A construction worker sustained an open fracture after being struck by a high-speed moving vehicle

Issue: February 2018

ByKelechi R. Okoroha, MD

ByStuart Trent Guthrie, MD

ByM. Chad Mahan, MD

A 46-year-old male construction worker presented to the ER complaining of midtibia pain after being struck by a vehicle. The patient was working in a closed driving lane when a motor vehicle entered the lane at approximately 70 mph. The vehicle struck him and another construction worker. The driver and the other construction worker expired at the scene. Upon arrival, the patient was hemodynamically stable, and an advanced trauma life support protocol was initiated.

Examination of the patient revealed a left eyebrow laceration, superficial abrasions on the lateral knee and a gross deformity of the left leg. At the mid-tibia level anteriorly, there was a 0.5-cm open wound and no open wounds were discovered around the knee joint. All four extremities were noted to be soft and compressible and the patient was neurovascularly intact.

Radiographs revealed a comminuted midshaft tibia and fibula fracture (Figure 1). There also appeared to be subcutaneous air at the knee joint. Radiographs of the left femur and ankle were negative. CT scan of the head was negative for any fracture or intracranial processes.

Initial orthopedic management in the trauma bay involved administration of cefazolin, gentamicin, tetanus and provisional irrigation of the left leg open wound. A reduction maneuver was performed with longitudinal traction to pull the tibia out to length. The left lower extremity was then placed in a well-padded posterior mold splint. The left eyebrow laceration was managed with nylon sutures. Post-reduction radiographs demonstrated improved alignment of the fracture. A CT scan of the left lower extremity demonstrated the comminuted midshaft tibia/fibula fractures with 1-cm overlap between the proximal and distal tibia. Deep subcutaneous air was noted at the fracture site, which tracked proximally to the knee joint (Figure 2).

**Figure 1.** AP (a), lateral (b) radiographs are shown demonstrating comminuted midshaft tibia and segmental fibula fractures.

What is your diagnosis?

See answer on next page.

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Open left tibia and fibula fractures with proximal tibiofibular disruption

Proximal tibiofibular joint (PTFJ) dislocations are a relatively rare injury that occurs most commonly in sports injuries or high velocity accidents. Dislocation of the PTFJ is often overlooked as it usually accompanies other lower extremity injuries. Long-term disability or failure of treatment may result with a failure to identify and treat PTFJ instability. Addressing PTFJ instability may reduce the progression of chronic dislocation, nerve palsy and pain requiring surgical management. There is limited literature regarding PTFJ instability and there are no quality studies to support specific treatment options.

Non-surgical management with immobilization has been described, as well as surgical management with open reduction and internal fixation, tendon grafting or biceps rerouting. Transfixation screws have been reported in previous case studies, however subsequent development of instability and ankle pain has been associated with the treatment. In distal tibiofibular injuries, suture buttons have shown similar efficacy to screw fixation without reports of complications associated with screw use, including increased risk for hardware removal and surgical site infections. Our case presents a traumatic open tibia/fibula fracture with PTFJ instability. Keen recognition and treatment of this associated injury is paramount to an optimal patient outcome.

Treatment

The treatment plan for the patient included irrigation and debridement, intramedullary (IM) nailing of the tibia, and proximal tibiofibular reduction and fixation. The patient was placed in a supine position and the extremity was prepped and draped in a sterile fashion. An ellipse-shaped incision was made over the open wound medially to remove non-viable skin and to expose the fracture site. Further deep exposure revealed the saphenous vein and nerve, which were carefully retracted and protected. The bone ends were debrided with curettage and the wound was irrigated with 9 L normal saline. Provisional fixation of the tibia was performed after realignment with point-to-point clamps.

**Figure 3.** Immediate postoperative AP (a) and lateral (b) of the left lower extremity radiographs demonstrate adequate reduction and stabilization of the left tibia fracture and PTFJ by using an IM nail and two suture buttons.

Next, an IM nail was placed in the standard fashion using a suprapatellar approach. A longitudinal incision was made through the quadriceps tendon to provide access to the joint. A protection sleeve was used and the guidewire was then placed under C-arm guidance. After the guidewire position was confirmed to be adequate, a channel reamer was used to enter the IM canal. Next, a ball-tipped guide-wire was placed into the canal to the fracture site. Manual reduction was performed with traction and previously placed point-to-point clamps. After verifying satisfactory alignment with C-arm guidance, the guidewire was extended to a site just proximal to the physeal scar. Sequential reaming was initiated to allow for placement of the appropriate-sized nail. The IM nail was inserted to the proper depth and anteroposterior (AP) and lateral films were used to confirm reduction. Three proximal and two distal locking screws were placed.

