Open fracture of lower leg

An open fracture of the tibia is a dangerous, pathological trauma. Consider its causes, the main symptoms, types, methods of diagnosis, treatment and rehabilitation.

The part of the leg from the knee to the ankle joint is the shin. It consists of two bones: the tibia and the tibia. Breaking their integrity is a turning point. Most often fix the damage to the tibia while maintaining the integrity of the peroneal, but it is possible to damage both. Injuries of the fibula occur extremely rarely.

The violation has a different level of complexity, which depends on such factors:

• Localization of damage
• How are the fragments located
• Severity of rupture of soft tissues, joints and vessels
• Presence of complications

That is, this kind of pathology is rather complicated, but the degree of its severity is assessed individually for each patient. The treatment is handled by a surgeon and traumatologist. The patient is waiting for an operation that will allow the bones to fold and fix them with spokes, pins, bolts or gypsum. After a long immobilization, the patient will have a difficult period of rehabilitation, aimed at complete restoration of leg functions.

[1], [2], [3], [4]

Epidemiology

The regularity and frequency of appearance of open fractures of the lower leg are more closely connected with age and sex factors. Epidemiology is based on the general state of the body and the type of activity. Very often injuries are found in athletes and people with pathological diseases that cause brittle bones.

According to the research, men suffer from fractures of the lower leg more than women. In the risk zone are people whose work is related to road transport, as this is the likelihood of accidents, athletes, workers. But you can not be 100% sure that the injury will not occur in people who are not in this category. That is, from open injuries of the leg, no one is immune.

[5], [6], [7], [8], [9]

Causes of the open shin fracture

The main cause of open fracture of the tibia is the directed action of a large force. Bones do not withstand strong pressure and break. Most often this happens when falling on the foot, fixed or bent in an uncomfortable position. Bumps, falling heavy objects, accidents, sports injuries, pathological and chronic processes (swelling, osteomyelitis, tuberculosis) provoke bone damage.

There is a certain classification of open injuries, which is based on the site of damage, the location and number of bone fragments, the nature and extent of damage to soft tissues, joints. Consider the main types of lesions:

• Single and multiple - with a single bone is broken in one place and there are two fragments, and for multiple in several places due to what is formed more than two fragments.
• Straight, spiral, oblique - depend on the defect line. If the bone is cracked across, it is straight, diagonally - oblique. If the line is uneven, then this is a spiral trauma.
• With displacement and without bias - depend on the location of bone fragments. If the injury is not displaced, then the normal position of the fragments to each other is observed. When shifting, there are changes in the position of the bones and if they are compared, they will not form a normal bone.
• Splinter and flat - even ones have the same fault line, splintered - uneven edges, teeth of different shapes and sizes.
• Intra-articular and extraarticular - if the joints are involved in the pathological process, then this is a severe intraarticular trauma. If the shin hit only the shin, and the joints are intact, then this intraarticular injury.

In addition, the traumas of one and both bones, upper, middle or lower third are distinguished:

• The proximal part of the lower leg or the upper third of the tibia and small bones - this category includes the injuries of the condyles, the head and neck of the fibula, and tuberosity of the tibia.
• The middle part or the middle third of the tibia - damage to the diaphysis.
• The distal part or the lower third of the tibia is the ankle fractures. As a rule, injuries of this group are accompanied by injuries of the ankle or knee, which significantly complicates the overall picture.

The most complex injuries are most often caused by injuries in accidents and falls from a height. But regardless of the cause of the pathology, the more parts of the bone are damaged, the longer the process of treatment and rehabilitation.

[10]

Pathogenesis

The mechanism of fracture development is based on the direct action of a force that is perpendicular to the axis of the bone. Pathogenesis is associated with severe strokes. In medical practice, this pathology is called a "bumper-fracture", since a blow to the car's bumper almost always causes an open trauma to both limbs. A characteristic feature of the damage is the direction of the shock wave. As a rule, the trauma has a wedge shape with a lot of splinters in the wound area.

Athletes are more often diagnosed with injuries of the right shin, since many have a support and a jogging. If the force was directed along the axis of the bone, then ankle injury, tibial condyles, and cruciate ligament ruptures develop.

