Open Fracture Management
High Yield Overview
OPEN FRACTURE MANAGEMENT
Gustilo-Anderson Classification and Soft Tissue Management
3%
—prevalence
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Gustilo-Anderson
Type I
Pattern<1cm wound, low energy
TreatmentAntibiotics + I&D
Type II
Pattern1-10cm wound
TreatmentAntibiotics + I&D
Type IIIA
PatternGreater than 10cm, adequate coverage
TreatmentDebridement + Fixation
Type IIIB
PatternExtensive stripping, needs flap
TreatmentFixation + Soft Tissue
Type IIIC
PatternArterial injury
TreatmentVascular Repair
Critical Must-Knows
- Definition: An open fracture is a fracture with direct communication between the bone and external environment through a wound in the skin and soft tissues
- Mechanism: High-energy trauma (MVA, motorcycle, falls from height), penetrating injuries, crush injuries
- Management: Emergency: tetanus, antibiotics, wound coverage, splintage
Examiner's Pearls
- "Clinical assessment, photography, wound exploration under anaesthesia, X-rays, CT for articular injury, angiography if vascular injury suspected
- "Type I: excellent union, low infection (less than 2%)
- "Type II: good outcomes (2-7% infection)
Clinical Imaging
Imaging Gallery
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Exam Warning
Open fractures are orthopaedic emergencies. Key exam points: Gustilo-Anderson classification (know grade IIIA vs IIIB vs IIIC differences), antibiotic choice (Co-amoxiclav + Gentamicin for grade III), timing of debridement (within 12-24 hours), and the principle that all open fractures require formal debridement regardless of wound size. The "6-hour rule" is now debated - wound cover and antibiotics are priorities, not rushing unprepared surgery.
At a Glance
Open fractures are orthopaedic emergencies requiring urgent antibiotics, tetanus prophylaxis, wound coverage, and formal debridement. The Gustilo-Anderson classification guides management: Type I (less than 1cm wound, less than 2% infection), Type II (1-10cm, 2-7% infection), Type IIIA (adequate soft tissue coverage, 7% infection), Type IIIB (requires flap coverage, 10-50% infection), and Type IIIC (arterial injury, 42% amputation rate). Antibiotics should include co-amoxiclav for Grade I-II and add gentamicin for Grade III; debridement should occur within 12-24 hours rather than the outdated "6-hour rule." The tibia is most commonly affected (40% of open fractures), and all open fractures require formal debridement regardless of wound size.
Mnemonic
M-E-S-SMESS Score
M
M - Muscle/soft tissue injury (1-4 points)
E
E - Energy mechanism: low (1), medium (2), high (3), very high (4)
S
S - Shock: SBP greater than 90 persistently (0), transient hypotension (1), persistent hypotension (2)
S
S - Skeletal/soft tissue ischaemia: less than 6h (0), 6-12h (+2), greater than 12h (+4)
Memory Hook:MESS predicts amputation - score 7 or greater associated with 100% amputation in original study
Overview and Epidemiology
Epidemiology
Open fractures represent approximately 3% of all fractures, with significant morbidity due to infection risk, soft tissue compromise, and potential limb-threatening complications. The tibia is the most commonly affected bone (40%), followed by the radius/ulna and femur.
Incidence patterns:
- Bimodal age distribution: young males (high-energy trauma) and elderly females (low-energy falls)
- Male predominance (3:1 ratio) due to higher-risk activities
- Road traffic accidents account for 50-60% of cases
- Agricultural and industrial injuries carry highest contamination risk
Risk factors for poor outcomes:
- Higher Gustilo grade
- Delayed antibiotic administration (greater than 3 hours)
- Farm or marine contamination
- Diabetes mellitus
- Smoking
- Peripheral vascular disease
Anatomy and Biomechanics
Soft Tissue Anatomy
Understanding soft tissue coverage is critical for open fracture management, particularly for tibial fractures where coverage options vary by anatomical location.
Tibial anatomy (most common site):
- Anteromedial tibia is subcutaneous with minimal soft tissue padding
- Posteromedial surface covered by pes anserinus tendons
- Anterolateral surface covered by anterior compartment muscles
- Blood supply: Posterior tibial, anterior tibial, and peroneal arteries
Coverage zones:
- Proximal third: Gastrocnemius muscle provides reliable coverage
- Middle third: Soleus muscle can reach from proximal or distal pedicles
- Distal third: Limited local options - often requires free tissue transfer
Vascular Anatomy
The zone of injury concept is essential for surgical planning:
- Direct trauma zone contains devitalized tissue
- Surrounding edema zone extends 5-10cm beyond visible injury
- Perforator vessels may be damaged beyond the wound margins
- External fixator pins must be placed outside the zone of injury
Classification
Gustilo-Anderson Classification
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The Gustilo-Anderson classification remains the gold standard for open fracture grading, though it has recognised limitations in inter-observer reliability:
Type I
- Wound size: less than 1 cm
- Mechanism: Low energy, inside-out injury
- Soft tissue damage: Minimal
- Periosteal stripping: Absent
- Contamination: Minimal
- Fracture pattern: Simple
Type II
- Wound size: 1-10 cm
- Mechanism: Moderate energy
- Soft tissue damage: Moderate, no flaps or avulsions
- Periosteal stripping: Moderate
- Contamination: Moderate
- Fracture pattern: Simple or comminuted
Type III - High-energy injuries with extensive damage
Type IIIA
- Wound size: Usually greater than 10 cm
- Adequate soft tissue coverage of bone possible
- High-energy mechanism
- Segmental fractures, gunshot wounds, farmyard injuries
Type IIIB
- Wound size: Variable
- Extensive soft tissue loss with periosteal stripping
- Requires local or free flap for coverage
- Bone exposed without adequate soft tissue
Type IIIC
- Any open fracture with arterial injury requiring repair
- Limb-threatening vascular compromise
- Highest amputation rate
Clinical Assessment
Initial Assessment
Primary Survey (ATLS Principles)
- ABCDE approach - life before limb
- Control haemorrhage with direct pressure
- Assess neurovascular status before and after any manipulation
- Identify associated injuries (polytrauma)
Emergency Department Management
- Photograph the wound - reduces need for repeated inspections
- Cover with saline-soaked gauze - moist environment, iodine-free
- Splint the limb - reduces bleeding, pain, further soft tissue damage
- Administer antibiotics - within 3 hours of injury
- Tetanus prophylaxis - based on immunisation status
- Analgesia - IV opioids as required
Mnemonic
GAGOpen Fracture Antibiotics
G
G - Grade I/II: Give Co-amoxiclav (or Cefuroxime)
