Management Open Fracture in Severe Generalized Tetanus Patient Emergency or Elective Case.
Case Report
Management Open Fracture in Severe Generalized Tetanus Patient
Emergency or Elective Case?
Disusun Oleh :
Made Agus Maharjana
Pembimbing
Dr. I Wayan Subawa, Sp.OT
PROGRAM STUDI ORTHOPAEDI DAN TRAUMATOLOGI
RSUP SANGLAH –FK. UNUD DENPASAR
Management Open Fracture in Severe Generalized Tetanus Patient
Emergency or Elective Case?
Case Report and Review Literature
Made Agus Maharjana* Subawa W **
*Resident of Orthopedic and Traumatology Department, Sanglah General Hospital,
Udayana University, Bali
** Staff of Orthopedic and Traumatology Department, Sanglah General Hospital,
Udayana University Bali
Background Open fracture is a limb threatening injury. The annual incidence of open fractures of
long bones has been estimated to be 11.5 per 100 000 persons with 40% occurring in the lower limb,
commonly at the tibial diaphysis. The management should had initial resuscitation, stabilization,
antibiotics, antitetanus and surgical debridement. Tetanus still a disease with high mortality in
developing world. In the severe disease, the muscle spasms can lead to respiratory compromise. In the
presence in both of case what we should do?
Case. 48 yo male sustained pain and 4 cm open wound on his right leg following traffic accident.
Five days later, he presented to our hospital with severe trismus, stiffness on his neck and back. He
suspected had severe generalized tetanus. The history taking and physical examination revealed his
Phillips’s Score was 24 (severe Tetanus). Because of the risk of anesthesiologist, we do delayed
surgery for this patient. We did debridement and external fixation after 12 days. The result was
excellent.
Discussion The three principle management in patient with generalized tetanus were : eradication
organism that actively produce toxin, toxin present in the body out from CNS must be neutralized,
toxin bound in CNS must be reduced. The reason to do emergency surgery is the thinking of the
wound as the source of the infection that can produce Toxin and the unstable fracture could induce
stimulation to muscle spasm. Without adequate surgical debridement it is difficult to make sure
eradication of the organism. In this case, delayed surgery is preferred. The result was excellent.
Seven days after debridement and external fixation the patient can mobilized non weight bearing with
two crutches.
Keyword : Open fracture, severe generalized tetanus
BACKGROUND
Open fracture is a limb threatening injury. The annual incidence of open fractures of long bones
has been estimated to be 11.5 per 100 000 persons with 40% occurring in the lower limb,
commonly at the tibial diaphysis. Open fracture is assessed according to energy of injury,
wound, comminution, contamination, and soft tissue damage. The management should had initial
resuscitation, stabilization, antibiotics, antitetanus and surgical debridement.
Tetanus is a rare disease in the developing world. Despite widespread immunization
programmes, Tetanus still a disease with high mortality. Approximately 800.000-1.000.000
death from tetanus every year (Cook et al, 2001). Tetanus is caused by clostridium tetanii, a
gram positive bacillus. Under anaerobic condition caused by necrotic tissue or wound, it can
secretes two toxins, tetanolysin and tetanospasmin (Cook et al, 2001). Tetanolysin is capable of
locally damaging otherwise viable tissue surrounding the infection and optimizing the condition
to bacterial multiplication. Tetanospasmin lead to clinical syndrome of tetanus. It can causes
muscle rigidity and weakness, muscle spasms, and autonomic instability (Beecroft et al, 2005) .
In the severe disease, the muscle spasms can lead to respiratory compromise. The mainstay of
the management of tetanus is supportive care with sedation, airway protection, and controlled
ventilation routinely required.
In the presence in both of case what we should do? Many study revealed surgically debridement
of the wound is the mainstay management but because of the risk of respiratory compromise and
ventilator associated disease, made the surgery in severe generalized tetanus was the high risk
procedure and delayed surgery after stabilization is preferred.
CASE
We report 48 yo male sustained pain and 4 cm open wound on his right leg following traffic
accident. The wound has cleaned at the time of accident but he refused to get tetanus booster and
advanced treatment for his right leg fracture because of financial problem. He went to traditional
bone setter. Five days later, he presented to our hospital with severe trismus, stiffness on his neck
and back. He suspected had severe generalized tetanus. The history taking and physical
examination revealed his Phillips’s Score was 24 (severe Tetanus).
