British Journal of Plastic Surgery (1999), 52, 462–470

© 1999 The British Association of Plastic Surgeons

Emergency management of type IIIB open tibial fractures

Y. Tropet, P. Garbuio, L. Obert and P. E. Ridoux

Department of Trauma, Orthopaedic and Plastic Surgery, Jean Minjoz Hospital, Besançon, France

SUMMARY. We present our therapeutic strategy for the treatment of type IIIB open tibial fractures. It involves
emergency internal stabilisation of the bone by locked intra-medullary nailing when appropriate and skin cover
using either a pedicled or free muscle flap. Where there is bone loss, a cancellous iliac graft is performed at the
same time. Eighteen cases of type IIIB open tibial fractures treated between 1986 and 1995 were analysed. There
were 17 men and 1 woman; the average age was 35 years. Each of the 18 patients underwent wound debridement
as a primary emergency procedure with no secondary reoperation. Bone fixation was performed by locked intra-
medullary nailing (AO nail, How Medica) 6–10 h after trauma. A primary cancellous iliac bone graft was
performed in three cases. Cover was applied immediately after nailing (muscular pedicle flaps in 12 cases, muscu-
lar free flaps in 6 cases). Local flap cover led to two failures: both these fractures were followed by postoperative
complications. The 6 free muscle flaps were successful. The average time to bone union was 6.5 months (range:
3–18.5 months) according to clinical criteria and 9 months (range: 4–27 months) according to radiological
criteria. Out of the 18 fractures, 13 were primarily united (72.2% of cases); 3 involved osteitis and 2 nonunion.
Sixteen patients were examined again with a mean follow-up of 4.8 years (range: 1–11 years). Six moderate mal-
unions occurred; none needed surgical reoperation. Ankle motion was normal in 7 cases and reduced to below
50% in 9 cases when compared with the healthy ankle. Thirteen patients resumed their previous professional
activities. This surgical strategy reduces bone union time, the number of operations and the time spent in
hospital; it improves functional results.

Keywords: lower limb, trauma, fracture, tibia, internal fixation, skin cover.

In Gustilo type IIIB open tibial fractures caused by
high-energy trauma, there is both loss of skin and/or
bone substance and extensive devascularisation of soft
tissue. Management of these serious lower limb
injuries is a subject of controversy: many authors still
advocate external fixation for bone stabilisation.
Internal osteosynthesis by intra-medullary nailing is a
difficult technique, which can lead to complications,
but new developments and better control of conven-
tional plastic procedures and microsurgical techniques
have forced many practitioners to reconsider their
view of this technique.
The present study explains our strategy for the
treatment of compound emergency fractures. Internal
stabilisation of the bone is achieved by locked intra-
medullary nailing; the fracture site is covered with a
pedicle or free muscle flap. Where there is bone loss,
we prefer to perform a cancellous iliac bone graft as
part of the same procedure.
Materials and methods
Eighteen cases of Gustilo type IIIB open tibial frac-
tures treated between 1986 and 1995 were analysed
retrospectively (Table 1). Five patients were not
included in the study because they were treated ini-
tially with external fixators in other hospitals and
transferred to us several days later. One patient whose
anatomical type of fracture required external stabilisa-
tion was also excluded.
462
Sixteen patients were examined again with a mean
follow-up of 4.8 years (range: 1–11 years); one injured
person died, another was not seen again. The average
age was 35 years (range: 18–76 years). There were 17
men and 1 woman. In almost all cases, the fracture
resulted from a high-energy trauma (7 motorbike acci-
dents, 4 car accidents, 4 pedestrians struck by a vehi-
cle, 3 crushing injuries). Twelve were isolated injuries
and six had multiple injuries. Six had comminuted
fractures. In three cases, there was segmental bone loss
and in three other cases there was extended tibial bone
loss. In all cases, debridement resulted in loss of soft
tissue exposing the fracture site, making direct closure
impossible. One fracture site was located in the upper
third of the leg, 13 were in the middle third or at the
junction of the middle third and the lower third, and
4 were in the lower third of the leg.
In the majority of cases, vascular status was
assessed by palpation or Doppler examination of
peripheral blood vessels. Doppler examinations were
abnormal for the three main arteries in two cases, and
we suspected a more proximal injury. We therefore
performed preoperative arteriography but no vascular
disruption was found.
Treatment
All patients received general antibiotics prescribed
over a period of 8 days on average. Surgery was
always performed as an emergency and included
Table 1 Eighteen cases of Type III B open tibial fractures treated by emergency locked intra-medullary nailing and flap coverage
Bone
healing
time
Partial
Emergency Hospitalisation (months)
weight
Case no. – Bone Op. Time bearing
Age – Sex Level Bone loss Fixation Flap graft Complications number (days) (months) Clinical X-rays
1 – 76 – M Upper 1/3 – L.I.M.N. Medial – – 1 26 2.5 4 7.5
gastrocnemius
2 – 32 – M Middle 1/3, – L.I.M.N. Fasciocutaneous – Osteitis, nonunion, 4 50 7 8 8.5
lower 1/3 flap Ilizarov
3 – 23 – M Middle 1/3 – L.I.M.N. Soleus – – 1 66 3 4 5
4 – 35 – M Middle 1/3 Antero-medial L.I.M.N. Medial – Nonunion, bone 3 55 7 14 18
gastrocnemius grafting
5 – 20 – M Middle 1/3 – L.I.M.N. Medial – – 1 36 2.5 3 4
gastrocnemius
6 – 37 – M Lower 1/3 – L.I.M.N. Latissimus dorsi – – 1 58 3.5 6 7
free flap
7 – 24 – M Middle 1/3 – L.I.M.N. Soleus – Osteitis, Ilizarov 2 65 4 5 8.5
8 – 53 – M Middle 1/3 – L.I.M.N. Soleus – – 1 38 2.5 6 8
9 – 21 – M Lower 1/3 – L.I.M.N. Soleus – Partial flap loss, 8 86 12 18.5 27
osteitis, Ilizarov
Emergency management of type IIIB open tibial fractures

