A 40-year-old woman is struck by a motorcycle while crossing the road. She is brought to the emergency department shortly after 10 p.m. These are her radiographs and clinical photo- graphs of her leg.
- Describe the photographs and x-rays.
The clinical photographs show the left leg, which is swollen and deformed. There is a wound over the anteromedial aspect of the middle third of the leg. The radiograph show a displaced and comminuted fracture of the midshaft of the tibia. The clinical photograph and radiograph clearly indicate an open fracture.
- Describe your initial investigation and management.
This is a high-energy injury and the patient should be treated along established ATLS principles. With respect to this specific injury I would take a careful history from the patient and examine the limb looking to confirm the state of the soft tis- sues, any gross contamination which I would remove, additional wounds or soft tissue injury, the neurovascular status of the limb and any features suggestive of compartment syndrome. I would look closely for any fracture or instability affecting the femur, patella, hip or adjacent joints.
Guidelines for the management of severe lower limb injuries have been for- malised by the BOA/BAPRAS and are summarised in BOAST 4. I would take a clinical photograph of the limb before dressing the wound with saline-soaked gauze and splinting the limb in an above knee backslab. I would administer intravenous cefuroxime (1.5 g) and tetanus toxoid. I would request periodic assessments for
Midshaft Diaphyseal Tibia Fracture 
pain, evidence of compartment syndrome and the neurovascular status of the limb. I would perform a complete secondary survey.
This patient will require surgery. I would prepare them for surgical wound debridement and fracture stabilisation as a joint case with orthopaedic and plastic surgery input on the routine trauma list the following day.
- How would you manage this injury and patient definitively?
Having confirmed that this is an isolated injury, I would obtain consent from the patient for wound debridement and surgical stabilisation. This would be performed with my plastic surgery colleagues the next day during working hours unless there was a limb-threatening injury such as a vascular injury needing repair or develop- ing compartment syndrome when emergent surgery would be necessary. Regular intravenous cefuroxime (750 mg) is given eight hourly until the debridement is per- formed. The debridement includes extension of the wound as required in order to allow a formal assessment of the soft and bony tissues in theatre where contami- nated or devitalised tissue is removed and I would wash the wound out with at least 6 litres of warmed saline. Loose bony fragments are assessed by the ‘tug test’ to see if they have any appreciable soft tissue attachments and by implication, a blood supply to suggest that they remain viable.
Following the debridement, the soft tissue envelope and bony stability are reas- sessed. Options for surgical stabilisation would include a temporary external fix- ator, reamed intramedullary nailing or Ilizarov or Taylor Spatial Frame. Where the wound can be safely closed or covered at the index procedure, my preference would be to treat this with an intramedullary nail. Antibiotics are continued until defini- tive wound closure or for 72 hours, whichever occurs soonest, and close observation is required for any signs of compartment syndrome
