Open Tibia Fractures Treatment & Management

Updated: Mar 17, 2020
  • Author: Minoo Patel, MBBS, PhD, MS, FRACS; Chief Editor: Thomas M DeBerardino, MD  more...
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Approach Considerations

The various limb salvage scoring systems, such as the Mangled Extremity Severity Score (MESS), are good indicators for salvage but poor indicators for amputation. Thus, a limb with a good MESS usually should be salvaged, but a limb with a poor MESS does not necessarily require amputation.

Absolute contraindications for limb salvage include the following:

  • Completely mangled limb
  • Presence of warm ischemia for longer than 6 hours
  • Poor facilities for salvage

Absolute contraindications for nailing an open fracture include the following:

  • Untreated compartment syndrome
  • Gustilo-Anderson types IIIB and IIIC open fractures

Antibiotic Therapy, Irrigation, and Debridement

Intravenous (IV) antibiotics are administered promptly. First-generation cephalosporins providing gram-positive coverage (eg, cephalothin 1-2 g q6-8hr) suffice for type I fractures. An aminoglycoside providing gram-negative coverage (eg, gentamicin 120 mg q12hr; 240 mg/day) is added for type II or III injuries. Metronidazole 500 mg q12hr or penicillin 1.2 g q6hr can also be added for coverage against anaerobes. Tetanus prophylaxis should be instituted. Antibiotics generally are continued for 72 hours after wound closure. Short courses of prophylactic antibiotics appear to be as effective as longer ones in this setting. [22]

After initial assessment, the wound is irrigated in the emergency department (ED). [23] A sterile dressing is applied, and the limb is splinted. Debridement should be performed in the operating room (OR) as soon as is feasible. Debridement within 6 hours is necessary to keep the rate of infection low. [24] A key factor in infection prevention is early rigid stabilization of the fracture.

The aims of antibiotic therapy and debridement are to sterilize the wound to a negligible bacterial load and to render the wound similar to a typical surgical wound. The first debridement is the best chance for infection prevention.

A tourniquet should not be used. This helps in identifying the devitalized tissue. The skin is sharply cut back to bleeding edges. Radical debridement is performed with sharp dissection until bleeding tissue is visualized. "Red is good, and gray is bad" is the general dictum to be followed. Devitalized muscle can also be identified by its lack of response to electrical stimulus.

All extrinsic debris is meticulously removed. Copious irrigation is employed. "The solution to pollution is dilution" is another dictum applicable to this setting. Irrigation works predominantly by mechanical means. A pulsatile lavage system works by creating local eddy currents and dislodging the debris from the soft tissues.

High-pressure pulsatile lavage should be avoided because it can cause soft-tissue damage. Bhandari et al found that high-pressure pulsatile lavage also resulted in bacterial seeding into the intramedullary canal and significant damage to the architecture of the bone. [25] However, both high- and low-pressure lavage were associated with similar degrees of periosteal separation from the cortical bone surface. Both high- and low-pressure lavage effectively removed adherent bacteria from bone after a delay of 3 hours before irrigation, but only high-pressure lavage removed adherent bacteria from bone at a delay of 6 hours. [26]

The bone ends should be debrided thoroughly. Aggressive bone debridement has been demonstrated to lower infection rates in high-grade open fractures. [13, 27]

Soft-tissue coverage can be achieved primarily in all cases except those with extensive contamination and risk of anaerobic infection. [28] A delayed primary closure or coverage is provided for wounds with extensive contamination and a significant risk of anaerobic infection. If the wound cannot be closed primarily, skin grafting or flap coverage can be provided, though muscle flaps provide better coverage and results. [29] Gustilo-Anderson types I and II injuries can also be allowed to granulate and close spontaneously by secondary intention.


Surgical Repair and Amputation

After primary debridement, the surgical setup should be changed and the limb redraped without losing sterility.