10 – 35 – M Middle 1/3, – L.I.M.N. Flexor digitorum – – 1 35 2.5 3.5 6

lower 1/3 longus
11 – 25 – M Middle 1/3 – L.I.M.N. Soleus – – 1 31 2 3.5 6
12 – 35 – M Lower 1/3 – L.I.M.N. Gracilis free – – 1 28 1.5 3 4
flap
13 – 66 – M Upper 1/3, – L.I.M.N. Gastrocnemius – Distal flap loss, 5 60 6 12 17
middle 1/3 + soleus nonunion nail
changed
14 – 18 – M Middle 1/3, Medial 5 cm L.I.M.N. Latissimus dorsi iliac – 2 34 3.5 6 10
lower 1/3 free flap
15 – 18 – M Upper 1/3 – L.I.M.N. Gracilis free – – 1 34 5 8 9
flap
16 – 20 – M Middle 1/3 Total 3 cm, L.I.M.N. Gracilis free iliac – 1 35 3 4 6
partial 10 cm flap
17 – 20 – M Upper 1/3, Total 3 cm L.I.M.N. Latissimus dorsi iliac – 1 48 3 5.5 7
middle 1/3 free flap
18 – 29 – M Middle 1/3 – L.I.M.N. Soleus – – 1 35 2.5 4 5

L.I.M.N.: locked intra-medullary nailing.