Phillips score (Farar JJ, 2000)
Laboratory finding revealed high white blood cells suggesting an acute infection. Radiography
revealed open fracture of diaphisis tibia and fibula middle third. Using Gustillo Anderson
Classification we classified this fracture to open fracture grade IIIB because of gross
contamination.
After resuscitation and stabilization, we planned for debridement surgically for the wound and
external fixation to fixated the bone, but the Neurosurgeon and the Anaesthesiologist suggested
to do delayed operation to avoid worsening the condition of the patient and the risk of
anaesthetion procedure. Finally we just do wound toilet and backslab to the patient. We also
gives antibiotics (third generation Cephalosporin and Metronidazole), antitetanus (Tetagam), and
muscle relaxants (Diazepam) to eradicate the bacteria and decrease muscle spasm. After
observation in the emergency room, patient is admitted to the intensive care unit for 2 days and
then 10 days in an isolated room.
After 10 days the condition of the patient was stable to do surgery. We underwent
surgical debridement and choose external fixation. Uniplanar monoaxial frames that use Schanz
pins above and below the fracture site is used to the patients. The results was excellent and
stable intraoperatively. After 7 days treatment patient discharge from the hospital and mobilized
non weight bearing with two crutches.
DISCUSSION
After initial adequate resuscitation and stabilisation of the patient, the open fracture should be
dealt with in the operating theatre as soon as possible, preferably within six hours of the injury
(Giannoudis et al, 2006). Restoration of gross alignment of the limb should take priority in the
initial management since obvious angulation and displacement or prominent bone fragments
could exert undue pressure on soft tissues or neurovascular structures.
Care should be taken to avoid the introduction of gross contamination into the
intramedullary canal (Giannoudis, 2006). The neurovascular status of the limb should be
carefully evaluated. The distal arterial pulses, capillary refill and overall colour of the limb, and
the presence of active bleeding from the wound must be recorded. The choice of treatment of the
open fracture is according to Gustillo and Anderson classification. This classification include of
energy of trauma, degree comminution, contamination, wound, and soft tissue damage (Petrisol
et al, 2007). Because of the degree of contamination, open fracture of this case classified to grade
III B and the treatment should include debridement of the bone, soft tissue and fixation of the
bone. The choose of the implant is external fixation to minimize the risk of infection to the
medullary canal.
The three principle management in patient with generalized tetanus were : eradication
organism that actively produce toxin, toxin present in the body out from CNS must be
neutralized, toxin bound in CNS must be reduced (Cook et al, 2001). The reason to do
emergency surgery is the thinking of the wound as the source of the infection that can produce
Toxin and the unstable fracture could induce stimulation to muscle spasm. Without adequate
surgical debridement it is difficult to make sure eradication of the organism. The anesthetic
procedure before surgey in generalized tetanus is difficult because of the risk of muscle spasm
induce respiratory compromise. Many sedation drugs use to sedated patient, but the results is not
quite good in severe cases (Beecroft et al, 2005). Ventilator is needed but there are risk weaning
failure after treatment. In this case, delayed surgery is preferred.
In our cases in delayed surgery after stabilization of patient. The reason to do delayed
surgery is the risk of anaesthesia procedure. Spasm is developed in the first 2 weeks. Autonomic
disturbance start several day after spasm and persist for 1-2 weeks (Farrar et al, 2000). Severe
uncomplicated hyperkinetic circulation will increase because of poor relaxation and can
increased spasm activity. In this state adequate muscle relaxant is needed and patient should
tighly observed in intensive care unit to protect the airways and had adequate ventilation. Spasm
will reduced after 2 weeks (Cook et al, 2001). Recovery from ilness occur because of regrowth
of axon terminal and by toxin destruction.
In this case in the contamination of tetanus, external fixation is our choice for
stabilization of the bone. External fixation usually is indicated for severe open fractures (type III
B and type C), especially fractures with gross contamination of the tibial canal, or if the
adequacy of the initial débridement (shotgun wound, crush injuries) is a concern (Canale and
Beaty, 2007). External fixation also can be used in the delayed management of fractures with
bone loss, either by providing stabilization for autogenous bone grafting or by creating
regenerated bone with circular wire fixators. The fixators can be used to span joints for
temporary fixation before definitive open reduction or to add stability to unstable plate or
intramedullary nail constructs, primarily in proximal-third tibial fractures. (Canale and Beaty,
2007). Many studies use temporary external fixation for tibial shaft fractures when the condition
of the patient or the extent of the injury does not permit definitive fixation (Petrisol et al, 2007).
