Endgames Picture Quiz

The management of open tibial shaft fractures

BMJ 2012; 345 doi: https://doi.org/10.1136/bmj.e6348 (Published 28 September 2012) Cite this as: BMJ 2012;345:e6348
  1. Nada Al-Hadithy, specialist trainee year 4 in plastic and reconstructive surgery1,
  2. Anna Panagiotidou, specialist trainee year 3 in trauma and orthopaedic surgery2
  1. 1St John’s Hospital, Plastic Surgery Department, Livingston EH54 6PP, UK
  2. 2Stanmore National Orthopaedic Hospital, Stanmore, UK
  1. Correspondence to: N Al-Hadithy nadaucl{at}yahoo.com

A 28 year old cyclist was hit by a car in a road traffic incident. It was a side on collision, and his left leg was caught between a bollard and the bumper of the car. The saloon car had been travelling at 30 miles per hour (48 km/h). The cyclist’s left leg had been trapped for 10 minutes before being freed. He had no medical history, was taking no drugs, and had no allergies.

On arrival at the emergency department, he was managed according to the advanced trauma life support protocol with a primary survey. His cervical spine was immobilised, his airway was clear, breathing was normal with saturations of 100%, and he was haemodynamically stable, with a Glasgow coma scale of 15 out of 15. He had an 11 cm wound over the anterior part of the left lower leg with an open tibia fracture (fig 1). He was neurovascularly intact with a capillary refill of less than 2 seconds. A trauma series was ordered with additional radiographs for the affected limb.

Fig 1 Left leg with open tibial shaft fracture held in a gutter splint


  • 1 How would you classify this injury?

  • 2 How would you manage this patient initially?

  • 3 How should this patient be managed definitively?

  • 4 When should definitive management be carried out?

  • 5 What specific complications would you expect with this injury?

1 How would you classify this injury?

Short answer

Open fracture of the tibia, Gustilo-Anderson type 3b.

Long answer

Tibial shaft fractures are the most common long bone fracture and usually affect the fibula too. The highest incidence is in young men—8 per 100 000 persons.1 These fractures usually occur as a result of a high energy impact, and the most common causes are sports injuries and road traffic injuries.2

The Gustilo-Anderson classification describes the contamination, neurovascular status, and soft …

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