463
464
Table 2 Types of flaps
Pedicle muscular flap 11
– gastrocnemius medial 3
–soleus 6 were covered with local flaps and six with free flaps.
–gastrocnemius + soleus 1 Free flaps led to favourable outcome in all these cases.
–flexor digitorum longus 1 However, there were two complications: phlebitis and a
Pedicle fasciocutaneous flap 1 haematoma beneath flaps, which had to be evacuated a
Free muscular flap 6
–gracilis 3 few days after the initial surgical procedure. The mean
–latissimus dorsi 3 number of operations was 1.1 per person if a second
debridement, followed by fracture stabilisation, with
bone grafting when necessary, and skin cover. Each of
the 18 patients underwent debridement as a primary
emergency procedure with no secondary reoperation.
Bone fixation was performed by intra-medullary nail-
ing (AO nail, How Medica) with reaming and proxi-
mal and distal locking in most cases. Nailing was done
as soon as debridement was finished, between 6 and
10 h after trauma. The mean diameter of the nail was
10 mm (range: 9–11 mm). Cover was applied immedi-
ately after nailing (Figs 1, 2); muscle flaps were used in
all but one case. We first used local flaps (12 cases) and
then free flaps (6 cases) (Table 2). We chose the gracilis
muscle when soft tissue loss was moderate and the
latissimus dorsi when it was extensive. Continuity of
the main vascular axes was respected whenever possi-
ble. Anastomoses were end-to-side (4 cases) and
end-to-end (2 cases). In four operations the recipient
vessel was the posterior tibial artery and in two the
anterior tibial artery. Microsurgical anastomosis was
performed distal to the injury zone in one case. In this
case the defect was located at the junction of the upper
third and the middle third of the leg; with the long
vascular pedicle of the latissimus dorsi, anastomosis in
the lower third was less difficult technically. All other
anastomoses were done in the vicinity of the site
so that vein grafts were avoided. Complementary
cancellous iliac bone grafting was necessary in three
cases; all three were done in emergency (Fig. 3). No
amputation was necessary in the series.
Results
Wound cover
Local flap cover led to two failures and was accompa-
nied by distal necrosis of the soleus muscle. Both these
fractures were followed by complex postoperative
complications. The six emergency free muscle flaps
healed well (average healing time 35 days, range:
21–60 days).
Bone union
The clinical criterion for bone union was total weight-
bearing with no apprehension or pain. Mean time
to bone union for the 18 patients was 6.5 months
(range: 3–18.5 months) using this clinical criterion,
and 9 months (range: 4–27 months) using radiological
criteria.
Of the 18 fractures, 13 (72.2%) were primarily
united. In this group, bone union was obtained within
British Journal of Plastic Surgery
4.6 months using the clinical criterion and 6.5 months
using rigorous radiological criteria. The postoperative
course was remarkably uncomplicated. Seven fractures
minor mesh grafting of a flap on the 8th day is
excluded. Average hospital stay was 36.8 days and the
average number of hospital stays was 1.1.
Bone union was delayed for five fractures (27%),
due to postoperative complications. Mean bone union
time for these cases was 11.5 months using the clinical
criterion and 16.5 months using radiological criteria.
The five fractures were covered with local flaps. The
average number of operations for this group was 5.6,
the average hospital stay was 58.5 days and the
average number of hospital stays 3.2. Analysis of the
postoperative courses of these five complicated frac-
tures shows that three (16.6%) involved osteitis, twice
at an early stage and once at a late stage with atrophic
nonunion; in these three cases, material was removed
and we had to use an external fixator of the Ilizarov
type. Bone union was achieved in all three cases. The
two other fractures developed sterile nonunion. One
united after inter-tibio-fibula grafting while the other
united after the nail was changed.
Some of the different factors delaying bone union
were: (a) a technical error at the beginning of our
series resulting in inadequate fixation of the fracture,
no nail locking (which is often necessary in such com-
pound fractures) and insufficient unipolar locking; (b)
lack of an immediate bone graft even though there
was a segmental bone defect; and (c) failure of local
flap cover in two cases, partially exposing the fracture
sites. In these two cases a local flap was chosen due to
the moderate size of the skin defect.
Functional results on second examination
Sixteen patients were re-examined. In the two patients
who were not re-examined, the fractures developed
towards per primam bone union. We were mainly con-
cerned with: (a) the functional results of knee, ankle,
foot and toe; (b) how long it took for the patients to
resume normal activity; and (c) what the other after-
effects were in terms of pain and claudication. There
were six malunions most of which were caused by a
technical flaw in the use of intra-medullary nailing
where locking was absent or insufficient. In general,
these malunions were rotatory or valgus/varus for
the low fractures (1 varus of 5°, 1 valgus below 10°;
1 extreme rotation of 10°). However, none needed
reoperation. In three cases, there was a 1–3 cm short-
ening because of septic complication of the fracture.
Apart from fracture of the tibial segment associated
with ligament damage to the knee, fracture damage to
the tibia or femur articular surfaces, or when com-
bined with diaphyseal fractures of the femur, the knee
never showed limitation of motion or pain. Four
patients displayed hammer toes, in three cases associ-
ated with the beginning of an exaggerated arch. Nine
Emergency management of type IIIB open tibial fractures 465

A B C

E F

Figure 1—33-year-old man. (A, B) Type IIIB open tibial fracture. In emergency: (C) locked intra-medullary nailing (X-ray 2 months later);
(D) with gracilis free flap. (E) Bone union 3 months later. (F) Postoperative view at 6 months.
466 British Journal of Plastic Surgery

A B C

D E F

Figure 2—18-year-old man. (A, B) Type IIIB open tibial fracture. In emergency: (C) locked intra-medullary nailing; (D) with gracilis free
flap. (E) Bone union 9 months later. (F) Postoperative view of the leg at 12 months.
Emergency management of type IIIB open tibial fractures 467