In this case we use a medially based uniplanar external fixation frame with two proximal
and two distal bicortical Schanz pins. There are two important principles that should be followed
when placing external fixation frames. For rigidity, the “near-far” technique, with two pins
placed close to either side of the fracture and two pins placed within the bone as far away from
the fracture as possible, allows for a more solid frame construct particularly if the bars are placed
close to the skin and double stacked (Petrisol et al, 2007). The result of this construct was good.
Evaluation intraoperatively was stable enough. One day after operation, the patient can do ankle
exercise well. The wound is treated well and after 2 weeks of intravenous antibiotics, we
changed to oral therapy. Seventh day after operation, at day 18 of admission patient is discharged
and mobilized non weight bearing with 2 crutches.
Although emergency operation is needed to surgically debride the wound in patient of tetanus,
delayed surgery also had a place in management open fracture with tetanus. The decision is
according to the clinical presentation of the patient and general status.
References
Beecroft CL, Enright SM, Beirne HA. 2005. Remifentanil in the Management of Severe Tetanus.
British J Anaesth. 94, Pp: 46-48.
Canale ST, Beaty JH. 2007. Tibia Shaft Fracture in Campbell’s Operative Orthopaedic. 11th
Edition. Elsevier : Philadelphia.
Cook TM, Protoe RT, Handel JM. 2001. Tetanus : A Review of the Literature. Br Journal
Anaesth, 87, Pp : 477-487.
Farar JR, Yen LM, Cook T. 2000. Tetanus. J Neurol Psychiatry, 69 : Pp: 292-301.
Giannoidis PV, Papakostidis C, Roberts C. 2006. A Review of Management of Open Fracture of
the Tibia and Femur. The Journal of Bone and Joint Surgery. Vol 88-B, Pp : 281-289.
Petrisol BA, Bhandari M, Schemitch. 2010. Tibia and Fibula Fracture in Rookwood and Green’s
Fracture in Adults 7th Edition. Lippincot William & Wilkins : New York.
Okike K, Bhattacharyya T. 2006. Trend In Management of Open Fracture : A Critical Analysis.
The Journal Bone and Joint Surgery. No 12. Vol 88. Pp : 2739-2746.
Management Open Fracture in Severe Generalized Tetanus Patient
Emergency or Elective Case?
Disusun Oleh :
Made Agus Maharjana
Pembimbing
Dr. I Wayan Subawa, Sp.OT
PROGRAM STUDI ORTHOPAEDI DAN TRAUMATOLOGI
RSUP SANGLAH –FK. UNUD DENPASAR
Management Open Fracture in Severe Generalized Tetanus Patient
Emergency or Elective Case?
Case Report and Review Literature
Made Agus Maharjana* Subawa W **
*Resident of Orthopedic and Traumatology Department, Sanglah General Hospital,
Udayana University, Bali
** Staff of Orthopedic and Traumatology Department, Sanglah General Hospital,
Udayana University Bali
Background Open fracture is a limb threatening injury. The annual incidence of open fractures of
long bones has been estimated to be 11.5 per 100 000 persons with 40% occurring in the lower limb,
commonly at the tibial diaphysis. The management should had initial resuscitation, stabilization,
antibiotics, antitetanus and surgical debridement. Tetanus still a disease with high mortality in
developing world. In the severe disease, the muscle spasms can lead to respiratory compromise. In the
presence in both of case what we should do?
Case. 48 yo male sustained pain and 4 cm open wound on his right leg following traffic accident.
Five days later, he presented to our hospital with severe trismus, stiffness on his neck and back. He
suspected had severe generalized tetanus. The history taking and physical examination revealed his
Phillips’s Score was 24 (severe Tetanus). Because of the risk of anesthesiologist, we do delayed
surgery for this patient. We did debridement and external fixation after 12 days. The result was
excellent.
Discussion The three principle management in patient with generalized tetanus were : eradication
organism that actively produce toxin, toxin present in the body out from CNS must be neutralized,
toxin bound in CNS must be reduced. The reason to do emergency surgery is the thinking of the
wound as the source of the infection that can produce Toxin and the unstable fracture could induce
stimulation to muscle spasm. Without adequate surgical debridement it is difficult to make sure
eradication of the organism. In this case, delayed surgery is preferred. The result was excellent.
Seven days after debridement and external fixation the patient can mobilized non weight bearing with
two crutches.