A
A - Add Gentamicin for Grade III injuries
G
G - Give Metronidazole if farm/soil contamination
Memory Hook:The wound GAGs if you don't cover it properly
Antibiotic Regimens for Open Fractures
Debridement Principles
Timing of Debridement
The "6-hour rule" for emergency debridement has been challenged by evidence:
- BOAST guidelines recommend debridement within 12-24 hours
- Exception: heavily contaminated wounds or vascular injury
- Priority is experienced surgeon and appropriate resources
- Night-time debridement by junior staff is not recommended
Debridement Technique
-
Extension of wound - adequate exposure
-
Systematic inspection - all tissue layers
-
Excision of non-viable tissue - "4 Cs" of muscle viability:
- Colour: Pink, not pale/dark
- Consistency: Firm, not mushy
- Contractility: Contracts when stimulated
- Capacity to bleed: Active bleeding when cut
-
Copious irrigation - 3L for Type I, 6L for Type II, 9L for Type III
-
Low-pressure lavage - bulb syringe preferred
-
Bone end debridement - remove contaminated cortex
Mnemonic
4CsMuscle Viability Assessment
C
Colour - should be pink (not pale or dusky)
C
Consistency - should be firm (not mushy)
C
Contractility - should contract when stimulated
C
Capacity to bleed - should bleed when cut
Memory Hook:Check the 4 Cs - if muscle fails, Cut it out
FLOW Trial - Low vs High Pressure Lavage
FLOW Investigators • NEJM (2015)
Key Findings:
- 2,551 patients with open fractures randomised
- Low pressure equivalent to high pressure for reducing infection
- Soap vs saline: no significant difference in reoperation rates
- Low pressure lavage is now recommended practice
Clinical Implication: Use low-pressure lavage (bulb syringe or gravity) rather than high-pressure pulsatile lavage for open fracture irrigation.
Skeletal Stabilisation
Fixation Strategies
Principles of Fixation
- Temporary stabilisation - external fixation ("fix and flap")
- Definitive fixation - timing depends on soft tissues
- Damage control orthopaedics - in polytrauma
External Fixation
Advantages:
- Rapid application
- No implant in zone of injury
- Allows wound access
- Can be done with basic equipment
Disadvantages:
- Pin site complications (5-10%)
- Patient inconvenience
- May need conversion to internal fixation
Intramedullary Nailing
Increasingly used as primary treatment for open tibial fractures:
- Type I and II: Primary IM nail is standard of care
- Type IIIA: IM nail often appropriate if soft tissues allow
- Type IIIB/C: External fixation, then delayed IM nail
SPRINT Trial - Reamed vs Unreamed Nailing
Study to Prospectively Evaluate Reamed Intramedullary Nails in Tibial fractures • JBJS (2008)
Key Findings:
- 1,226 patients with tibial shaft fractures
- Reamed nailing reduced reoperation rate (OR 0.67)
- No difference in infection rates
- Benefits most pronounced in closed fractures
Clinical Implication: Reamed IM nailing is safe and may be beneficial even in open tibial fractures, particularly Types I-IIIA.
Soft Tissue Coverage
Coverage Principles
Timing of Soft Tissue Coverage
BAPRAS/BOA guidelines recommend:
- Definitive soft tissue coverage within 72 hours of injury
- Preferably primary closure or flap coverage at initial debridement
- If delayed, coverage within 7 days reduces infection
Coverage Options
- Primary closure - only if no tension, viable edges
- Split-thickness skin graft - requires healthy granulating bed
- Local muscle/fasciocutaneous flaps
- Gastrocnemius flap (proximal tibia)
- Soleus flap (middle third tibia)
- Distally-based flaps (lower third)
- Free tissue transfer
- Required for large defects
- Lower third tibial coverage
- Latissimus dorsi, rectus abdominis, gracilis
Mnemonic
GSFTibial Soft Tissue Coverage
G
G - Gastrocnemius flap for proximal third
S
S - Soleus flap for middle third
F
F - Free flap often needed for distal third
Memory Hook:Going South? You need a Free flap!
Godina Timing of Flap Coverage
Godina M • Plastic and Reconstructive Surgery (1986)
Key Findings:
- Early flap coverage (within 72 hours) associated with 0.75% flap failure
- Delayed coverage (72h to 3 months) had 12% flap failure
- Late coverage (greater than 3 months) had 9.5% failure
- Infection rates: early 1.5%, delayed 17.5%
Clinical Implication: Early soft tissue coverage within 72 hours significantly reduces infection and flap failure rates.
BOAST Guidelines - Standards for Open Fractures
British Orthopaedic Association and British Association of Plastic Reconstructive and Aesthetic Surgeons • BOA Standards for Trauma (2017)
Key Findings:
- Debridement within 12-24 hours by senior surgeon with appropriate resources
- The 6-hour rule for emergency debridement is outdated
- Soft tissue coverage within 72 hours for Type IIIB fractures
- Combined ortho-plastic approach essential for complex injuries
Clinical Implication: Modern practice prioritises experienced surgeon availability over arbitrary time limits. Joint ortho-plastic planning is mandatory for Type IIIB injuries.
Special Considerations
Marine and Farm Contamination
Farmyard Injuries
- High risk of Clostridial infection (gas gangrene)
- Add Metronidazole or Penicillin for anaerobic cover
- More aggressive debridement required
- Lower threshold for amputation
Marine Injuries
- Risk of Vibrio vulnificus infection
- Can cause necrotising fasciitis
- Add Doxycycline to antibiotic regimen
- Immunocompromised patients at highest risk
Gustilo IIIC Management
📊 Management Algorithm
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Vascular Injury Assessment
- Absent pulse mandates urgent exploration
- Doppler assessment if pulses diminished
- Angiography (CT or conventional) if stable
- Prepare for temporary shunting if prolonged ischaemia
Limb Salvage vs Amputation
Consider amputation if:
- Warm ischaemia time greater than 6 hours
- Complete tibial nerve injury
- MESS score ≥ 7 (though controversial)
- Severe associated injuries (polytrauma)
- Patient factors (comorbidities, occupation)
LEAP Study Findings
- At 2 years, no difference in outcomes between limb salvage and amputation
- 3.4 operations for amputation vs 5.3 for limb salvage
- Neither MESS nor other scores reliably predict outcomes
- Treat patient, not the score
LEAP Study - Limb Salvage vs Amputation
Bosse MJ, et al. • JBJS (2002)
Key Findings:
- 569 patients with severe lower extremity trauma
- No significant difference in Sickness Impact Profile scores at 2 years
- Neither MESS, LSI, PSI, nor NISSSA predicted functional outcomes
- Only significant predictors: rehospitalisation, education, self-efficacy
Clinical Implication: Scoring systems should not be used to indicate amputation. Shared decision-making with patient is essential.
