Debridement and External Fixation for Bilateral Neglected Open Tibial Shaft Fractures

Abstract

Open tibial shaft fractures represent a significant clinical challenge, particularly when presentation is delayed and wounds have become infected. This case demonstrates the surgical management of bilateral neglected open tibial shaft fractures in a young adult male who presented three weeks after initial injury from a motor vehicle collision in rural Malawi. He also suffered a bimalleolar fracture of the left ankle. The patient had grossly contaminated wounds with exposed bone and signs of infection bilaterally. The key procedural steps included aggressive irrigation and debridement of necrotic and infected tissue, skeletal stabilization with external fixation, local antibiotic therapy with gentamicin-impregnated collagen pellets, and soft tissue coverage with primary wound closure and a rotational subcutaneous flap on the left leg. External fixation is an essential treatment modality for open fractures with severe soft tissue injury when internal fracture fixation is not possible, especially in delayed cases with early signs of infection. This allows for staged management, repeated wound access, and preservation of blood supply while providing adequate stability for bone healing and soft tissue rest. This technique is particularly valuable in resource-limited settings where staged reconstruction and damage control orthopaedics are essential. The bilateral nature of these injuries, prolonged contamination period, immunocompromised status, and need for complex soft tissue reconstruction make this case unique and highlight the principles of managing neglected open fractures in challenging clinical circumstances.

Keywords

Surgical flaps; neglected fracture; open fracture; bimalleolar fracture; global health; tibial fractures.

Case Overview

Background

Road traffic injuries are the leading cause of death for individuals aged 5–29 years globally, with 93% of the 1.35 million annual road traffic deaths occurring in low- and middle-income countries (LMICs).¹ In sub-Saharan Africa, the road traffic mortality rate is 26.6 per 100,000—nearly three times higher than in Europe—and the economic cost of these injuries consumes 5% of GDP in low-income countries.² In Malawi specifically, tibial/fibular fractures represent the second most common fracture type (17% of all fractures), with road traffic injuries being the most common mechanism for open tibial fractures (68% of cases).^3,4 Fracture-related infection rates in sub-Saharan African settings reach 31.4% for open tibial fractures, with delayed presentation being a critical predictor—a 6-hour delay to first wound debridement increases infection odds 8-fold.⁵ Antibiotic administration 120 minutes or more after presentation to the emergency department is associated with significantly increased odds of wound infection (2.4-fold greater odds), which is a particular concern in rural Malawi, where delayed presentation and high patient volumes are common.⁶ Systemic antibiotics, such as ceftriaxone given in this case, are a critical adjunct to surgical management, as early administration within 1–3 hours of injury significantly reduces wound infection rates in open fractures.⁷

This patient presents with a complex, bilateral limb-threatening injury pattern: bilateral open tibial/fibular fractures with grossly contaminated, frankly infected wounds and exposed bone, compounded by a left bimalleolar ankle fracture—presenting 3 weeks after injury. The combination of bilateral involvement, established infection, severe soft tissue compromise, and polyarticular injury creates a surgical challenge requiring multistage reconstruction with significant risk of limb loss, chronic infection, and long-term disability. The staged approach—aggressive irrigation and debridement,⁸ bilateral external fixation with ankle-spanning fixation on the left,⁸ and primary wound closure and rotational flap coverage of exposed bone⁹—directly addresses each component of this complex injury.

Focused History of the Patient

The patient is a 32-year-old male farmer from rural Malawi who presented with bilateral open fractures of the lower extremities to Mzuzu Central Hospital. These injuries were sustained after being hit by a motor vehicle approximately 3 weeks prior to presentation. Both lower extremities demonstrated grossly contaminated open wounds with purulence and exposed bone. There was also an ankle fracture on the left side.

Due to the limited availability of resources at Mzuzu, minimal bloodwork was available and there was no medical comanagement or operative clearance prior to the time of surgery. While past medical history was not well known to the patient, they were receiving antiretroviral therapy and diclofenac from the time of admission, and received a single dose of ceftriaxone for the open wounds—this is the standard available antibiotic at Mzuzu.

Given the degree of soft tissue compromise and frankly infected appearance, the patient was planned for surgical irrigation and debridement, external fixation, and soft tissue coverage of exposed bone. Although the left ankle fracture was closed, its proximity to the open injuries was felt to increase the risk of contamination if open reduction and internal fixation were to be attempted, so the decision was made to extend external fixation to span the ankle. The decision to leave the wounds open or attempt closure was to be made intraoperatively depending on the quality of soft tissues and adequacy of debridement achieved.