Damage is distinguished depending on the direction of the force of impact on the bone: spiral, transverse, helical, oblique. The worst trend is longitudinal. This is due to poor blood supply of the tibia. Another serious injury, it's a screw-like fracture. They occur with the rotational movements of the shin with the fixation of the foot. Accompanied by bone fragments, strong muscle and skin ruptures.

[11], [12], [13]

Symptoms of the open shin fracture

Like any injury, bone damage has characteristic signs. Symptoms of open shin fracture depend on the location of the defect, its cause and a number of other factors. The first thing the victim faces is severe pain, bleeding and swelling. When you try to move a limb or palpate it, there is a crunch of bone fragments rubbing against each other. It is impossible to lean on one's leg, as well as to commit an active motion of the shin. From a wound it is visible sticking out splinters of a bone, also elongation or a shortening of a leg is observed.

Injuries of the lower leg have a number of similar signs with other injuries of the lower limbs:

• Anatomical and functional disorders.
• In the area of fracture appears excessive mobility of the leg.
• In the place of trauma there is severe pain and swelling, a rupture or sprain of the ankle joints is possible.
• If the injury with a shift, then there are bruises and bruises.

If the bone has damaged the peroneal nerve, the foot hangs down and it can not be bent. When injured with fragments of blood vessels, the skin turns blue.

The main symptoms of an open shin fracture:

• Severe bleeding
• An open wound with bones breaking through soft tissues and skin
• Sharp pain
• Mobility limitation
• Traumatic shock condition
• Dizziness, weakness, loss of consciousness

To diagnose the degree of damage and their location, the victim is given an X-ray, MRI or CT scan. If the injury fell on the diaphysis, then there is edema and cyanosis with severe pain. The shin is strongly deformed, a crunch of bones is heard in the tissues, the foot is turned outward. With injuries of the tibia on the leg it is impossible to lean on, while, as with fractures of the fibula, the support is possible. Distal injuries are characterized by severe soreness and swelling, the foot is turned outward or inward, a support on the limb is impossible.

First signs

Pathological damage of the peroneal or tibia can be suspected, knowing the first signs of fracture. The victim has a shorter leg and deformity of the limb. The shortening is due to the fact that the muscular tissues surrounding the broken bone are trying to connect it, so the limb is pulled up. Another characteristic feature is pain and bleeding, which are amplified when trying to move the leg or touch it.

The first signs include the appearance of swelling in the area of trauma. It is associated with a hemorrhage in the joint. In this case, crepitation of bone fragments and increased mobility of the foot are observed. It is impossible to rely on a damaged limb, and a pain shock can cause loss of consciousness.

[14], [15], [16]

An open fracture of the fibula

The fibula consists of two epiphyses, it is thin, long and tubular. The main components of the ankle are the lower end of the bone (outer, lateral ankle), which acts as the stabilizer of the joint. There are several types of open fractures of the fibula, which can be formed at different levels. But in most cases, the damage occurs in the region of the lateral ankle, accompanied by dislocation and shortening of the foot, rupture of the distal syndesmosis.

The body of the bone has a triangular shape and three surfaces: lateral, medial, posterior. They are divided among themselves by rowing. Damage is transverse, fragmentary, spiral and oblique. Diagnosing pathology is not difficult, because the trauma has a vivid clinical picture:

• A strong sense of pain and bleeding from bone-ruptured tissues.
• Puffiness and limitation of movement.
• Damage to the peroneal nerve (possibly with a fracture of the neck and head of the bone).
• The hanging of the foot and the inability to bend it (appears when the nerve is completely ruptured).

Most often there is damage to the diaphysis, which is possible with a direct impact on the outside of the shin, due to the turn of the foot, a fall from the height. A variety of pathological diseases of the bones provokes their fragility, which can also cause injury. Fracture of the diaphysis increases the risk of injuring the nerve of the fibula.

Diagnosis of damage is based on symptoms. To identify the injured area, the victim is sent to X-ray (the images are made in two projections). If there is a need for a more thorough examination, CT or MRI is performed.

The treatment is lengthy and depends on the severity of the injury. The main danger of open injuries is the possibility of infection of the wound, which will significantly complicate the process of recovery. The risk of infection increases during the post-operative period, when the patient's body is weakened. Without timely medical assistance, an open fracture of the fibula may lead to amputation of the injured limb or part of it.

