Soft tissue coverage techniques for management of open fractures of tibia (type IIIB)
Keywords:Open fracture, Tibia, Flap, Skin graft
Background: Open fractures are surgical emergencies; incidence of open fractures is increasing with more high-energy road traffic accidents. The tibia is exposed to frequent injury because of its location. The need for aggressive debridement, adequate fracture fixation, and early flap coverage in reducing the morbidity cannot be over emphasized.
Methods: Treatment of open fracture by immediate debridement and anatomical fracture reduction using external fixator device. Gastrocnemius muscle flap done in upper 1/3 open fractures (type IIIB) with larger defects along with split thickness skin graft (STSG). In middle and lower 1/3 open fractures (type IIIB), fasciocutaneous and soleus muscle flaps done with relatively smaller soft tissue defects and exposed bone with STSG.
Results: The study included 15 patients with open tibia fracture Gustillo Anderson type IIIB classified after the initial debridement. Excellent flap takes up was seen in all cases. 11 cases (73.3%) achieved union at the end of 6 months follow-up while 4 cases (26.7%) showed delayed union which required additional procedures like BMI or bone graft.
Conclusions: Soft tissue coverage techniques like fascicutaneous flap, gastrocnemius and soleus muscle flap had a definitive role in the management of open fractures of tibia (type IIIB).
Norris BL, Kellam JF. Soft-Tissue Injuries Associated with High-Energy Extremity Trauma: Principles of Management. J Am Acad Orthop Surg. 1997;5(1):37-46.
Templeman DC, Gulli B, Tsukayama DT, Gustilo RB. Update on the management of open fractures of the tibial shaft. Clin Orthop Relat Res. 1998;350:18-25.
George W. General principles of fracture treatment. In: Terry Canale S, Beaty JH, editors. Campbell’s Operative Orthopaedics. 11th ed. Philadelphia: Elsevier; 2007: 3025.
Small JO, Mollan RA. Management of soft tissue in open tibia fractures. Br J Plast Surg. 1992;45:571-7.
Chittoria R, Mishra SM. Fasciocutaneous flaps in reconstruction of lower extremity: Our experience. Kathmandu Univ Med J (KUMJ). 2004;2:344-8.
Mackenzie DJ, Seyfer AE. Reconstructive surgery lower extremity coverage. In: Mathes SJ, Hentz VR, editors. Plastic Surgery Trunk and Lower Extremity. 2nd ed. Philadelphia: Saunders Elsevier; 2006: 1364.
Mess D. Lower extremity trauma principles of evaluation and early management. In: Cohen M, editor. Mastery of Plastic and Reconstructive Surgery. 1st ed. New York: Little Brown and company; 1994: 1773.
Fischer MD, Gustilo RB, Verecka TF. The timing of flap coverage, bone grafting and IM nailing in patients with tibial shaft fractures with extensive soft tissue injury. J Bone Joint Surg Am. 1991;73(9):1316-22.
Cole JD, Ansel LJ, Schwartzberg R. A sequential Protocol for Management of severe open tibial fractures. Clin Orthop. 1995;315:84-103.
Chung, Jae Y, Kim, Gene, Sohn, Kyu B. Reconstruction of a lower extremity soft-tissue defect using the gastrocnemius musculoadipofascial flap. Ann Plast Surg. 2002;49:91-5.
Wiss DA, Sherman R, Oechsel M. External skeletal fixation and rectus abdominis free flap in the management of severe open fractures of the Tibia. Orthop Clin North Am. 1993;24(3):549-56.