Physical Exam

On initial examination, this patient was sitting comfortably in bed, breathing room air without supplemental oxygen. Both lower extremities had posterior long leg splints with soft dressings covering multiple soft tissue injuries bilaterally, some with purulent drainage (Figures 1–3). There was no active bleeding on exam by the orthopaedics team. He was able to grossly fire extensor hallucis longus and flexor hallucis longus with intact peripheral nerve sensation in all distributions of the feet and intact dorsalis pedis pulses bilaterally. There was significant tenderness to palpation throughout the legs and ankles bilaterally. Range of motion examination was deferred in the setting of his unstable fractures. 

Figure 1. Initial clinical exam photo of bilateral lower extremities.

Figure 2. Initial clinical exam photo of right lower extremity soft tissue wound.

Figure 3. Initial clinical exam photo of left lower extremity soft tissue wound.

Imaging

Preoperative plain radiographs were obtained of both lower extremities. The commonplace “rule of twos” would generally be recommended for the workup of suspected bony injury. For example, two perpendicular views, two joints (the included bone or joint as well as that above and below), at two times (pre- and postoperatively). However, only necessary imaging of the suspected injury site was obtained in this case due to limited availability of imaging resources (including for example, availability of technicians and high demand due to the number of patients requiring radiography). On the right side, this showed a comminuted distal third tibial shaft fracture with an associated same-level fibular fracture (Figures 4 and 5). On the left, this demonstrated a proximal fibular fracture and tibial shaft fracture, as well as a bimalleolar (medial and lateral malleoli) fracture of the left ankle (Figure 6).

Figure 4. Preoperative anteroposterior plain radiograph of the distal right lower extremity showing comminuted distal third tibial shaft fracture with an associated same-level fibular fracture.

Figure 5. Preoperative anteroposterior plain radiograph of the right lower extremity showing comminuted tibial shaft fracture.

Figure 6. Preoperative anteroposterior plain radiograph of the distal left lower extremity showing proximal tibial shaft fracture with associated fibular head fracture and bimalleolar ankle fracture.

Additional imaging to consider would include CT scans or additional radiographic views. An additional mortise view obtained with the left ankle in 15–20 degrees of internal rotation could help to assess joint congruency and syndesmotic integrity, and characterize other potential fractures not visible on standard anteroposterior and lateral views.¹⁰ A CT scan would be ideal for operative planning in a high-resource environment with this high-energy polytrauma patient with complex injuries, given it could help to determine extent, displacement, comminution, intra-articular extension, and associated injuries not otherwise seen. This includes not only musculoskeletal injuries, but also CT imaging for associated vascular or soft tissue injuries that are critical to the patient’s care (e.g., CT angiography). Additionally, plain radiographs had 78% sensitivity for talar fractures compared to CT in one study, and CT scans changed the treatment plan in 23% of foot and ankle cases in another recent study with 40% of patients having at least one missed fracture on plain radiography.¹¹

However, given the resource-limited setting of Mzuzu, this patient received the essential and pragmatic imaging necessary for characterizing the injuries present and allowing the initial surgery to be planned accordingly.

Natural History

Tibial shaft fractures typically achieve union in 61% of cases with a mean healing time of 17 weeks, though delayed union occurs in 26% (mean 35 weeks) and nonunion in 15% (mean 69 weeks), with open fractures carrying an 8.2-fold increased risk of nonunion.¹² 

Long-term outcomes show that 78% of patients with malleolar fracture achieve good or excellent ankle function at a mean follow-up of 17.8 ± 2.0 years, though 40–47% experience persistent pain and work-related disability at 1 year postinjury.¹³ Bimalleolar fractures demonstrate poor outcomes, with only 70–82% achieving good functional outcomes at long-term follow-up and 5 times the odds of developing complications in comparison to even isolated unimalleolar fractures.¹⁴

Options for Treatment

The primary treatment options in open tibial and fibular fractures include deciding between immediate definitive fixation (such as with intramedullary nailing for both shaft fractures and plate and/or screw fixation for the left ankle fracture) and staged management with external fixation (with or without serial debridement) followed by delayed definitive fixation with immediate or staged soft tissue coverage if necessary.

Rationale for Treatment

In this patient, with delayed presentation of bilateral open tibial fractures and grossly infected open wounds, a staged fixation approach is necessary. Active infection,⁸ a compromised soft tissue envelope,¹⁵ and the high likelihood of biofilm formation¹⁶ make urgent, aggressive surgical debridement the essential first operative step. Intraoperative debridement also allows for accurate assessment of the true extent of soft tissue and osseous injury.

The decision was made to perform thorough debridement of all wounds. If adequate debridement could be achieved—as evidenced by healthy, viable tissue margins—primary wound closure would be attempted with close postoperative wound monitoring.