Consider the treatment options for injury:

• If the damage occurred in the middle third of the bone, then a gypsum from the middle of the hip is placed on the leg. In addition, immobilization of the knee and ankle is carried out for 2-3 weeks.
• If a fracture in the upper half without damage to the peroneal nerve, then impose a plaster tutor for a month. But for 2-3 days, the victim can walk, leaning on a crutch.
• Injury of the fibular head with nerve damage is accompanied by severe hemorrhage and bruises. The patient is given a plaster bandage to the middle of the thigh and fixes the foot at a right angle.

Mandatory appoint medicines, physiotherapy procedures, a course of massage and therapeutic gymnastics. After 3-4 weeks, the gypsum bandage is replaced with a removable longtail to the knee. If the therapy method does not give the desired results (an incorrect therapy regimen, the presence of serious co-morbidities), then full recovery and recovery may not occur. In this case, the victim loses the ability to move normally.

[17],

Open fracture of the tibia

The tibia is a long tubular bone, which accounts for most of the leg injuries. As a rule, with its fracture, deformation and peroneal strain occurs. An open fracture of the tibia is possible with high-energy injuries, that is, accidents, falling from a height or with sports injuries. Very often, pathology is combined with fractures of the pelvis, ribs, other limbs, abdominal and thoracic injuries.

Symptoms:

• Sharp pain
• Bleeding from the place of injury
• Edema and deformities of the foot
• Crepitation and pathological limb mobility
• Bruising on the skin
• Through the wound you can see fragments of bones

To confirm the diagnosis, the shin is radiographed. According to the pictures, the doctor determines the number of fragments, the presence of bias and damage to the fibula, ankle or knee joints. If there is damage to the joints, an additional CT scan is performed. If the nerves or blood vessels are damaged, a neurosurgeon, neurologist and vascular surgeon must be consulted.

The first aid consists of taking an anesthetic and immobilizing the limb. The skin around the wound must be cleaned of foreign bodies and contamination, covered with a sterile bandage. If there is severe bleeding, then put a tourniquet on the thigh. In case of traumatic shock, anti-shock measures are shown.

Inpatient treatment can be operative and conservative, it depends on the complexity of the injury. If the fracture is without displacement, then immobilization of the limb and wound processing are indicated. In other cases, skeletal traction is done. Through the heel bone put the spoke and apply a tire. In this position, the leg is located for a month, after which the control x-ray is made. If the picture shows signs of a callus, then the traction is removed and the plaster is applied for 2-3 months. It is mandatory to use drug therapy, which consists of analgesics and drugs to stop infection from an open wound.

In particularly severe cases and with fragmentation fractures, surgical intervention is performed. The treatment is aimed at restoring the normal position of bone fragments. Also, posttraumatic contractures are prevented. The operation is carried out 7-10 days after the patient's admission to the hospital. During this time, edema decreases, and the general condition is normalized. The entire preoperative period of the patient spends on a skeletal tract.

During the operation, the doctor chooses the method of osteosynthesis, focusing on the nature and level of the fracture. For this purpose, various metal structures are used: locking rods, pins, plates. Very often, extra-osseous osteosynthesis is used by Ilizarov's apparatus. The period of adhesion of the tibia with uncomplicated fracture takes 3-4 months. With comminuted trauma, treatment can last six months or more. During the entire period of therapy, physiotherapy and exercise therapy are performed. After the adhesion of the patient's bone, a rehabilitation course is awaited.

Open fracture of the tibia with displacement

Direct shock in the transverse direction is the main cause of fractures with displacement. Because of the injury, bone fragments are formed, which move in different directions. Their displacement can be peripheral, angular, lateral, fragments can wedge in and go for each other.

An open fracture of the tibia with displacement is characterized by the following symptoms:

• Pain and crunch when getting injured.
• In the place of lesion, bruising and swelling with marked disturbances of the motor function of the foot are formed.
• Due to the displacement of fragments, soft tissues and skin are torn.
• At the site of the movement of the fragments, a depression or a depression is formed.
• The injured limb is shorter than the healthy one.
• The movement of the shin is carried out in an unnatural direction.

