Open Fracture Management, ABOS Oral Boards Preparation

This is a 22-year-old male brought to the trauma bay after a high-speed motorcycle collision. He was helmeted but had no lower extremity protection. He was hemodynamically stable. ATLS primary survey was intact. On secondary survey, the right leg had a 6-centimeter wound over the anterior tibia with exposed bone, gross contamination with road debris, and active bleeding controlled with direct pressure. The foot was warm with a palpable dorsalis pedis pulse but a diminished posterior tibial pulse. Sensation was intact. Compartments were soft. There was significant soft tissue stripping with periosteal exposure extending beyond the wound edges.

AP and lateral radiographs showed a comminuted tibial shaft fracture with a butterfly fragment and approximately 2 centimeters of bone loss. The fibula was fractured at the same level. No articular involvement proximally or distally.

In the emergency department, I started IV cefazolin and gentamicin, a first-generation cephalosporin plus an aminoglycoside for a Gustilo IIIB open fracture, and confirmed tetanus prophylaxis. Given the diminished posterior tibial pulse, I obtained an ABI which was 0.7 on the affected side. I consulted vascular surgery, and a CTA showed no major arterial disruption, the diminished pulse was due to vasospasm that resolved with warming.

I took him to the operating room within 90 minutes. I performed a thorough debridement and low-pressure irrigation, then stabilized the fracture with a spanning external fixator. The wound was left open with negative-pressure wound therapy.

He returned to the OR at 48 hours for a planned second look. The wound bed looked healthy. Plastic surgery performed a free anterolateral thigh flap for soft tissue coverage at day five. At two weeks, once the soft tissue envelope was stable, I converted to a reamed intramedullary nail for definitive fixation.

At six weeks, early callus was forming. At three months, the fracture was healing but the bone defect required additional time. At six months, the fracture had consolidated with some residual cortical remodeling. He was fully weight-bearing without assistive devices. At one year, he was back to all activities with a well-healed soft tissue envelope and no signs of infection.

The patient was satisfied with his outcome. Looking back, I would have coordinated the plastic surgery consultation earlier, ideally at the time of the initial debridement rather than post-operatively. Having them evaluate the wound on day one would have streamlined the timing of definitive soft tissue coverage, which is one of the most important factors in preventing deep infection. I watched him closely for late infection and nonunion throughout the first year, and he had no complications.