However, this does not discharge treating physicians from their responsibility of discussing the advantages and disadvantages of the various treatment options with the patient. As soon as the patient’s condition permits it, the external fixator should be replaced with internal fixation after adequate soft tissue coverage has been achieved.įrom the perspective of the patient, there is no evidence that treatment with nail or with plate fixation is preferred. The fracture should be primarily stabilised with an external fixator and definitive fixation carried out at a later stage. In polytrauma, the principles of Damage Control Orthopaedics should be followed. On suspicion of this, the working party advises carrying out a four-compartment fasciotomy. The development of compartment syndrome must be checked for at all times. An open injury does not exclude the possibility that pressure can build up in compartments in the lower limb. Open fractures of the lower limb carry the risk of the development of compartment syndrome, certainly as they are often high-energy injuries. Nonetheless, on the basis of this the working party is of the opinion that the reamed nail is preferable. Taking the above-mentioned factors into consideration, it is unclear if this affects clinical outcomes disadvantageously. Screw or nail fracture occurs more commonly in thinner, unreamed nails. In the event of doubt about prior contamination, the working party advises using a reamed nail. However, the risk of infection increases slightly if an unreamed nail is used. In the treatment of an open fracture of the lower limb, there is no difference between reamed and an unreamed nail if the following are taken into account: 1) time to fracture consolidation, 2) number of reoperations, 3) prevention of compartment syndrome. In doing this, early weight bearing should feature strongly in their decision-making as this accelerates rehabilitation. The working party recognises that each open fracture of the lower limb has its own distinct characteristics (fracture pattern and soft tissue status), and that the surgical team should base their decisions on which fixation technique to use in each case individually. Those RCTs that included mainly closed fractures showed no significant differences in outcomes or complications between these techniques. A potential disadvantage is the higher risk of soft tissue complications such as delayed wound healing, superficial and deep infections and more implant-related irritation. The potential advantages of plate fixation include open reduction thus enabling better alignment. Recent developments in intramedullary nail technology including more distal locking options and the possibility of siting fixed-angle locking screws, and improved techniques including Poller’s interference screws, have made intramedullary nail fixation more suitable for the treatment of metaphyseal fractures. The potential for malalignment and worsened stability may contribute to the development of malunion, delayed healing and non-union. A consequence of this is more pressure on the locking screws, which may lead to implant failure or loss of alignment. In very distal or proximal fractures there is less contact between bone and implant which leads to lower intrinsic stability. Fractures of the proximal and distal tibial metaphyses that are stabilised with an intramedullary nail are at a biomechanical disadvantage compared with those stabilised with a plate. In shaft fractures, the advice of the working party is to use an intramedullary nail, with the aim of making a construction that that can weight bear at an early stage. This is possibly due to the heterogeneity of the patient populations studied. On the grounds of the literature it is not possible to say unequivocally if it is best to treat open fractures of the lower limb with an intramedullary nail or with a plate.
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