Very often such traumas cause traumatic shock. Treatment begins with the comparison of displaced bones. This is necessary for giving the limb a regular shape and its normal fusion. The procedure is carried out manually or with the help of special tools. In order for the victim not to suffer from pain, he is settled on his back and anesthetized. After that, the patient is taken for the thigh, and the second doctor grasps the leg, holding the heel and the back of the foot. In this position, the doctors slowly stretch the limb and determine the position of the displaced fragments.

After the repositioning, the doctor checks the length of the damaged leg with a healthy one. If their parameters converge, then treat the open wound and immobilize the shin. After 10 days the patient must undergo a control x-ray. This is necessary to confirm normal fusion. If the reposition can not be carried out, metal structures are used to fix the displacements.

Splintered open shin fracture

Breach of the integrity of the bone with more than three fragments and rupture of soft tissues is a splintery open fracture of the shin. It is considered one of the complex injuries, since it carries the risk of interposition of soft tissues, compression of nerves and vessels. With a large number of fragments during reposition, difficulties arise, since fragments can not be compared.

Symptoms of a comminuted open leg injury:

• Pain and bleeding
• Puffiness
• Hematomas
• Leg deformation and pathological mobility

For diagnostics, an X-ray is performed. Treatment begins with the creation of conditions for the fusion of fragments and the subsequent restoration of the functioning of the limb. At the first stage, the bone fragments are displaced and fixed to prevent repeated shifts. The method of therapy depends on the nature and location of the injury, its severity, the general health of the victim, the presence of concomitant injuries and diseases.

With a large number of fragments, the treatment is performed by surgical restoration of the surface. For this, various methods are used: Ilizarov apparatus, osteosynthesis with screws, plates and pins. In complex multi-lobular intraarticular injuries with displacement, the operation is an absolute indication. In some cases, with damage to the tibia and fibula, the operation is performed only on the first. When it is restored, the fusion of the second bone will occur itself.

The duration of immobilization depends on the severity of the injury, but as a rule, this is 3-5 months. Rehabilitation for the restoration of normal functioning of the leg and its motor functions takes 3-4 months. The patient is waiting for exercise therapy, massages, special gymnastics.

Open fracture of lower third of lower leg

Most often, the fractures of the legs fall on the lower third of the shin. If the mechanism of a direct injury (directed bumps, car accidents), then there is a transverse fracture of one or two bones. With indirect injuries (kink, rotation of the shin with a fixed foot), a helical shape occurs, that is oblique damage.

An open fracture of the lower third of the tibia is very dangerous, since it has a passive limb position. In particularly severe cases, it is so pronounced that the surface of the foot can be placed on any plane. When palpation appears severe soreness, lateral deviations of the lower leg are determined. If both bones are broken, then there is crepitation and mobility of the fragments.

To accurately determine the position of the defect, X-rays are performed. Treatment depends on the severity of the fracture, the presence of displacement, the state of soft tissues. The open wound is cleaned and disinfected, the fragments are removed surgically. To fix them, use knitting needles, bolts or plates. For 1-1,5 months, a V-shaped gypsum is applied, but before that, use the Belera bus and the system of skeletal tension, in order to heal the wound and the puffiness has come down. Damage in the lower third of the shin grows slowly, unlike injuries in the overlying areas. Complete restoration of the limb takes 4-5 months.

Double open shank fracture

In frequency among double injuries of tubular bones, a double open fracture of the tibia takes first place. The mechanism of its origin is direct in most cases, but is accompanied by extensive damage to surrounding tissues. The intermediate bone fragment enters the main blood supply, deforming the artery. It must be turned off from the blood stream, as this causes slow consolidation and frequent cases of non-admission. The duration of immobilization is extended and can reach 4-6 months.

Depending on the features of displacement, there are four types of double open shin injuries:

• Without bias
• With offset at the level of distal injury
• With displacement at the level of proximal injury
• With the displacement of the intermediate fragment

All these species have a typical clinical picture with more or less pronounced signs of soft tissue rupture and bleeding. Diagnosis is carried out using radiography in different projections. Treatment depends on the nature of the injury:

• When displaced, immobilization is carried out with a circular cast strip, wrapping the knee joint for up to 4-5 months.
• If there is an offset at the level of the distal fracture, then reposition with skeletal traction for 1.5-2 months is shown. This is necessary to eliminate the displacement along the length. After extension to the limb, circular gypsum is applied to the upper third of the thigh for 3.5-4 months.
• When the intermediate fragment is displaced or at the level of the proximal fracture, an open reposition is performed. Due to impaired blood supply, surgical intervention should be with minimal trauma. For this purpose apparatuses of extra-osteosynthesis or osteosynthesis with a rod fixative are used. The duration of consolidation of injuries of this nature is 2 times longer than the period of fusion of single fractures. Complete restoration of the limb comes in 7-10 months.