Infection
Risk Factors for Infection
- Higher Gustilo grade
- Delayed antibiotic administration (greater than 3 hours)
- Inadequate debridement
- Delayed soft tissue coverage
- Farm/soil contamination
- Smoking
- Diabetes
Infection Rates by Grade
| Gustilo Grade | Infection Rate |
|---|---|
| Type I | 0-2% |
| Type II | 2-7% |
| Type IIIA | 7-10% |
| Type IIIB | 10-50% |
| Type IIIC | 25-50% |
Management of Established Infection
- Deep tissue samples (minimum 5)
- Suppression until definitive plan
- Debridement with dead space management
- Biofilm disruption
- Antibiotic-loaded cement if appropriate
- Appropriate antibiotic therapy (minimum 6 weeks for osteomyelitis)
Nonunion
Risk Factors
- Bone loss greater than 4 cm
- High-energy mechanism
- Infection
- Smoking
- Soft tissue compromise
- Inadequate fixation
Management Options
- Bone grafting (autograft, allograft)
- Induced membrane technique (Masquelet)
- Bone transport (Ilizarov)
- Free vascularised fibula graft
- BMP-2/7 (adjuvant)
BOAST Guidelines Summary
Key Principles Overview
Essential Open Fracture Management Principles
Definition: An open fracture is a fracture with direct communication between the bone and external environment through a wound in the skin and soft tissues.
Epidemiology:
- 3% of all fractures
- Tibia most common (40%)
- Bimodal distribution: young males (high energy) and elderly (low energy)
Critical Management Steps:
- Photograph the wound - reduces repeated inspections
- Cover with saline-soaked gauze - moist environment
- Splint the limb - reduces bleeding, pain, soft tissue damage
- Administer antibiotics within 3 hours
- Tetanus prophylaxis
- Formal debridement - all open fractures require this
Key Exam Points:
- Gustilo-Anderson classification is gold standard
- "6-hour rule" is outdated - BOAST guidelines recommend 12-24 hours
- All open fractures require formal debridement regardless of wound size
Anatomic Considerations
Soft Tissue Anatomy Relevant to Open Fractures
Tibial Coverage (Most Common Site):
- Anteromedial tibia is subcutaneous - minimal soft tissue coverage
- Highest risk of exposure and requiring flap coverage
- Soft tissue flap options vary by location (GSF mnemonic)
Coverage Options by Location:
| Location | Flap Option | Characteristics |
|---|---|---|
| Proximal third | Gastrocnemius flap | Reliable, large muscle, easy arc of rotation |
| Middle third | Soleus flap | Smaller muscle, can reach from proximal |
| Distal third | Free flap usually required | Limited local options, poor vascularity |
Vascular Anatomy:
- Three main vessels: anterior tibial, posterior tibial, peroneal
- IIIC definition: injury to any vessel requiring repair
- Temporary shunting may be required for ischaemia
Classification Summary
Gustilo-Anderson Classification Summary
Type I:
- Wound less than 1cm, low energy, inside-out injury
- Minimal soft tissue damage, no periosteal stripping
- Infection rate: 0-2%
Type II:
- Wound 1-10cm, moderate energy
- Moderate soft tissue damage, no flaps/avulsions
- Infection rate: 2-7%
Type III: High-energy with extensive damage
| Subtype | Key Feature | Infection Rate |
|---|---|---|
| IIIA | Greater than 10cm but adequate soft tissue coverage possible | 7-10% |
| IIIB | Extensive soft tissue loss, requires flap coverage | 10-50% |
| IIIC | Arterial injury requiring repair | 25-50% |
Clinical Assessment
Systematic Assessment
Primary Survey (ATLS):
- ABCDE approach - life before limb
- Control hemorrhage with direct pressure
- Identify associated injuries (polytrauma common)
Wound Assessment:
- Photograph the wound before covering
- Size, location, depth
- Contamination type (soil, road, farm, marine)
- Bone exposure
- Muscle viability (gross assessment)
Neurovascular Assessment:
- Document before AND after any manipulation
- Distal pulses (dorsalis pedis, posterior tibial)
- Capillary refill
- Sensation all nerve territories
- Motor function (if possible)
Important: Complete tibial nerve injury is an independent predictor for amputation consideration
Investigations
Standard Investigations
Imaging:
- X-rays: AP and lateral of affected bone, include joints above and below
- CT scan: For articular fractures (tibial plateau, pilon)
- Angiography: If vascular injury suspected (CT angiography or conventional)
Laboratory:
- FBC, coagulation profile
- Group and save/crossmatch
- Lactate (if shocked)
- Baseline renal function
Wound:
- Photography (reduces repeated inspections)
- Deep tissue samples at debridement (not superficial swabs)
- Minimum 5 tissue samples for culture
Management Algorithm
Stepwise Management
Phase 1: Emergency Department
- ATLS primary survey
- Photograph wound
- Cover with saline-soaked gauze
- Splint the limb
- Antibiotics within 3 hours (GAG mnemonic)
- Tetanus prophylaxis
- Analgesia
Phase 2: Theatre (within 12-24 hours)
- Extend wound for adequate exposure
- Systematic debridement (4 Cs muscle viability)
- Copious low-pressure lavage (3L Type I, 6L Type II, 9L Type III)
- Skeletal stabilization
- Wound management (leave open or VAC)
Phase 3: Definitive Care
- Soft tissue coverage within 72 hours (Type IIIB)
- Definitive fixation when soft tissues allow
- Serial debridement as needed
Surgical Technique
Debridement Technique
Wound Extension:
- Extend wound margins for adequate visualization
- Follow tissue planes
- Create access to all contaminated areas
Systematic Debridement Layers:
- Skin edges - excise non-viable margins
- Subcutaneous tissue - remove contaminated fat
- Fascia - assess and debride as needed
- Muscle - use 4 Cs criteria (Color, Consistency, Contractility, Capacity to bleed)
- Bone - remove loose fragments, debride contaminated cortex
Irrigation:
- Low-pressure lavage (FLOW trial evidence)
- Volume: 3L Type I, 6L Type II, 9L Type III
- Normal saline (no benefit from soap per FLOW trial)
- Bulb syringe or gravity irrigation preferred
Skeletal Stabilization:
- External fixation for severely contaminated or IIIB/C
- Primary IM nailing appropriate for Type I-IIIA
Complications Overview
Common Complications
Infection:
- Most common serious complication
- Rates by grade: Type I 0-2%, Type II 2-7%, IIIA 7-10%, IIIB 10-50%, IIIC 25-50%
- Risk factors: delayed antibiotics, inadequate debridement, delayed coverage
Nonunion:
- Higher rates than closed fractures
- Risk factors: bone loss, infection, smoking, poor soft tissue
- May require bone grafting, transport, or free vascularized fibula
Compartment Syndrome:
- Can occur despite open wound
- Especially post-revascularization (IIIC)
- High index of suspicion required
Amputation:
- IIIC has 42% amputation rate in some series
- Not always initial decision - may be secondary
Postoperative Care
