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
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
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.
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.
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 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).
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.