Keyword : Open fracture, severe generalized tetanus
BACKGROUND
Open fracture is a limb threatening injury. The annual incidence of open fractures of long bones
has been estimated to be 11.5 per 100 000 persons with 40% occurring in the lower limb,
commonly at the tibial diaphysis. Open fracture is assessed according to energy of injury,
wound, comminution, contamination, and soft tissue damage. The management should had initial
resuscitation, stabilization, antibiotics, antitetanus and surgical debridement.
Tetanus is a rare disease in the developing world. Despite widespread immunization
programmes, Tetanus still a disease with high mortality. Approximately 800.000-1.000.000
death from tetanus every year (Cook et al, 2001). Tetanus is caused by clostridium tetanii, a
gram positive bacillus. Under anaerobic condition caused by necrotic tissue or wound, it can
secretes two toxins, tetanolysin and tetanospasmin (Cook et al, 2001). Tetanolysin is capable of
locally damaging otherwise viable tissue surrounding the infection and optimizing the condition
to bacterial multiplication. Tetanospasmin lead to clinical syndrome of tetanus. It can causes
muscle rigidity and weakness, muscle spasms, and autonomic instability (Beecroft et al, 2005) .
In the severe disease, the muscle spasms can lead to respiratory compromise. The mainstay of
the management of tetanus is supportive care with sedation, airway protection, and controlled
ventilation routinely required.
In the presence in both of case what we should do? Many study revealed surgically debridement
of the wound is the mainstay management but because of the risk of respiratory compromise and
ventilator associated disease, made the surgery in severe generalized tetanus was the high risk
procedure and delayed surgery after stabilization is preferred.
CASE
We report 48 yo male sustained pain and 4 cm open wound on his right leg following traffic
accident. The wound has cleaned at the time of accident but he refused to get tetanus booster and
advanced treatment for his right leg fracture because of financial problem. He went to traditional
bone setter. Five days later, he presented to our hospital with severe trismus, stiffness on his neck
and back. He suspected had severe generalized tetanus. The history taking and physical
examination revealed his Phillips’s Score was 24 (severe Tetanus).
Phillips score (Farar JJ, 2000)
Laboratory finding revealed high white blood cells suggesting an acute infection. Radiography
revealed open fracture of diaphisis tibia and fibula middle third. Using Gustillo Anderson
Classification we classified this fracture to open fracture grade IIIB because of gross
contamination.
After resuscitation and stabilization, we planned for debridement surgically for the wound and
external fixation to fixated the bone, but the Neurosurgeon and the Anaesthesiologist suggested
to do delayed operation to avoid worsening the condition of the patient and the risk of
anaesthetion procedure. Finally we just do wound toilet and backslab to the patient. We also
gives antibiotics (third generation Cephalosporin and Metronidazole), antitetanus (Tetagam), and
muscle relaxants (Diazepam) to eradicate the bacteria and decrease muscle spasm. After
observation in the emergency room, patient is admitted to the intensive care unit for 2 days and
then 10 days in an isolated room.
After 10 days the condition of the patient was stable to do surgery. We underwent
surgical debridement and choose external fixation. Uniplanar monoaxial frames that use Schanz
pins above and below the fracture site is used to the patients. The results was excellent and
stable intraoperatively. After 7 days treatment patient discharge from the hospital and mobilized
non weight bearing with two crutches.
DISCUSSION
After initial adequate resuscitation and stabilisation of the patient, the open fracture should be
dealt with in the operating theatre as soon as possible, preferably within six hours of the injury
(Giannoudis et al, 2006). Restoration of gross alignment of the limb should take priority in the
initial management since obvious angulation and displacement or prominent bone fragments
could exert undue pressure on soft tissues or neurovascular structures.
Care should be taken to avoid the introduction of gross contamination into the
intramedullary canal (Giannoudis, 2006). The neurovascular status of the limb should be
carefully evaluated. The distal arterial pulses, capillary refill and overall colour of the limb, and
the presence of active bleeding from the wound must be recorded. The choice of treatment of the
open fracture is according to Gustillo and Anderson classification. This classification include of
energy of trauma, degree comminution, contamination, wound, and soft tissue damage (Petrisol
et al, 2007). Because of the degree of contamination, open fracture of this case classified to grade
III B and the treatment should include debridement of the bone, soft tissue and fixation of the
bone. The choose of the implant is external fixation to minimize the risk of infection to the
medullary canal.
