Emergency management of type IIIB open tibial fractures

We present our therapeutic strategy for the treatment of type IIIB open tib ial 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 ili ac graft is performed at the same time. Eighteen cases of type IIIB open ti bial fractures treated between 1986 and 1995 were analysed. There were 17 m en and 1 woman; the average age was 35 years. Each of the 18 patients under went wound debridement as a primary emergency procedure with no secondary r eoperation. Bone fixation was performed by locked intramedullary nailing (A O nail, How Medica) 6-10 h after trauma. A primary cancellous iliac bone gr aft was performed in three cases. Cover was applied immediately after naili ng (muscular pedicle flaps in 12 cases, muscular free flaps in 6 cases). Lo cal flap cover led to two failures: both these fractures were followed by p ostoperative complications. The 6 free muscle flaps were successful. The av erage 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 radiologi cal criteria. Out of the 18 fractures, 13 were primarily united (72.2% of c ases): 3 involved osteitis and 2 nonunion. Sixteen patients were examined a gain with a mean follow-up of 4.8 years (range: 1-11 years). Six moderate m alunions occurred; none needed surgical reoperation. Ankle motion was norma l in 7 cases and reduced to below 50% in 9 cases when compared with the hea lthy ankle. Thirteen patients resumed their previous professional activitie s. This surgical strategy reduces bone union time, the number of operations and the time spent in hospital; it improves functional results.