Active infection contraindicated internal fixation due to the risk of hardware colonization and chronic osteomyelitis. External fixation was selected for stabilization of the bilateral tibial shaft fractures. The left bimalleolar ankle fracture, given its proximity to the ipsilateral open tibial wound and risk of contiguous infection spread, was also deemed unsuitable for internal fixation. The external fixation construct was therefore extended across the ankle joint to provide provisional stabilization while minimizing the risk of introducing hardware into a potentially contaminated field.

Definitive internal fixation and soft tissue coverage were to be considered at a later stage, contingent upon successful infection control and development of a healthy soft tissue envelope.

Special Considerations

Given this patient’s 3-week delay to presentation with contaminated open fractures, the prognosis is particularly concerning. A prospective cohort study from Malawi found that adults with open tibial fractures had poor function and quality of life at 1 year postinjury (mean SMFA score 10.5–14.9), with delayed definitive fixation after 5 days carrying 5-fold greater odds of infection compared with early management within 2 days.^4,5 In sub-Saharan African settings, fracture-related infection rates reach 31.4% for open tibial fractures, with a 6-hour delay to first wound washing being an independent predictor of infection.⁵ It was imperative to have proper surgical debridement and fixation in this patient given there was already an infection, but immediate management should remain paramount for similar polytrauma patients—especially in low-resource environments.

Discussion

This case presents the surgical management of bilateral neglected open tibial shaft fractures with an associated left bimalleolar ankle fracture in a young male polytrauma patient who presented three weeks after initial injury (pedestrian vs motor vehicle) with grossly contaminated wounds, exposed bone, and signs of infection. The unique and noteworthy aspects of this case include the bilateral nature of the injuries, the prolonged period without treatment leading to severe soft tissue compromise, and the need for complex reconstructive techniques including rotational flap coverage in a resource-limited setting. The nature of the case, being an open fracture with delayed presentation, is what makes the case management difficult. However, this is not an uncommon scenario in Malawi and similar settings where more than 12% of patients with open fractures present after one week of injury, further complicating management. The complexity of delayed, polytraumatic open fractures is compounded by existing limitations in resources in this setting to manage the case in a timely manner, including equipment availability, treatment cost, and operating room availability.

Preoperative planning for this case required careful consideration of multiple competing priorities in a resource-limited environment where reconstructive options are inherently restricted. The standard of care treatment for open fractures aims to control infection (early antibiotic initiation and adequate debridement), address soft tissue defects, and provide appropriate skeletal stabilization. The three-week delay since injury with established infection dictated an aggressive debridement to attempt eradication of the infection. Although adequate debridement is the single most important factor in attaining good outcomes, it may result in further soft tissue loss, requiring more advanced options for soft tissue coverage of exposed bone. A key consideration was the placement of the external fixators in order to preserve potential flap options including local perforating vessels and harvest flap sites—essentially balancing stability with planned soft tissue reconstruction. This was further complicated by the bimalleolar ankle fracture necessitating ankle-spanning fixation on the left, requiring pin placement in anatomically safe zones while maintaining adequate working corridors for potential flap inset. While these competing priorities are not unique to the low-resource setting and careful planning would be important in any setting, reduced availability of equipment and plastic surgical specialty providers, especially with microsurgical capabilities to perform free flap reconstruction, further limited treatment options. 

Given the severity of injuries, prolonged contamination, and immunocompromised status, extensive preoperative counseling was essential. The patient was informed that treatment would be staged and that the initial surgery would focus on infection control through aggressive debridement, skeletal stabilization with external fixation, and assessment of soft tissue viability. He was counseled that the extent of soft tissue loss and infection might necessitate multiple procedures and that limb salvage could not be guaranteed; amputation remained a possibility in the future if infection could not be controlled or tissue viability was insufficient for reconstruction. Thorough counseling is particularly critical in resource-limited settings where free tissue transfer may not be feasible, delayed presentation increases the risk of chronic infection and nonunion, and patients may be primary breadwinners facing potential permanent disability. Language barriers and cultural considerations further emphasize the need for clear, realistic communication about expected outcomes and treatment timelines.

Key aspects of the surgical management of infected fractures include adequate debridement and irrigation, fracture stability, dead space management, and adequate soft tissue coverage. The surgical approach prioritized staged management under spinal anesthesia. This case shows the initial aggressive excisional debridement of all wounds, bilateral skeletal stabilization using external fixation, and soft tissue coverage. Currently, the approach for soft tissue defect management in lower limbs has two major schools of thought: the so-called "reconstructive ladder" where a stepwise approach starting with simple procedures and moving towards more complex is used to achieve adequate closure, and the more recent "reconstructive elevator," which uses creative thought and modern methods to prioritize ideal form and function. The latter is considered best overall for appropriately selected individuals and in settings where it can be easily performed. In contrast, the "reconstructive ladder" approach is still a viable option in settings similar to that of this case. Soft tissue coverage was achieved with primary closure with Stimulan placed prior to closure, but wounds were carefully monitored postoperatively for infection and may require further debridement. A rotational flap was needed to achieve primary closure on the left. On the right side, an external fixator was applied spanning the tibial shaft fracture with distal pins positioned in the distal tibia avoiding injury to neurovascular structures and crossing tendons. The left side required a monoplanar construct for the tibial shaft, extended into a delta frame configuration spanning the ankle distally. Given the three-week exposure of bone and significant contamination, local antibiotic therapy with Stimulan and gentamicin beads was employed, and definitive soft tissue coverage was achieved with a rotational flap.