A B C

D E

Figure 3—18-year-old man. (A) Type IIIB open tibial fracture with bone loss. (B, C, D) In emergency: locked intra-medullary nailing; iliac
bone grafting; and latissimus dorsi free flap. (E) Bone union 12 months later. (F) Postoperative view of the leg at 3 years.
468
patients’ motion was reduced by 50% when compared
with normal ankle motion. Of the 16 patients with a
follow-up of more than 8 years, 13 suffered from
various pains of the knee or ankle. One experienced
claudication and one used a cane from time to time.
Thirteen patients resumed their previous professional
activities; one was retired and reduced his leisure
activities; one lost his job because of the functional
consequences of the accident; one was considered
disabled.
Discussion
This strategy in dealing with open tibial fractures with
severe soft-tissue injury may seem aggressive; nonethe-
less it is justified because of the encouraging results of
this prospective series. Wound debridement is impor-
tant in the initial management of the fracture.
Following Godina,1 Arnez̆ 2 and Chen et al3,4 in this
respect, we think that it must be performed thoroughly
and immediately as a single procedure as soon as the
injured patients are admitted to hospital. This should
apply to both lower and upper limb fractures.5
Extensive aggressive and definitive debridement con-
verts a dirty, traumatic wound into a flat, surgically
clean wound without cavities. It is a time-consuming
part of the operation. Debridement should be done
first under tourniquet control so as to make surgical
exploration easier. All suspect tissues are excised back
to viable margins. All degloved skin is removed.
Crushed muscles are excised methodically. All small
bone fragments without periosteum in comminuted
fractures are removed. Large bone fragments with sig-
nificant soft-tissue attachments are not excised during
the debridement procedure. Copious wound irrigation
is performed. The tourniquet is then deflated to assess
the tissue viability and vascularity.
We believe that radical debridement is the most
important factor in avoiding the need for secondary
surgery.
In many cases in the literature, successive debride-
ment operations6–12 are needed due to the lack of
initial cover with greater overall loss of bone and soft
tissue.
Techniques for the treatment of open fractures have
commonly involved external fixators.4–6,8,10,11,13–17 If the
type and site of the fracture are appropriate, locked
nailing facilitates plastic or microsurgical procedures.
Nailing is indicated as for a closed tibial fracture and
its use is limited by the site of the fracture. It is not rec-
ommended when the patient is admitted several days
after trauma, because of the risk of infection.18,19 If
the technique is rigorous and covering of the internal
fixation in emergency is guaranteed, the risk of infec-
tion is minimal. The three cases of osteitis out of the
18 patients in our series (16.6%) were caused by a
covering failure, which exposed the site and metal-
work. High rates of complications due to infection in
the published series (Whittle et al20 25%, Tu et al21
37.5%) are explained by delayed covering of the frac-
ture sites as stressed by Court-Brown et al.22
Secondary nailing of a fracture initially treated with
British Journal of Plastic Surgery
external fixators also carries a high risk of infection
(Gustilo et al9,10 33%, Fischer et al23 48%). Infection
rates for stabilisation by external fixators vary from 10
to 50% according to Gustilo et al.9 Yaremchuk et al17
note a 14% infection rate, Peat and Liggins15 a 30%
rate and Caudle and Stern24 a 29% rate.
Reaming the intra-medullary canal is controversial.
Klein et al25 have experimentally shown that reaming
the intra-medullary canal decreases cortical bone flow
by as much as 70%. Previous studies have shown that
intra-medullary nailing causes circulatory disturbance
in the diaphyseal cortex.26–28 Intra-medullary nailing
leads to extensive necrosis of the inner half to two-
thirds of the cortical bone.29,30 Schemitsch et al30 have
demonstrated that muscle perfusion is significantly
greater in the unreamed group. These findings were
also supported by other authors28,31 who have
noted that efferent vessels at the periosteal surface
undergo reversal of flow and become compensatory
afferent vessels. Schemitsch’s studies30 suggest that the
devascularisation produced by reaming may be com-
pensated for by an early increase in soft-tissue blood
flow.
In a clinical study, Anglen and Blue32 showed a
prolonged healing time, more postoperative complica-
tions and additional surgery for tibial fractures treated
by unreamed nailing compared to fractures treated by
reamed nailing. In a recent report, Court-Brown et al33
noted that the theoretical advantages of unreamed
nails with respect to endosteal blood supply and spread
of infection appear to be counter-balanced in clinical
practice by the benefits of reaming in inducing bone
healing and the greater strength of the larger implants.
External fixation is not as efficient as internal
fixation for bone union. The mean bone union time in
the 13 cases of uncomplicated fractures in our series is
