A sequential protocol for management of severe open tibial fractures.

Fifty consecutive open fractures of the tibia, including 22 Grade IIIB and 4 Grade IIIC, were treated using a protocol of debridement, immediate wound coverage, and intramedullary nailing. Fasciocutaneous flaps were used extensively to cover areas of exposed bone. The severity of the soft tissue injury dictated the timing of definitive fixation. Fracture location determined implant selection and nailing technique. Patients were observed for an average of 21 months. Ninety-eight percent of the fractures united < 6 months postoperatively. There was 1 infection (2%), 2 malunions (4%), and 1 case of partial flap necrosis. Locking screws broke in 1 patient (2%); the fracture united with < 5 mm of shortening. Immediate postdebridement wound coverage, and intramedullary nailing after reconstruction of the soft tissue envelope facilitate fracture healing in these complex open injuries. Intramedullary nailing can be performed safely to include all grades of open tibial fractures from the proximal to distal metaphysis.