Postoperative Protocols
Antibiotic Continuation:
- Continue until wound closure (max 72 hours if wound closed)
- Extend if wound left open or VAC applied
- Step down to oral when appropriate
Wound Management:
- Regular wound inspection (daily)
- VAC therapy if wound left open (change every 48-72 hours)
- Plan for soft tissue coverage if needed
Return to Theatre:
- Planned second look at 24-48 hours (IIIB/C)
- Serial debridements until wound bed clean
- Soft tissue coverage within 72 hours (IIIB)
Physiotherapy:
- Early ROM when fixation allows
- Weight bearing per fracture type and fixation
- Edema control
Outcomes
Outcomes by Gustilo Grade
Infection Rates:
| Grade | Infection Rate | Union Rate |
|---|---|---|
| Type I | 0-2% | greater than 95% |
| Type II | 2-7% | 90-95% |
| Type IIIA | 7-10% | 85-90% |
| Type IIIB | 10-50% | 70-85% |
| Type IIIC | 25-50% | Variable |
Amputation Rates:
- Type I-II: Less than 1%
- Type IIIA: 1-5%
- Type IIIB: 5-15%
- Type IIIC: 42% in some series
Functional Outcomes:
- Generally good for Type I-II
- Variable for Type III depending on soft tissue, nerve injury
- LEAP study: No difference in function between salvage and amputation at 2 years
Evidence Base Summary
Key Evidence for Open Fractures
FLOW Trial (NEJM 2015) - Level I:
- 2,551 patients with open fractures
- Low-pressure lavage equivalent to high-pressure
- Soap vs saline: no significant difference
- Implication: Use low-pressure lavage (bulb syringe)
SPRINT Trial (JBJS 2008) - Level I:
- 1,226 patients with tibial shaft fractures
- Reamed nailing reduced reoperation rate
- No difference in infection rates
- Implication: Reamed IM nailing is safe in open fractures
LEAP Study (NEJM 2002) - Level II:
- 569 patients with severe lower extremity trauma
- No difference in 2-year function between salvage and amputation
- MESS score unreliable for amputation decision
- Implication: Treat patient, not the score
Exam Viva Scenarios
Practice these scenarios to excel in your viva examination
VIVA SCENARIOStandard
Scenario 1: Gustilo IIIB Open Tibial Fracture - Multidisciplinary Management
EXAMINER
"A 35-year-old motorcyclist is brought to the emergency department after a road traffic collision. He has sustained an open tibial fracture with a 12cm wound on the anterolateral aspect of his right leg. There is significant muscle loss visible, but you can palpate a dorsalis pedis pulse. The wound contains road debris. He is haemodynamically stable with no other injuries. X-rays show a comminuted mid-shaft tibial fracture. Describe your immediate and definitive management."
EXCEPTIONAL ANSWER
This is a **Gustilo Type IIIB** open tibial fracture requiring urgent multidisciplinary management. The key features are: greater than 10cm wound (12cm), high-energy mechanism (motorcycle accident), and most critically **significant muscle loss** indicating that adequate soft tissue coverage will **not be possible with local tissue alone** - this defines Type IIIB and mandates flap coverage. The palpable dorsalis pedis pulse is reassuring and excludes Type IIIC. **Immediate Management** follows the BOAST guidelines: First, I would complete an ATLS primary survey to exclude other life-threatening injuries - airway, breathing, circulation, then focused secondary survey. For the limb specifically: (1) **Photograph the wound** to reduce need for repeated inspections, (2) Cover with **saline-soaked gauze** (not betadine-soaked), (3) **Splint the limb** to reduce bleeding, pain, and further soft tissue damage, (4) Administer **IV antibiotics within 3 hours** - this is Grade III so I would give **Co-amoxiclav 1.2g IV plus Gentamicin** (GAG mnemonic - Add Gentamicin for Grade III), (5) **Tetanus prophylaxis** based on immunization status, (6) Adequate **analgesia** - IV morphine titrated to effect. Crucially, I would **document the neurovascular status** before and after splintage - this patient has palpable DP pulse which is reassuring, but I would also assess posterior tibial pulse, capillary refill, sensation (superficial peroneal, deep peroneal, sural, tibial nerve distributions), and motor function. I would assess for compartment syndrome clinically. **Surgical Planning**: This requires **senior involvement early** - I would contact my trauma consultant and alert the plastic surgery team immediately, as this will require combined ortho-plastic approach. According to BOAST guidelines, debridement should occur within **12-24 hours** by an experienced surgeon with appropriate resources - the old 6-hour rule for emergency surgery is outdated. The priority is having the **right team** and **right equipment**, not rushing to theatre unprepared late at night. **Definitive Surgical Management**: In theatre, I would perform: (1) **Extension of the wound** if needed for adequate exposure, (2) **Systematic debridement** of all non-viable tissue using the **4 Cs** to assess muscle viability - **Colour** (pink not pale/dusky), **Consistency** (firm not mushy), **Contractility** (responds to stimulation), **Capacity to bleed** (bleeds when cut). Any muscle failing these criteria should be excised. (3) **Copious low-pressure lavage** - the FLOW trial showed low-pressure irrigation is as effective as high-pressure. For Grade III injuries, use **9 litres** of normal saline. (4) **Skeletal stabilisation** - for this Type IIIB injury, I would favour **external fixation** initially to allow wound access and avoid placing metalwork in the zone of injury. This is the fix and flap approach. (5) Most critically, **plan for definitive soft tissue coverage within 72 hours**. Godina's classic study showed early flap coverage (within 72h) had only **0.75% flap failure** rate versus **12% for delayed coverage**. For middle third tibial defects, options include **soleus muscle flap** or more likely a **free tissue transfer** (latissimus dorsi, rectus abdominis). For proximal third, gastrocnemius flap. For distal third, almost always requires free flap. The plastic surgery team would assess flap requirements and plan reconstruction. **Definitive Fixation**: Once soft tissues have healed (typically 6-8 weeks), I would consider conversion from external fixator to **intramedullary nail** for definitive skeletal stabilization. The SPRINT trial showed reamed nailing can be used safely in open fractures and reduces reoperation rates. **Follow-up**: Close monitoring for complications - **compartment syndrome** (especially post-revascularization or with swelling), **infection** (Type IIIB has 10-50% infection risk), delayed union/nonunion (high risk with bone loss and soft tissue stripping), and physiotherapy for early range of motion once healing permits.