Fracture repair

Intramedullary nailing is the best option for Gustilo-Anderson types I, II, and III fractures. [30, 31, 32] Type IIIB fractures can also be treated with unreamed nails. Solid-core nails are associated with the lowest rate of infection. [33]  In a study comparing suprapatellar and infrapatellar approaches to medullary nailing of the tibia in patients with open tibia fractures, Marecek et al found the two approaches to be essentially similar with respect to the risk of knee sepsis. [34]

One randomized trial studied the addition of an absorbable collagen sponge containing recombinant human bone morphogenetic protein-2 (rhBMP-2) to reamed intramedullary nail fixation in patients with open tibial fractures compared with patients treated with intramedullary nail fixation and the standard of care. A healed fracture was the primary endpoint as depicted by radiography and clinical examination at 13 and 20 weeks after wound closure. The addition of rhBMP-2 did not significantly increase healing compared with those in the standard of care group. [35]

External fixation is used for types IIIA and IIIB fractures. Thakur and Patankar demonstrated excellent results using a protocol of early bone grafting and fixator dynamization with monolateral fixators. [36, 37]

Alternatively, an exchange nailing can be performed after removal of the fixator. This procedure is associated with a high risk of infection. Infection risk can be minimized by avoiding and treating pin-site infection and by exchanging to a nail after less than 15 days of external fixation. [38, 39] Alternately, the fixator can be removed and the limb immobilized in a cast until the pin sites have healed; the tibia can then be nailed.

A meta-analysis by Bhandari et al found that in comparison with external fixation, the use of unreamed nails decreased the risk of reoperation, superficial infection, and malunion in open tibial fractures. [40, 41] It also showed that the risk of reoperation was lower with reamed nails than with unreamed nails. This finding appears to support some authors who have suggested initial nailing with a small-diameter nail and subsequent exchange nailing with a larger-diameter reamed nail.

In this meta-analysis, plate fixation was found to be uniformly the worst of all methods of internal fixation. [41] Although plating a fracture that is exposed may be tempting (because of the open nature of the injury), the risk of nonunion, malunion, and deep infection [42] is too high to justify it.

Cast treatment is avoided for many reasons. It does not provide rigid fracture stabilization, the wound is not open for inspection and regular dressing changes, and a circumferential cast increases the risk of circulatory compromise.

Delayed union or nonunion may be avoided with early prophylactic posterolateral bone grafting. [36, 43]

The Masquelet technique (or induced membrane technique [IMT]) has beed described as a means of managing Gustilo II and IIIB open tibia fractures. [44, 45, 46]

Monolateral external fixators generally are preferred for the tibia, though multiplanar and circular fixators provide greater stability. For periarticular plateau and plafond fractures, circular or hybrid frames yield the best results, with the lowest morbidity, especially related to infection and soft-tissue complications.

Devices such as the Taylor Spatial Frame can be applied quickly in an emergency situation. Using the so-called rings-first method, each ring is applied individually orthogonal to each fragment, and the struts are connected. The fracture is then reduced gradually in a nonemergency fashion by bringing all the struts to equal length and all the rings parallel. The reduction can then be fine-tuned by using the residual correction program. This is especially useful when rapid stabilization is required before a vascular repair, though the device may impede surgical access.


Not every severely injured limb can be salvaged. Several scoring methods have been developed to predict the chances of limb salvage. The MESS is the best known. Many authors have found these scoring systems to be unreliable. [30] The presence of warm ischemia for longer than 6 hours, infrapopliteal vascular injury, and posterior tibial and/or common peroneal nerve neurotmesis are the strongest indications for amputation. [30]

With a good MESS, a limb should be considered salvageable; however, a poor MESS should not automatically prompt amputation. Clinical judgment and availability of limb reconstruction facilities should be the ultimate factors in decision-making. [47, 48]



Open tibial fractures have higher rates of nonunion, infection, and chronic pain syndrome (CPS). [49]  The Gustilo-Anderson classification of the fracture is a good predictor of the likelihood of nonunion and infection. [50]

Osteomyelitis may occur and can be acute, subacute, or chronic. It may surface many months or years after injury.

Pin-site infections are common with external fixator treatment. Chronic osteomyelitis in the pin sites is relatively common.


Long-Term Monitoring

Given the higher rates of nonunion, infection, and CPS seen with open tibial fractures, close follow-up is required until union. CPS should be anticipated and treated early, rather than after the pain patterns are entrenched. Follow-up should also watch for possible acute, subacute, or chronic osteomyelitis surfacing months or even years after the injury. Pin-site infections arising after external fixation should be aggressively treated with oral or parenteral antibiotics and debridement or even pin exchange. Pin-site chronic osteomyelitis may develop as well.