[18], [19], [20],

Complications and consequences

The most difficult therapeutic effect is open fractures. This is associated with the risk of possible displacements, fragments, ruptures of blood vessels and nerves. All the consequences and complications are divided into three large groups, depending on when they appeared.

1. Direct - observed during the injury.
2. Early - appear a couple of days after the fracture.
3. Late - appear after a long time after damage.

Direct	Early	Late
System
Hypovolemic shock	Hypovolemic shock Fat embolism Deep vein thrombosis Sepsis Infection	Incorrect bone fusion Nerastanie Cross-fusion
Local
Damage to large blood vessels Damage to muscles, tendons, joints	Infection Traumatic Compression Syndrome	Aseptic necrosis Shortening and stiffness of the joints Osteomyelitis Ischemic contracture Osteoarthritis Zudeck's Dystrophy

With open fractures of the lower leg, the injured can face such consequences and complications:

• Damage to nerves and vessels - deformation of a large artery can cause amputation of the entire limb, which is below the fracture. There may be abnormalities in gait and movement of the foot.
• Infection - an open wound causes suppuration, purulent damage to the ends of bone fragments, their shortening and slow healing. Infection is possible after surgery.
• When untimely or incorrect surgical treatment, deformity of the limb is observed.
• Fat embolism - particles of adipose tissue that have entered the vessels can migrate with the blood flow, disrupting the blood supply in different organs.
• The formation of a false joint is possible if there are strangulated tissues between the splinters of the scythe that do not coalesce, but there remains mobility between them.
• Complications arise after using the Ilizarov apparatus - infection in the sites of the spokes, damage to the tendons, vessels and nerves, curvature of the limb, incorrect fusion of the debris due to insufficient fixation.

Particularly severe injuries, as well as untimely or incorrect treatment can cause limb amputation. In this case, the decisive factors are: the extent of the damage, the degree of violation of the blood supply to the shin and foot, the volume of the damaged skin. The longer a decision is made about the method of treatment or amputation, the higher the risk of developing gangrene.

[21], [22], [23], [24]

Diagnostics of the open shin fracture

If suspicion of a fracture is very important to correctly diagnose, as the correct treatment depends on the further treatment and recovery. Diagnosis of an open fracture of the tibia is based on characteristic signs indicating a pathological trauma. The victim is examined by a traumatologist or surgeon, using clinical and instrumental methods, consider them:

• A patient's examination and anamnesis
• Comparison of damaged limb with intact
• Palpation and percussion
• Assessment of the volume of joint mobility
• Blood circulation check
• Determination of sensitivity and muscle strength

With visual inspection, an open fracture can not be confused with other injuries. Since the fragments of a bone protrude from an open wound, there is bleeding, swelling, crepitus. The leg does not perform the supporting function. The mechanism of injury can be direct and indirect, on which the nature of the fracture depends: transverse, oblique, comminuted, helical, with displacement, double. To clarify the diagnosis, additional studies are being carried out.

Instrumental diagnostics

In determining the degree of traumatic lesion, special attention is paid to instrumental diagnostics. If suspected of shin injuries, radiography is indicated. The picture is taken in two projections. To clarify the severity of the compression fracture, a computed tomography scan is performed. This is a special X-ray study, which provides complete information about the nature of the injury and the presence of additional injuries.

In addition to X-rays and CT, magnetic resonance imaging and other methods that visualize the lesion area can be used. As a rule, several methods are used during the diagnosis simultaneously. This is due to the high incidence of intra-articular lesions with open shin fractures. The destruction of the joints of the subchondral plates tightens the treatment process and worsens the prognosis for complete recovery. The data obtained as a result of complex diagnosis allow to determine the tactics of treatment and avoid possible mistakes.

