Treatment of open fracture of shaft of tibia-fibula Gustilo type III-B by SIGN interlocking nail and wound coverage by muscle flap within 72 hours of injury

Ayub Ali, Mizanur Rahman, Sajedur Reza Faruquee, Tazul Islam, Zamil Zaidur Rahim, Abdullah Yusuf


Background: The open fracture of tibia-fibula Gustilo type III-B may threaten the survival of the injured leg. The objective of the study purpose was to see the effect of early coverage following fixation of open tibial shaft fracture.

Methods: This clinical trial was carried out in National Institute of Traumatology and Orthopaedic Rehabilitation (NITOR), Dhaka from July 2004 to June 2006 for a period of two (2) years. Patients at age group of 18 years or above with both sexes presented with open fracture shaft of tibia-fibula Gustilo type III-B were selected as study population. The patients were surgically managed by SIGN Interlocking nail and wound coverage by muscle flap within 72 hours of injury. Bacteriological study of the wound was done in all cases. All fixation and coverage were performed within 72 hours of injury. Patients grading improved on subsequent follow up. Evaluation of results was done at every post-operative follow up.

Results: A total number of 12 young patients with open fracture tibia-fibula Gustilo III-B were recruited for this study. Their age varies from 18 years to 48 years. A total number of 83.33% cases wound debridement was done within 12 hours of injury. Most of the soft tissue healed (91.67%) within 0 to 20 days.  There were no cases developed limb length discrepancy angulations or rotation. Superficial infections were occurred in 1(8.33%) case but no evidence of deep infection. In this study excellent result were obtained from 9 cases (75%), good results were found in 2 cases (16.67%), fair results from 1 case (8.33%).

Conclusions: In conclusion early intramedullary fixation and exposed bone coverage by muscle flap is very important for prevention of infection, minimizing bone death simultaneously enhances bone healing.


Open fracture, Gustilo type III-B, SIGN interlocking nail, Muscle flap

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Charnley J. The closed treatment of common fractures. 3rd edn. Livingstone, Edinburgh: 1961.

Gustilo RB, Anderson JT. Prevention of infection in the treatment of one thousand and twenty-five open fractures of long bones: retrospective and prospective analysis. J Bone Joint Surg [Am]. 1976;58:453-8.

Hansen ST Jr. Editorial. The type-IIIC tibial fracture: salvage or amputation. J Bone Joint Surg. 1987;69:799-800.

Georgiadis GM, Behrens FF, Joyce MJ, Earle S, Simmons AL. Open tibial fractures with severe soft-tissue loss: limb salvage com- pared with below-the-knee amputation. J Bone Joint Surg. 1993;75:1431-41.

Fairhurst MJ. The Function of Below-Knee Amputee Versus the Patient With Salvaged Grade I11 Tibia1 Fracture. Clin Orthop Rel Res. 1994;301:227-32.

Cierney G III, Byrd HS, Jones RE. Primary versus delayed soft tissue coverage for severe open tibial fractures: a comparison of results. Clin Orthop. 1983;178:54-63.

Russell GG, Henderson R, Arnett G. Primary or delayed closure for open tibial fractures. J Bone Joint Surg [Br]. 1990;7:125-8.

Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285-92.

Caudle RJ, Stern PJ. Severe open fractures of the tibia. J Bone Joint Surg Am. 1987;69(6):801-7.

Wheelwright EF, Christie J, McQueen MM. External fixation for type III open tibial fractures. Bone Joint J. 1990;72(5):801-4.

Hertel R, Lambert SM, Muller S, Ballmer FT, Ganz R. On the timing of soft-tissue reconstruction for open fractures of the lower leg. Arch Orthop Trauma Surg. 1999;119:7-12.

British Orthopaedic Association and British Association of Plastic Surgeons. A working party report. The early management of severe tibial fractures: the need for combined plastic and orthopaedic management. September, 1997.

Green AR. The courage to co-operate: the team approach to open fractures of the lower limb. Ann R Coll Surg Engl. 1994;76:365-6.