KEY POINTS TO SCORE
Gustilo IIIB definition: Extensive soft tissue loss requiring flap coverage (cannot achieve coverage with local tissue)
GAG antibiotic mnemonic: Grade I/II give Co-amoxiclav, Add Gentamicin for Grade III, Give Metronidazole for farm contamination
BOAST guidelines: Debridement within 12-24h by senior surgeon (not emergency 6h rule), soft tissue coverage within 72h
4 Cs muscle viability: Colour, Consistency, Contractility, Capacity to bleed - excise any muscle failing these criteria
FLOW trial (NEJM 2015): Low-pressure lavage as effective as high-pressure (9L for Grade III), Godina study: Early flap coverage within 72h reduces failure 0.75% vs 12% delayed
COMMON TRAPS
✗Classifying as IIIA instead of IIIB - the critical distinction is whether local tissue can cover bone (IIIA) or requires flap (IIIB)
✗Forgetting to photograph the wound before covering it (reduces need for repeated painful inspections)
✗Rushing to theatre within 6 hours - BOAST guidelines prioritize experienced surgeon over arbitrary time, 12-24h is appropriate
✗Not involving plastic surgery early - combined ortho-plastic planning essential for IIIB, cannot add plastics as afterthought
✗Missing compartment syndrome - high-energy open fractures still at risk, examine carefully despite open wound
LIKELY FOLLOW-UPS
"What if the dorsalis pedis pulse disappears during your examination?"
"How would you manage a 6cm segmental bone defect identified at debridement?"
"What are the specific options for soft tissue coverage for proximal vs middle vs distal third tibial defects?"
"What is the evidence for reamed versus unreamed intramedullary nailing in open tibial fractures?"
VIVA SCENARIOChallenging
Scenario 2: Gustilo IIIC Open Tibial Fracture - Limb Salvage vs Amputation Decision
EXAMINER
"You are the on-call orthopaedic registrar and receive a trauma call from the emergency department about a Gustilo IIIC open tibial fracture. The patient is a 55-year-old diabetic man who was struck by a car while crossing the road. He has a severely displaced tibial shaft fracture with a 15cm wound and absent dorsalis pedis and posterior tibial pulses. The accident occurred 5 hours ago at a rural location and he has just arrived after inter-hospital transfer. He is haemodynamically stable. How do you proceed?"
EXCEPTIONAL ANSWER
This is a **limb-threatening emergency** - a Gustilo Type IIIC open fracture defined by **arterial injury requiring repair**, regardless of wound size. The absence of both DP and PT pulses indicates complete vascular disruption, and with **5 hours warm ischaemia time** already elapsed, this requires **immediate action** to prevent irreversible ischaemic damage (traditional threshold is 6 hours for skeletal muscle). **Immediate Emergency Actions**: (1) **Alert vascular surgery immediately** - this is a vascular emergency requiring urgent revascularization. (2) **Alert my trauma consultant** and theatre coordinator - emergency case, mobilize trauma team. (3) **Assess patient stability** - ensure adequate resuscitation, large bore IV access, group and save (possible transfusion), blood products available. (4) Administer **broad-spectrum antibiotics immediately** - Co-amoxiclav 1.2g IV plus Gentamicin for Grade III. Given the mechanism (road traffic), I would also consider adding **Metronidazole** for potential soil/faecal contamination (anaerobic cover). (5) Keep limb at **heart level** (not elevated - reduces arterial inflow), remove all constricting dressings, **splint gently** to prevent further vascular injury. (6) **Document neurovascular status fully** - motor and sensory function all nerve distributions. Complete tibial nerve injury is an **independent predictor for amputation**. **In Theatre - Sequence of Events**: The key principle in IIIC fractures is **life before limb** and **rapid restoration of perfusion**. The sequence should be: **Step 1 - Vascular Assessment**: The vascular surgeon explores the injury. With 5 hours already elapsed and surgery/prep adding time, we are approaching the 6-hour warm ischaemia threshold. The vascular surgeon has two options: (a) **Temporary shunt** (Sundt or Javid shunt) - this restores arterial inflow immediately while allowing time for orthopaedic stabilisation. This is preferred if the vascular injury is complex or ischaemia time is critical. (b) **Definitive vascular repair** immediately if straightforward (simple laceration, good vessels). Given the 5-hour ischaemia time, I would advocate for **temporary shunting first** to restore perfusion within 10-15 minutes, then proceed with skeletal stabilisation, then definitive vascular repair. **Step 2 - Skeletal Stabilisation**: Rapid **external fixation** to provide stability for the vascular repair. This must be quick (20-30 minutes maximum) - two or three Schanz pins proximal and distal, simple bar construct. Avoid prolonged fracture manipulation as this can disrupt temporary shunt. **Step 3 - Debridement**: While skeletal fixation is being applied, the vascular surgeon can be preparing vessels. Debridement should be performed but must be **rapid and focused** - remove grossly contaminated tissue, but this is not the time for meticulous 4Cs assessment. Priority is restoring blood flow. More thorough debridement can occur at second look in 24-48 hours. **Step 4 - Definitive Vascular Repair**: Temporary shunt removed, definitive repair (primary repair if possible, interposition vein graft if tension, or synthetic graft if vein unavailable). **Step 5 - Fasciotomies**: **Mandatory** after revascularization to prevent compartment syndrome from reperfusion injury. Four-compartment fasciotomy of leg (anterior, lateral, superficial posterior, deep posterior) via two incisions (anterolateral and posteromedial). Do not close fasciotomy wounds - leave open, plan delayed closure or skin grafting. **Step 6 - Wound Coverage**: Temporary coverage with saline-soaked gauze or negative pressure wound therapy. Plan return to theatre in 24-48 hours for reassessment. **Critical Decision Point - Salvage vs Amputation**: This is the most challenging aspect. Factors favouring **amputation**: (1) **Complete tibial nerve injury** - strong predictor of poor functional outcome, patient may prefer amputation to insensate painful foot. (2) **Warm ischaemia time greater than 6 hours** - irreversible muscle damage, high risk of Volkmann's contracture, poor function. (3) **Severe soft tissue destruction** - massive muscle loss, bone exposure, unlikely to achieve coverage. (4) **Associated life-threatening injuries** - polytrauma where damage control principles dictate, prolonged vascular/orthopaedic surgery may destabilize patient. (5) **MESS score ≥7** - historically associated with 100% amputation rate. **However**, the **LEAP study** (Lower Extremity Assessment Project, JBJS 2002) showed that **scoring systems like MESS are unreliable** for predicting functional outcomes. At 2 years, there was **no significant difference** in functional outcomes (Sickness Impact Profile scores) between limb salvage and amputation groups. The study showed the decision should incorporate **patient factors** - occupation, education, self-efficacy, motivation - not just injury severity scores. **In this specific case**: (1) 5 hours ischaemia is **within the 6-hour window** - salvage is reasonable. (2) Diabetic patient - increases infection risk (IIIC has 25-50% infection rate baseline) but not an absolute contraindication. (3) Need to assess tibial nerve function - if complete palsy, discuss with patient about implications for foot sensation and function. (4) **Shared decision-making** - if patient is conscious and stable, discuss realistic expectations: multiple surgeries (5-6 operations average for IIIB/C salvage vs 3-4 for amputation), high infection risk, possible eventual amputation anyway, prolonged recovery. My approach would be to **attempt limb salvage** given the ischaemia time is salvageable, ensure fasciotomies, and closely monitor. If there is complete tibial nerve injury or if revascularization fails, I would have a low threshold to proceed with amputation to save the patient's life. **Post-Revascularization Management**: (1) **Monitor for reperfusion injury** - metabolic acidosis, hyperkalemia, myoglobinuria. (2) **Renal protection** - IV fluids, monitor urine output for myoglobin (dark tea-colored urine), alkalinize urine if needed, may require dialysis. (3) **Serial neurovascular checks** - ensure perfusion maintained, monitor compartments (though fasciotomies done). (4) **Return to theatre in 24-48h** for reassessment - further debridement, wound inspection, assess viability, plan soft tissue coverage.
KEY POINTS TO SCORE
Gustilo IIIC definition: ANY open fracture with arterial injury requiring repair, highest amputation rate (42% in some series)
Warm ischaemia time critical: 6 hours traditional threshold for skeletal muscle, act urgently to restore perfusion before irreversible damage
Temporary shunting (Sundt/Javid shunt) restores perfusion rapidly (10-15 min), allows time for skeletal stabilization before definitive vascular repair
Fasciotomies MANDATORY post-revascularization: Four-compartment via two incisions, prevents compartment syndrome from reperfusion injury
LEAP study (JBJS 2002): MESS score and other scoring systems unreliable for amputation decision, no difference in 2-year functional outcomes salvage vs amputation, shared decision-making essential
COMMON TRAPS
✗Delaying vascular surgery consultation - this is a vascular emergency requiring immediate vascular involvement, not just orthopaedic problem
✗Using MESS score alone to indicate amputation - LEAP study showed scoring systems unreliable, must incorporate patient factors and shared decision-making
✗Forgetting fasciotomies after revascularization - reperfusion injury causes massive swelling, compartment syndrome is almost inevitable without prophylactic fasciotomy
✗Not protecting kidneys from myoglobin - rhabdomyolysis from muscle breakdown can cause acute renal failure, need IV fluids, monitor urine, consider alkalinization
✗Prolonged orthopaedic surgery when ischaemia time critical - skeletal stabilization must be rapid (external fix, not perfect alignment), priority is restoring blood flow
LIKELY FOLLOW-UPS
"How specifically would you manage rhabdomyolysis and prevent acute renal failure post-revascularization?"
"What are the long-term functional outcomes and late sequelae for patients who undergo limb salvage after prolonged ischaemia?"
"At what point would you definitively decide to proceed with amputation rather than continuing salvage attempts?"
"What are the indications for and technique of temporary vascular shunting in trauma?"
VIVA SCENARIOCritical
Scenario 3: Gas Gangrene in Open Fracture - Life-Threatening Clostridial Infection
EXAMINER
"You are called to the ward at 2am by a worried nurse about a 45-year-old farmer who was transferred from a rural hospital 6 hours ago. He sustained an open tibial fracture 18 hours ago when his leg was caught in farm machinery. At the rural hospital, he underwent debridement and external fixator application, and was started on Co-amoxiclav and Gentamicin before transfer. The nurse reports he has become acutely unwell - fever 38.8°C, heart rate 130, BP 95/60, appears confused. On examination, the leg is tense and swollen far beyond the wound margins. You can feel crepitus extending from the knee to ankle. The wound now has a bronze discoloration with thin serosanguinous discharge that has a foul, sweet smell. What is your diagnosis and immediate management?"