[25], [26], [27], [28]

Differential diagnosis

The fracture line is a characteristic radiographic evidence, so differential diagnosis is performed in rare cases and presents difficulties. This is due to the fact that pathological and healthy images of tissues in some cases simulate fracture lines, cracks or bone fragments.

• An erroneous diagnosis can be made in the presence of epiphyseal lines. In this case, ossification is possible within many variants, which complicates the interpretation of the nature of the shadow lines. To do this, a control radiograph of a healthy limb is carried out, on which there may also be lines simulating a fracture.
• Pseudoepiphysis is another reason for differential diagnosis. Of great importance are the extra bones. Distinctive feature of pathology are the contours of tissues. With fractures they are finely serrate and uneven, the additional tip is rounded and has smooth contours.

The presence of an open wound with torn tissues and protruding bone fragments from it extremely rarely causes difficulties with diagnosis or requires differentiation. Therefore, the diagnosis is based on X-ray and CT data.

Treatment of the open shin fracture

Different types of shin fractures require different therapies. Treatment consists of a set of procedures aimed at normal fusion of damaged bones and healing of an open wound.

Algorithm of treatment:

• Comparison of bone fragments to give it a normal position. This is necessary for proper fusion. The procedure is performed under local anesthesia, manually or with the help of a skeletal tract system during surgery.
• Treatment of an open wound with the mandatory introduction of several drainage systems. The wound is fixed with a rare suture. If the skin rupture is not formed immediately, but because of the puncture of bone fragments and is secondary, it is treated with antibacterial agents and stitches without drainage. If an open fracture is accompanied by extensive damage to the skin, then a transplant is required.
• Fixation of bone fragments with the help of spokes, bolts, side loops, various apparatuses (Ilizarov, Tkachenko, Kalnberz, Hoffmann).
• Immobilization of the tibia with the application of longi, the installation of a compression-distraction apparatus for several weeks or months. This is necessary for the fracture to grow together.

For each specific case, different methods and materials are used. If some methods were ineffective, then they are replaced by others. Duration of treatment is from 4 months.

First aid with an open shin fracture

An open fracture is a serious injury, in which the integrity of the bone and surrounding tissues is impaired. It is very important to provide timely assistance, warning of possible complications. Trauma can be accompanied by such dangers:

• Traumatic shock - an open wound causes severe pain, this can provoke a temporary loss of consciousness.
• Severe bleeding - an important task is to stop bleeding. Since severe blood loss, this is a threat to life.

If you suspect a bone injury, you need to call an ambulance, which will take the injured person to the trauma and provide professional medical care. But before the arrival of doctors in order to minimize or completely prevent all sorts of complications, first aid is shown. When the fracture of the lower leg is open, the following measures are recommended:

1. To fix a damaged leg. For these purposes, any handy materials (boards, fittings, tree branches) will do. To them you need to reattach the limb with a bandage or a long piece of tissue. If possible, it is better to make the tire in the form of the letter G, this will allow to fix the knee and the foot. If you do not have any materials at hand, then the injured leg will be pribinthovuyut to the damaged.
2. Always take off your shoes. Pathological trauma causes swelling, so shoes can cause bleeding in the limb. Tight shoes will bring even more painful sensations. If the victim does not undo, then later it will be difficult.
3. Give an anesthetic. This will help overcome the pain shock. To do this, any drugs that are available (Analgin, Sedalgin, Nimesulide) will do. If possible, it is better to make an intramuscular injection (Novocain, Lidocaine), the closer to the fracture will be the injection, the better the analgesic effect. Upon the arrival of the physicians, it is necessary to report which preparations were used and at what dosage.
4. Stop the bleeding. Open fractures are very often accompanied by severe blood loss. In order to assess the degree of damage, you need to cut clothes that cover the injured leg. When rupture of large vessels, blood flows out with a strong stream. To stop her on the wound, a tampon of cotton wool and bandage should be applied, and a bandage on top of them. The tourniquet is not recommended, as the muscles under it will be strained, and if the fracture is comminuted, the fragments will be further displaced. There is also a risk of damage to other vessels. If the blood flows slowly, then the tampon is not applied, but the antiseptic treatment of the wound is performed. As an antiseptic, you can use: iodine, zelenok, hydrogen peroxide and any liquid based on alcohol. It is necessary to treat only the edges of the wound, it is impossible to pour the antiseptic inside.

