and extend+location of the injury
  3. Non-union of an open fracture is a difficult complication, possible causes are:
  4. Low grade infection that may have required a more aggressive approach with surgical cleaning, deep cultures and antibiotics based on these cultures 
  5. A better fixation with a nail or plate after the infected had subsided
  6. When doctors are not satisfied with the outcome, it can still be good enough for a patient (the other way around is also possible).
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Open tibia fracture in Tanzania

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