EXCEPTIONAL ANSWER
This is **gas gangrene** (clostridial myonecrosis) - a **life-threatening surgical emergency** with mortality rates of 25-30% even with treatment, and up to 100% if untreated. This patient has the classic triad of: (1) **Systemic toxicity** (fever, tachycardia, hypotension, confusion from septic shock), (2) **Crepitus** (gas in tissues from Clostridium perfringens producing hydrogen and CO2), and (3) **Characteristic wound appearance** (bronze discoloration, thin dishwater serosanguinous discharge with sweet, foul smell). The key risk factor is **farmyard contamination** - soil is heavily contaminated with Clostridial spores (C. perfringens, C. septicum), and this patient's open fracture occurred in farm machinery, making it a **heavily contaminated injury**. The inadequate antibiotic cover (Co-amoxiclav and Gentamicin were given, but **Metronidazole or Penicillin for anaerobic cover was likely omitted**) and the 18-hour delay have allowed the infection to establish. Gas gangrene typically presents **12-24 hours post-injury** with rapid progression - this fits the timeline perfectly. **Immediate Emergency Management** - this is a **save life over limb scenario**: **Step 1 - Resuscitation** (ABC approach): (1) **Airway and Breathing**: Patient confused - assess GCS, consider need for intubation if deteriorating, high-flow oxygen 15L non-rebreather. (2) **Circulation**: Large bore IV access (two lines), **aggressive fluid resuscitation** for septic shock (aim SBP greater than 90mmHg), start vasopressors if fluid refractory (noradrenaline), blood products available. (3) **MET call** - this patient is peri-arrest, needs ICU involvement early. **Step 2 - Urgent Microbiology Samples and Antibiotics**: (1) Blood cultures, wound swabs (though don't delay surgery for this). (2) **Immediate high-dose IV antibiotics**: This requires **triple therapy for clostridial infection**: **Benzylpenicillin 2.4g IV 4-hourly** (first-line for Clostridium perfringens, high dose), plus **Clindamycin 600mg IV 6-hourly** (inhibits toxin production - critical adjunct), plus **Metronidazole 500mg IV 8-hourly** (anaerobic cover). (3) I would also **contact microbiology** urgently for guidance and to alert them to potential Clostridium. **Step 3 - Emergency Theatre** (within 1 hour): (1) Alert **theatre coordinator**, **trauma consultant**, and **anaesthetist** - emergency case, cannot wait. (2) Alert **ICU** - will need post-op ventilation and monitoring. (3) **Consent** - if patient has capacity despite confusion, explain high risk of amputation and death. If lacks capacity, proceed under emergency best interests (Doctrine of Necessity). **Step 4 - Surgical Management (Radical Debridement vs Amputation)**: This is the critical decision. Gas gangrene requires **radical debridement of all infected tissue** to remove the source of toxin production and stop progression. **In theatre, I would**: (1) **Remove the external fixator** and extend the wound extensively to assess the full extent of gas and necrosis. (2) **Assess muscle viability** - with gas gangrene, the 4 Cs are helpful but infection spreads rapidly. Characteristic findings are **brick-red muscle** that becomes **pale and doesn't bleed** when cut, with visible **gas bubbles** in tissue and a **sweet, putrid smell**. (3) **Gram stain** - intraoperative Gram stain may show **Gram-positive rods** (Clostridium) which supports diagnosis. (4) Send **deep tissue specimens** (at least 5) for culture and histopathology. (5) **Decision point - Debridement vs Amputation**: **Debridement** is appropriate if: Gas and necrosis **limited to the zone of injury** (i.e., not extending throughout the entire leg compartment), patient is **stable enough** to tolerate prolonged surgery, and I am confident I can achieve **complete excision** of all infected tissue with adequate margins. This would require excision of all affected muscle (potentially entire compartments), copious irrigation, and **leave the wound completely open**. The patient would return to theatre **every 12-24 hours** for serial debridement until infection controlled. **Amputation** is indicated if: Crepitus and gas extend **throughout the leg** (knee to ankle as in this case), **systemic toxicity is severe** (this patient is in septic shock), or I cannot achieve **adequate source control** with debridement alone. In this case, with crepitus from knee to ankle and severe sepsis, **I would proceed with guillotine above-knee amputation** to achieve rapid source control and save the patient's life. This is done at the level that achieves healthy bleeding muscle - likely high above knee or even through-knee. This is a **damage control** amputation - rough guillotine, no attempt to create a definitive stump, leave wound **completely open**, pack with betadine-soaked gauze. The priority is removing the source of toxin production as rapidly as possible. **Definitive stump revision** can be performed 5-7 days later once infection controlled and patient stable. **Step 5 - Adjunctive Treatment (Hyperbaric Oxygen)**: **Hyperbaric oxygen therapy (HBO)** at 2.5-3 atmospheres provides oxygen to ischaemic tissues, inhibits clostridial toxin production, and has bacteriostatic effect. **Evidence is mixed** - some retrospective studies suggest benefit, but difficult to prove in prospective trials due to rarity. If available at a hyperbaric facility nearby, this could be used as **adjunct** to surgery, but **NOT a substitute** - debridement/amputation is the primary treatment. HBO typically given 2-3 times daily for 90-120 minutes. I would **contact the hyperbaric unit** if available, but would **not delay surgery** to transfer for HBO - surgical source control is paramount. **Post-Operative ICU Management**: (1) **Intensive care monitoring** - likely intubated and ventilated, vasopressor support, monitor for multi-organ failure. (2) **Continue triple antibiotics** for at least 7-10 days, step down from IV to oral as patient improves. (3) **Serial debridement** if debridement was performed (return to theatre every 12-24h), or **stump revision** planning if amputated. (4) **Monitor for complications** - acute renal failure (myoglobin from muscle necrosis), DIC (clostridial toxins), multi-organ failure. **Key Learning Point - Prevention**: This case highlights the critical importance of **recognizing high-risk contamination** at the initial injury. **Farmyard injuries** should automatically trigger: (1) **Addition of Metronidazole or high-dose Penicillin** to the antibiotic regimen (GAG mnemonic - Give Metronidazole for farm/soil contamination), (2) **More aggressive initial debridement** with lower threshold for excision of questionable tissue, (3) **Lower threshold for amputation** in severe farm injuries, (4) Close monitoring for 24-48 hours for signs of clostridial infection. The initial treating hospital likely gave standard antibiotics (Co-amoxiclav + Gentamicin for Grade III) but **missed the critical step of adding anaerobic cover** for the farm contamination. **Prognosis**: Even with optimal treatment, mortality from gas gangrene is **20-30%**. Limb salvage is rare once established gas gangrene develops. The priority is **saving the patient's life** by removing the source of infection, even if this means amputation. Delayed amputation (attempting debridement first and failing) is associated with **higher mortality** than early definitive amputation.