These are the basic rules that must be followed when providing first aid. In addition, a cold or a towel dampened with water can be applied to the injury site. It is very important to avoid any movements and attempts to stand on the foot. This will lead to even more traumatization, displacement of fragments, damage to nerves and vessels. Also, you can not do anything, this can be done by a traumatologist and only after radiography.

Operative treatment

Shin injury can occur in different places, so a combination of different techniques is used for treatment. Operative treatment is the most difficult, because the results of its results depend on the correctness of bone splicing and further recovery. The main indications for the operation:

• Comparison of bones is impossible without additional opening of the wound.
• Double fracture of the tibia with a significant displacement of the fragments.
• The clenching of nerves and blood vessels with bone fragments.
• Interpretation of tissues

If both bones are damaged, the operation is performed only on the tibia, as in the process of its recovery, the peroneal fusion grows independently. Surgical correction of fragments is possible only with their additional fixation.

There is a certain sequence of operation, consider it:

• Comparison of bone fragments. The procedure is performed by the surgeon under local anesthesia. For this, skeletal traction is used.

• Bone fragments are fixed with the help of the most suitable device.

• The operated limb is to be immobilized with a special apparatus or plaster bandage.

The main types of surgical treatment of the tibial and fibular bones of the lower leg:

Type of fixation	Features	Duration of treatment and recovery
Rods	A pointed steel rod is inserted into the spinal canal. To access the bone in the skin make a cut. The sharp part of the core goes into the bone, and the dull part remains under the skin. This will remove it after the adhesion of the injury.	After surgery, the leg is allowed to give no more than 25% of the body weight load. After 2 weeks, you can start to get out of bed and move with crutches. After 3-4 weeks, you can try to fully stand up. Every 2 months they make control x-rays. Rods, screws and plates are removed 1-2 years after the injury.
Screws	With the help of special screws from surgical steel, the fragments are fixed to each other.
Plates	Plates of steel with holes fix to the bones with screws. This method is not used to treat children, as it can cause damage to the periosteum and impaired bone growth.
Ilizarov's apparatus	The operation is performed under local or general anesthesia (depends on the age of the victim). Through the bones stretch metal spokes forming a structure of rods, bolts and nuts. The doctor tightens the nuts, adjusting the degree of tension for the adhesion.	Load on the leg is allowed in the early stages, since the device holds the bone securely. Full recovery is possible in 3-4 months.

During surgical treatment, the advantage is given to a less traumatic method. This will make it possible to properly splice the bones and favorably affect the recovery process. In order for the leg to function normally and assume weight in the future, the bones of the shin should properly grow together. If the treatment process was wrong or violated, it would cause disability of the victim and disability.

Two-stage treatment of open fractures of the lower leg

To eliminate damage to the limbs, an integrated therapeutic approach is needed. Two-stage treatment of open fractures of the bones of the shin consists of osteosynthesis by external fixation of the stem apparatus, followed by gypsum and treatment of an open wound, for which autoplastic is required in most cases.

1. Osteosynthesis is a surgical operation, the essence of which is the fixation of bone fragments with different structures. This procedure allows you to combine all the fragments in the correct position, preserving the functioning and mobility of the damaged area after healing.

There are several types of osteosynthesis:

• Outer (transosseous) - I fix the place of damage with knitting needles without applying gypsum.
• Immersion - the latch is inserted into the affected area, no gypsum application is required.
• Trans-limb - rods or other fixatives are pulled through the bone, that is across the lesion.
• Intraosseous - a denticle or a pointed stem is immersed in the bone, which is there until complete fusion. Requires complete immobilization of the limb.
• Cumulative - internal surgery, the locks are placed around or near the injury.

Osteosynthesis is the main indication with open fractures. The whole procedure is under anesthesia, so the victim does not feel pain. With the correct operation, the adhesion occurs within 3-4 months.

2. Autoplasty of damaged skin - transplantation or transposition of own tissues. The flaps used during the operation are divided into simple and complex. On the presence or absence of blood supply in the place of injury depends on the transplant option. Simple flaps are distinguished by tissue belonging: skin, fascial, muscular, tendon, bone, fat, vascular and others. They are necroduced by transplants. Their engraftment depends on the diffusion of nutrients.