After securing the IM nail, the ankle was stressed under fluoroscopy and found to be stable. However, the proximal fibula was found to be unstable after displaying significant lateral translation with manual stressing. A lazy S-shaped incision was made over the proximal fibula and dissection was made down to the PTFJ and proximal fibula, with care taken to avoid injury to the common fibular nerve. Reduction was performed with a periarticular reduction clamp and secured with a K-wire. Adequate reduction was confirmed using fluoroscopy. Two suture buttons were placed through the proximal fibula to the tibia, and the PTFJ was noted to be stable under stress per fluoroscopic evaluation. The wound was irrigated with normal saline and a drain was placed in the deep and subcutaneous layers of the skin. Standard closure was performed. The open fracture site was sealed with incisional wound vacuum-assisted closure.

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The patient was admitted to the hospital and placed in a hinged knee brace that was unlocked 0° to 90°. His compartments were monitored closely postoperatively, and postoperative radiographs were obtained (Figure 3). He was instructed not to bear weight on the left lower extremity, placed on low-molecular-weight heparin for deep venous thrombosis prophylaxis and started on physical therapy during hospitalization. The patient was discharged on the third postoperative day and he began 25% weight bearing at 6 weeks postoperatively. At 6 months, the patient was able to walk without support and he had returned to work. Radiographs at 6 months demonstrated adequate healing.

Commentary

PTFJ dislocations are uncommon injuries that are usually repaired with transfixation screws or tendon grafting. These methodologies have been associated with long-term consequences. Grafting of the hamstrings tendon has been shown to cause donor site pain and potential muscle weakness. A systematic review evaluating return to sport after biceps femoris rerouting found a variable return-to-sport rate with half of the patients returning by 4 months while others required 17 months. Stabilization of the syndesmosis with transfixation screws has been shown to be less forgiving in terms of ankle function and rotation. Subsequent removal of these screws carries the inherent risk of second surgery, including potential SSI.

Our case provides promising results following a novel method of repair using suture buttons. Although there does not appear to be literature on the use of suture buttons for PTFJ stabilization, there are studies exploring the biomechanics, efficacy and long-term results of suture button repair in ankle syndesmosis disruption. Previous studies have demonstrated adequate ankle syndesmosis fixation and healing with suture button repair. Additionally, there have been many studies demonstrating in vivo efficacy of suture button repair for ankle injuries. In one prospective randomized study by Kortekangas and associates, malreduction rates were slightly increased with trans-syndesmotic screw fixation in comparison to suture button. Another comparative study by Seyhan and colleagues showed superior range of motion with dorsiflexion and plantar flexion at 6-month and 12-month follow-up in patients who received suture button repair for ankle syndesmosis injuries. Additionally, this study demonstrated decreased incidence of symptomatic hardware requiring removal with suture buttons, which may have significant economic benefits. Our case demonstrates a high-energy trauma with an associated PTFJ disruption. The injury was managed successfully with IM nailing of the open tibia fracture and suture-button fixation of the proximal tibiofibular disruption. Future studies should investigate PTFJ injury further to provide optimal management and alternative options.

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Key points are as follows:

PTFJ joint disruption is an uncommon injury of which physicians should be mindful in high-energy traumatic or athletic injuries; and
Suture button fixation in instances of proximal or distal tibiofibular disruption offers advantages in achieving anatomic reduction of the joint with less-rigid fixation and potentially provides more anatomic limb biomechanics.

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For more information:
Stuart Trent Guthrie, MD, can be reached at Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI 48202; email: tguthri1@hfhs.org.
M. Chad Mahan, MD, can be reached at Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI 48202; email: mmahan3@hfhs.org.
Kelechi R. Okoroha, MD, can be reached at Henry Ford Health System, 2799 W. Grand Blvd., Detroit, MI 48202; email: krokoroha@gmail.com.
Edited by Gregory L. Cvetanovich, MD, and Benedict U. Nwachukwu, MD, MBA. Cvetanovich is in the Division of Sports Medicine at Rush University Medical Center. Nwachukwu is an orthopedic surgery chief resident at Hospital for Special Surgery. For information on submitting Orthopedics Today Grand Rounds cases, please email: orthopedics@healio.com.

Disclosures: Guthrie, Mahan and Okoroha report no relevant financial disclosures.