The three principle management in patient with generalized tetanus were : eradication
organism that actively produce toxin, toxin present in the body out from CNS must be
neutralized, toxin bound in CNS must be reduced (Cook et al, 2001). The reason to do
emergency surgery is the thinking of the wound as the source of the infection that can produce
Toxin and the unstable fracture could induce stimulation to muscle spasm. Without adequate
surgical debridement it is difficult to make sure eradication of the organism. The anesthetic
procedure before surgey in generalized tetanus is difficult because of the risk of muscle spasm
induce respiratory compromise. Many sedation drugs use to sedated patient, but the results is not
quite good in severe cases (Beecroft et al, 2005). Ventilator is needed but there are risk weaning
failure after treatment. In this case, delayed surgery is preferred.
In our cases in delayed surgery after stabilization of patient. The reason to do delayed
surgery is the risk of anaesthesia procedure. Spasm is developed in the first 2 weeks. Autonomic
disturbance start several day after spasm and persist for 1-2 weeks (Farrar et al, 2000). Severe
uncomplicated hyperkinetic circulation will increase because of poor relaxation and can
increased spasm activity. In this state adequate muscle relaxant is needed and patient should
tighly observed in intensive care unit to protect the airways and had adequate ventilation. Spasm
will reduced after 2 weeks (Cook et al, 2001). Recovery from ilness occur because of regrowth
of axon terminal and by toxin destruction.
In this case in the contamination of tetanus, external fixation is our choice for
stabilization of the bone. External fixation usually is indicated for severe open fractures (type III
B and type C), especially fractures with gross contamination of the tibial canal, or if the
adequacy of the initial débridement (shotgun wound, crush injuries) is a concern (Canale and
Beaty, 2007). External fixation also can be used in the delayed management of fractures with
bone loss, either by providing stabilization for autogenous bone grafting or by creating
regenerated bone with circular wire fixators. The fixators can be used to span joints for
temporary fixation before definitive open reduction or to add stability to unstable plate or
intramedullary nail constructs, primarily in proximal-third tibial fractures. (Canale and Beaty,
2007). Many studies use temporary external fixation for tibial shaft fractures when the condition
of the patient or the extent of the injury does not permit definitive fixation (Petrisol et al, 2007).
In this case we use a medially based uniplanar external fixation frame with two proximal
and two distal bicortical Schanz pins. There are two important principles that should be followed
when placing external fixation frames. For rigidity, the “near-far” technique, with two pins
placed close to either side of the fracture and two pins placed within the bone as far away from
the fracture as possible, allows for a more solid frame construct particularly if the bars are placed
close to the skin and double stacked (Petrisol et al, 2007). The result of this construct was good.
Evaluation intraoperatively was stable enough. One day after operation, the patient can do ankle
exercise well. The wound is treated well and after 2 weeks of intravenous antibiotics, we
changed to oral therapy. Seventh day after operation, at day 18 of admission patient is discharged
and mobilized non weight bearing with 2 crutches.
Although emergency operation is needed to surgically debride the wound in patient of tetanus,
delayed surgery also had a place in management open fracture with tetanus. The decision is
according to the clinical presentation of the patient and general status.
References
Beecroft CL, Enright SM, Beirne HA. 2005. Remifentanil in the Management of Severe Tetanus.
British J Anaesth. 94, Pp: 46-48.
Canale ST, Beaty JH. 2007. Tibia Shaft Fracture in Campbell’s Operative Orthopaedic. 11th
Edition. Elsevier : Philadelphia.
Cook TM, Protoe RT, Handel JM. 2001. Tetanus : A Review of the Literature. Br Journal
Anaesth, 87, Pp : 477-487.
Farar JR, Yen LM, Cook T. 2000. Tetanus. J Neurol Psychiatry, 69 : Pp: 292-301.
Giannoidis PV, Papakostidis C, Roberts C. 2006. A Review of Management of Open Fracture of
the Tibia and Femur. The Journal of Bone and Joint Surgery. Vol 88-B, Pp : 281-289.
Petrisol BA, Bhandari M, Schemitch. 2010. Tibia and Fibula Fracture in Rookwood and Green’s
Fracture in Adults 7th Edition. Lippincot William & Wilkins : New York.
Okike K, Bhattacharyya T. 2006. Trend In Management of Open Fracture : A Critical Analysis.
The Journal Bone and Joint Surgery. No 12. Vol 88. Pp : 2739-2746.