KEY POINTS TO SCORE
Gas gangrene triad: (1) Systemic toxicity (septic shock), (2) Crepitus (subcutaneous gas), (3) Characteristic wound (bronze discoloration, dishwater discharge, sweet foul smell)
Farmyard injuries HIGH RISK for Clostridium - must add Metronidazole or Penicillin for anaerobic cover (GAG mnemonic - Give Metronidazole for farm contamination)
Triple antibiotic therapy essential: Benzylpenicillin 2.4g IV 4-hourly (first-line), Clindamycin 600mg IV 6-hourly (inhibits toxin production), Metronidazole 500mg IV 8-hourly (anaerobic cover)
Surgical source control URGENT (within 1 hour): Radical debridement if limited, guillotine amputation if extensive - priority is saving life not limb, delayed amputation has higher mortality
Hyperbaric oxygen (2.5-3 atmospheres) potential adjunct but NOT substitute for surgery, evidence mixed, do not delay surgery for HBO transfer
COMMON TRAPS
✗Mistaking for simple cellulitis or compartment syndrome - crepitus, systemic toxicity, and characteristic dishwater discharge are pathognomonic for gas gangrene
✗Relying on antibiotics alone without urgent surgical debridement/amputation - gas gangrene mortality 100% without source control, antibiotics are adjunct only
✗Attempting limb-sparing debridement when extensive infection present - with crepitus knee to ankle and septic shock, guillotine amputation is life-saving, delayed amputation after failed debridement has higher mortality
✗Forgetting Clindamycin in antibiotic regimen - specifically inhibits clostridial toxin production, essential adjunct to Penicillin
✗Delaying surgery to transfer for hyperbaric oxygen - HBO is adjunct, surgical source control is primary treatment and cannot be delayed
LIKELY FOLLOW-UPS
"What is the mechanism by which Clostridium perfringens causes tissue necrosis and systemic toxicity?"
"What are the specific indications and contraindications for hyperbaric oxygen therapy in gas gangrene?"
"How would your antibiotic choice differ if this was a marine-contaminated injury rather than farmyard?"
"What is the evidence base for guillotine amputation versus aggressive limb-sparing debridement in established gas gangrene?"
MCQ Practice Points
Gustilo Classification
Q: What distinguishes Type IIIA from Type IIIB open fractures?
A: Type IIIA: Greater than 10cm wound OR high-energy mechanism, but adequate soft tissue coverage of bone is possible with local tissue. Type IIIB: Extensive soft tissue loss with bone exposed, requiring flap coverage (local or free). Both are high-energy injuries, but IIIB has periosteal stripping and cannot achieve primary soft tissue coverage.
Antibiotic Timing
Q: What is the optimal timing for antibiotic administration in open fractures?
A: Antibiotics should be administered within 1 hour of injury (ideally in the field or ED). BOAST guidelines recommend Cefazolin 2g IV as first-line for Types I-II. Add Gentamicin 1.5mg/kg for Type III injuries. Delay greater than 3 hours is associated with significantly increased infection rates.
Wound Coverage Timing
Q: What is the current evidence regarding timing of wound coverage in open fractures?
A: The traditional "golden period" of 6 hours is no longer considered an absolute rule. BOAST guidelines recommend soft tissue coverage within 72 hours for Type IIIB fractures. Early coverage (within 72h) reduces flap failure (0.75%) versus delayed (12%). Serial debridement every 48-72 hours until wound is suitable for coverage.
MESS Score Interpretation
Q: How should the MESS score be used in clinical decision making for mangled extremities?
A: MESS score ≥7 was originally associated with 100% amputation rate, but the LEAP study showed scoring systems are unreliable predictors of amputation. MESS should not be used as the sole determinant. Decision should incorporate: complete tibial nerve injury, prolonged warm ischaemia (greater than 6h), severe soft tissue destruction, associated life-threatening injuries, and patient factors.
Australian Context
Trauma System Organisation
Major Trauma Centres: Open fractures Type IIIB/C should be transferred to major trauma centres with ortho-plastic services. Victorian State Trauma System, NSW Trauma Network, Queensland Trauma System all have established referral pathways.
RACS Guidelines: Royal Australasian College of Surgeons supports the BOAST guidelines framework for open fracture management in Australasia.
Antibiotic Prescribing
eTG Recommendations:
- Type I-II: Cefazolin 2g IV 8-hourly (or flucloxacillin if penicillin allergic)
- Type III: Add gentamicin 5mg/kg IV once daily
- Farm contamination: Add benzylpenicillin 1.8g IV 6-hourly OR metronidazole
PBS Considerations: IV antibiotics in hospital setting. Oral step-down options include cephalexin or flucloxacillin (PBS listed).
Surgical Considerations
Emergency Theatre Access: All Australian major trauma centres should have 24/7 emergency theatre access for open fractures. Time to debridement targets should be monitored as part of trauma centre accreditation.
Ortho-Plastic Collaboration: Major centres provide combined ortho-plastic services for Type IIIB fractures requiring flap coverage. Rural and remote hospitals should have clear referral pathways established.
Open Fractures Quick Reference
High-Yield Exam Summary
Gustilo Classification
- •Type I: Less than 1cm wound, low energy, clean
- •Type II: 1-10cm wound, moderate energy
- •Type IIIA: greater than 10cm OR high energy, adequate soft tissue
- •Type IIIB: Bone exposed, requires flap coverage
- •Type IIIC: Any open fracture with vascular injury
Antibiotic Regimen
- •Grade I/II: Co-amoxiclav 1.2g IV TDS
- •Grade III: Add Gentamicin
- •Farm injury: Add Metronidazole
- •Start within 3 hours of injury
- •Continue until soft tissue closure (max 72h for closed wounds)
Key Timings
- •Antibiotics: Within 3 hours
- •Debridement: Within 12-24 hours (senior surgeon)
- •Soft tissue coverage: Within 72 hours ideally
- •Maximum delay for flap: 7 days
4 Cs of Muscle Viability
- •Colour (pink, not pale/dusky)
- •Consistency (firm, not mushy)
- •Contractility (stimulation response)
- •Capacity to bleed (bleeding when cut)
References
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Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analyses. J Bone Joint Surg Am. 1976;58(4):453-458.
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British Orthopaedic Association Standards for Trauma (BOAST). Open Fractures. BOA, 2017.
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Nanchahal J, Nayagam S, Khan U, et al. Standards for the Management of Open Fractures of the Lower Limb. Royal Society of Medicine Press, 2009.
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FLOW Investigators. A trial of wound irrigation in the initial management of open fracture wounds. N Engl J Med. 2015;373(27):2629-2641.
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Study to Prospectively Evaluate Reamed Intramedulary Nails in Patients with Tibial Fractures (SPRINT) Investigators. Randomized trial of reamed and unreamed intramedullary nailing of tibial shaft fractures. J Bone Joint Surg Am. 2008;90(12):2567-2578.
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Bosse MJ, MacKenzie EJ, Kellam JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924-1931.
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Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285-292.