For autoplasty with the help of simple fascial flaps, there is a small thickness with preservation of the skin at the donor site. This variant of transplantation is limited to a small volume of tissues. In the future, dermatomy plastic is used to close the transplanted fascia. This method is excellent for treating open fractures of the tibia with skin defects.

Rehabilitation

During the treatment of an open fracture of the tibia, and after its adhesion, the patient is expected to have a long recovery course. Rehabilitation consists of a set of measures aimed at restoring the functions of a damaged limb. Its main objectives are:

• Elimination of muscle atrophy, puffiness and other stagnant phenomena in soft tissues
• Restoration of elasticity and tone of the calf muscles
• Normalization of blood supply
• Development of mobility of the ankle and knee joint

Rehabilitation consists of the following stages:

1. In the first stage, the affected person is prescribed massages and rubbing of the shins with hands using creams and ointments, which include substances that accelerate tissue repair (Chondroxide, Collagen Plus). In addition to the massage shows the sessions of magnetotherapy. During this period, the diseased limb can not be loaded with exercises, as this provokes severe pain. You can try to move the foot, bend the leg in the knee joint, strain and relax the muscles of the calf. This rehabilitation stage lasts until the removal of the device, the fastening bone, or plaster bandage.
2. The second stage is aimed at restoring limb functions. To do this, apply massages, rubbing, special trays and exercises. The complex consists of such exercises:

• Makhi foot from a standing position to the sides, forward and backward
• Walking at the most accessible pace
• Lifting on toe socks from sitting and standing position
• Rotational movements of the foot in different directions

Exercises are performed in different variations, but on a regular basis, that is, every day. The second stage begins right after the first and its duration is 2-3 months.

3. At this stage, the patient is prescribed a course of exercise therapy to strengthen the muscles. The success of rehabilitation depends on proper nutrition. In the diet should be foods containing large amounts of calcium and silicon (milk, cottage cheese, nuts, beans, cabbage, currants, bread with bran), vitamins C, D, E. This will speed up healing and improve overall health. This stage lasts for 1-2 months after completion of the previous one.

Special attention should be paid to physiotherapy. In the first week after injury, such procedures are recommended:

• UV irradiation - prevents infection of an open wound, as it destroys pathogenic bacteria.
• Interference currents - dissolve bruises, remove puffiness and painful sensations.
• Bromine electrophoresis - used for severe pain.

In the future, during the month, the following physiotherapy procedures are carried out:

• Massage and ultraviolet irradiation.
• UHF - strengthens local immunity, improves blood flow, restores normal bone structure.
• Interference currents - are used to normalize metabolism and accelerate bone adhesion.

The rehabilitation techniques described above are used until the limb is fully restored under the supervision of a surgeon or trauma specialist.

Prevention

Prevention of fracture of the bones of the lower leg is based on the prevention of injuries, which can provoke it. Prevention consists of such activities:

1. Medical gymnastics - every day you need to perform a number of physical exercises with a selected load. It helps to restore and maintain muscle structure, normalize blood circulation, remove inflammation and prevent atrophy of muscles.
2. Physiotherapy is necessary to reduce inflammation, accelerate healing and restore tissue structure. Helps improve blood supply and metabolism.
3. Massage - daily rubbing procedures and massages help prevent joint stiffness, dystrophy of the leg muscles, the appearance of scarring in soft tissues.
4. Diet - therapeutic and preventive nutrition should consist of products rich in vitamins and minerals, especially calcium, iron, magnesium.

Prevention is aimed at preventing complications after trauma. After the complete fusion of the bones, the doctor prescribes the patient recommendations for the development of leg mobility and the restoration of its normal functioning.

[29], [30], [31], [32], [33]

Forecast

An open fracture of the tibia is considered to be the most serious damage. The prognosis for recovery largely depends on the timeliness and correctness of the medical care provided. The quality of primary antiseptic and antibacterial treatment is of great importance. Since its absence can provoke infection of the wound. Also, the correct immobilization of the injured leg, the technique of fixing bone fragments and healing the open wound are important. Procrastination at any stage of therapy can cause limb amputation, which makes the forecast for complete recovery impossible.

[34], [35]