a potent argument. Referring to the published cases
using external fixation, bone union time is 16 months
in Seyfer’s series (7 IIIB cases),34 12 months for Chen’s3
two cases of type IIIC fractures and between 17 and
34 months for Spiro’s11 five cases. Bone union time is
over 15 months in Yaremchuk’s series (22 cases).17
From their study of 33 cases, Peat and Liggins15
mention a mean bone union time of 9.2 months. Only
Francel’s series14,35 (7 months with no bone loss) and
Godina’s1 (6.8 months) show bone union times similar
to ours, when only the clinical criterion of bone union
is considered (6.5 months). Intra-medullary locked
nailing is better than an external fixator for controlling
rotation and angulation as well as the length of com-
minuted fractures.20,36 Internal fixation helps early par-
tial weight-bearing, walking and facilitates an early
return to work; it improves functional recovery of the
ankle.
Immediate skin cover of the exposed fracture site is
undoubtedly an advantage, confirming currently pub-
lished data.7,8,16,17,37 This is best achieved with a muscle
flap: its plastic properties (filling up dead space), its
vascular and trophic qualities and its resistance to
infection are better than those of a fasciocutaneous
flap,15,38 which is likely to cause secondary necrosis due
to tissue contusion at the acute stage of the trauma.6 A
pedicle flap is traditionally used if the topography and
Emergency management of type IIIB open tibial fractures
limited skin loss permit. However, attention must be
paid to the degree of contusion of neighbouring soft
tissue, which is often underestimated.7 If there is any
doubt about the use of a pedicle flap, the surgeon
should use a free muscle flap, particularly on the lower
third of the leg; the flap adds well-vascularised tissue
and causes no devascularisation. It is chosen as a
priority by some in cases of high-energy trauma
because of debridement considerations.3,12,14,17,39,40 We
used free flaps in five out of the last seven cases in our
series. In our small series, analysis of the results shows
that when flaps are chosen, free flaps are more reliable
than pedicle flaps for the postoperative course of the
fracture: the 6 free flaps engendered a simple post-
operative course for the fracture whereas 5 fractures
out of the 12 covered with a pedicle flap turned out to
be fractures that were more difficult to treat. There are
three main reasons for this. First, if there is significant
muscle contusion, a local flap will not be perfectly
healthy and will not have the trophic qualities of a free
flap. Second, there is local devascularisation subse-
quent to removal of a muscle flap. Third, the soft
tissue defect is very often covered with the least
vascularised distal part of the pedicle flap; conse-
quently, the much sought after trophic qualities are
impaired so that bone union is likely to be delayed.
While early covering is advocated by many
authors,1,3,4,13,14,16,17 emergency covering combined with
bone stabilisation as a single procedure is still rarely
performed. Small and Mollan,16 Sadove et al,41 Arnez̆ 2
and Chen et al,3 while using early covering, continue to
support the external fixator technique.
Type IIIB open fractures are prone to bone loss.
It may be unicortical if a third fragment is present or
if an anterior part of the bone is missing. In these
cases, surgical opinion is diverse; most authors per-
form bone grafting 4 weeks after covering at the
earliest.10,16,17,34,42,43 Francel14 is the only one who
stresses the importance of bone grafting at the same
time as covering. In our series we performed a can-
cellous graft as an emergency for three cases. Thus, we
were able to reduce bone union times significantly
with respect to type IIIB fractures with bone loss
(6–10 months).
Our surgical option is ideal for the patient because
we have permanent surgical teams with wide experi-
ence in the various techniques of orthopaedics, micro-
surgery and plastic surgery. In our department, two
senior surgeons, one specialised in orthopaedic
trauma and the other in microsurgery and plastic
surgery, are on 24-hour duty.
Most type IIIB open tibial fractures can benefit
from this surgical strategy, the main limiting factor
being secondary admission of the injured person.
Management of the patient remains demanding for
the surgical team. However, it is the only way to
shorten bone union times, reduce the number of oper-
ations and limit time spent in hospital. Social and
economic benefits are indisputable. Medical expendi-
ture is greatly reduced. It is less constraining for the
patients, who can resume their professional activities
earlier; it improves functional as well as aesthetic
results.
469
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The Authors
Y. Tropet MP, Consultant Plastic Surgeon
P. Garbuio MD, Consultant Orthopaedic Surgeon
L. Obert MD, Consultant Orthopaedic Surgeon
P. E. Ridoux MD, Consultant Orthopaedic Surgeon
Department of Trauma, Orthopaedic and Plastic Surgery, Hôpital
Jean Minjoz – C.H.U. – F-25030 Besançon Cedex, France.
Correspondence to Professor Yves Tropet.
Paper received 3 July 1997.
Accepted 11 May 1999, after revision.