Byrd HB, Cierney G III, Tebbetts JB. The management of open tibial fractures with associated soft-tissue loss: external pin fixation with early flap coverage. Plast Reconstr Surg 1981;68:73-9

Gopal S, Majumder S, Batchelor AGB, Knight SL, Boer PD, Smith RM. ‘Fix and flap: the radical Orthopaedic and plastic treatment of severe open fractures of the tibia’. J Bone Joint Surg. 2000;82:959-66.

Gopal S, Giannoudis PV, Murray A, Matthews SJ, Smith RM. The functional outcome of severe, open tibial fractures managed with early fixation and flap coverage. Bone & Joint J. 2004;86(6):861-7.

Islam R. Result of management of open tibial shaft fractures with external skeletal fixation in adults, MS thesis, University of Dhaka. 1989.

Shahidullah M. Study on indigenous external fixator in the management of open fracture shaft of the tibia and fibula, MS thesis, University of Dhaka, 1996.

Tucker HL, Kendra JC, Kinnebrew TE. Management of unstable open and closed tibial fractures using the Ilizarov method. Clin Orthop Rel Res 1992;280:125-35.

Rahaman MH. Soft tissue Coverage by Gastrocnemius muscle flap in management of Gustilo type III B fracture of upper third of tibia-fibula, MS thesis, University of Dhaka. 2003.

Nazim M. Soft tissue coverage by combined gastrocnemius and soleus muscle flap in management of Gustilo type III B fracture involving upper two-third of tibia-fibula, MS thesis, University of Dhaka. 2004.

Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24:742-6.

Hansen ST Jr. Open fractures in orthopaedic trauma protocols. Hansen and Swinotowski, editors. New York: Raven Press; 1993.

Fischer MD, Gustilo RB, Varecka TF. The timing of flap coverage, bone-grafting, and intramedullary nailing in patients who have a fracture of the tibial shaft with extensive soft-tissue injury. J Bone Joint Surg Am. 1991;73(9):1316-22.

Worlock P, Slack R, Harvey L, Mawhinney R. The prevention of infection in open fractures: an experimental study of the effect of fracture stability. Injury. 1994;25:31-8.

Holden CEA. The role of blood supply to soft tissue in the healing of diaphyseal fractures: an experimental study. J Bone Joint Surg. 1972;54:993-1000.

MacNab I, de Haas WG. The role of periosteal blood supply in the healing of fractures of the tibia. Clin Orthop. 1974;105:27-33.

Gustilo RB, Kyle RF, Templeman DC. Fracture of the tibia and fibula. Fractures and dislocations. Volume 2. St. Louis: Mosby- Year Book. Inc; 1993: 901-941.

Gustilo RB, Merkow RL, Templeman DA. The management of open fractures. J Bone Joint Surg Am. 1990;72(2):299-304.

Tornetta P III, Bergman M, Watnik N, Berkowitz G, Steuer J. Treatment of grade IIIB open tibial fractures: a prospective random- ised comparison of external fixation and non-reamed locked nailing. J Bone Joint Surg [Br]. 1994;76:13-9.

Rhinelander FW. Tibial blood supply in relation to fracture healing. Clin Orthop. 1974;105:34-81.

Keating JF, O’Brien PJ, Blachut PA, Meek RN, Broekhuyse HM. Interlocking intramedullary nailing of open fractures of the tibia. Clin Orthop. 1997;338:182-91.

Tu YK, Lin CH, Su JI, Hsu DT, Chen RJ. Unreamed interlocking nail versus external fixator for open type III tibia fractures. J Trauma Acute Care Surg. 1995;39(2):361-7.

Zirkle LG. SIGN, Technique Manual of I.M nail insertion, extraction and data reporting protocols, Surgical implant Generation Network. Washington: 1-30.

Behrens F, Searls K. External fixation of the tibia. Basic concepts and prospective evaluation. Bone Joint J. 1986;68(2):246-54

Choudhury MA. Treatment of open tibial shaft fractures by Unreamed interlocking SIGN nail, MS thesis, University of Dhaka, 2000.