The procedure was successfully completed with an operative time of 81 minutes and estimated blood loss (EBL) of 150 mL. The patient was followed in the orthopaedics ward on pethidine, intravenous (IV) ceftriaxone, and paracetamol for 9 days by the operative team with every other day wound dressing changes over the rotational flap (Figure 7). Postoperative x-rays were also taken on the bilateral external fixation constructs (Figures 8–10).

Figure 7. Postoperative day 2 clinical exam photo of left lower extremity soft tissue injury covered with surgical subcutaneous rotational flap.

Figure 8. Postoperative proximal anteroposterior plain radiograph of bilateral lower extremity external fixator constructs.

Figure 9. Postoperative distal anteroposterior plain radiograph of bilateral lower extremity external fixator constructs.

Figure 10. Postoperative lateral plain radiograph of right lower extremity external fixator construct.

The patient stayed inpatient for a total of 96 days due to persistent pin-site infections that eventually were controlled with repeated debridement and antibiotics, persistent issues with ambulation with the assistance of physiotherapy and crutches, and difficulty with pain control. At 3-month follow-up, the patient had a couple of small sinus tracts that had formed oozing pus, “a lot” of pain, as well as some continued issues with ambulation and taking care of themselves independently. This is relatively consistent with existing literature on outcomes for open tibial shaft fractures in Malawi, which tend to have poor outcomes in terms of return to function and quality of life at 1 year in a cohort of 287 participants. At 6 weeks, which is more comparable to the follow-up we currently have available for this patient, this cohort was also showing delays in returning to function. The authors found that central orthopaedic management including early definitive fixation may be beneficial for patients. However, our case shows the difficulty in balancing soft tissue management and bony fixation in complex cases, where bilateral, multiple, and open injuries with a delayed presentation make early definitive management difficult.

Modern external fixation evolved from Ilizarov's circular fixator (1950s–1960s), which established principles of tension-stress tissue regeneration and staged management.¹⁷ The protocol of external fixation followed by delayed intramedullary nailing was established in the late 1980s, with a deep infection rate of only 5%.¹⁸ Future treatment possibilities include potential changes in early versus delayed definitive fixation in certain settings; meta-analyses show intramedullary nailing has lower rates of superficial infection, pin-track infection, and malunion compared with external fixation.¹⁸ However, in resource-limited settings, a randomized controlled trial in Tanzania found no significant difference in composite outcomes between the two approaches (18.0% vs 21.9%), and this is currently not the standard of care when resources permit for gross infection, especially in delayed presentations such as this one.¹⁹ For rotational flaps, 89% success rates are achievable by orthopaedic surgeons in African trauma centers, with early coverage (< 7 days) significantly reducing infection (17.6% vs 72.2%).⁹ 

Emerging technologies include hexapod fixators with computer-aided correction, 3D-printed, patient-specific devices, adjustable stiffness constructs, and sensor-enabled "smart" fixation systems for real-time healing monitoring.^20,21

Key Summary

• External fixation remains a key tool in appropriately selected patients, enabling a safe staged management of complex open fractures.
• Infection control by aggressive debridement and local as well as systemic antibiotics are very important considerations before definitive fixation.
• Local soft tissue reconstruction is a viable and effective option if carefully planned.

Equipment

This case utilized donated external fixators and antibiotics based on what was locally available, including Synthes clamps (West Chester, PA) on the right and Stryker Hoffmann clamps on the left (Kalamazoo, MI). Donated Stimulan (Biocomposites, Wilmington, NC) and gentamicin antibiotic beads were also used.

Disclosures

Kiran J. Agarwal‑Harding serves as a Section Editor at JOMI for Orthopaedic Surgery and has not been involved in the editorial processing of this article in any capacity other than as an author.

Artificial intelligence was used to enhance the figures, and all figures were manually reviewed and verified for accuracy.

We report no other conflicts of interest, financial relationships, funding, sponsorship, equipment support, or other relationships that could be perceived to influence the content of this article.

Statement of Consent

The patient referred to in this video article has given their informed consent to be filmed and is aware that information and images will be published online.

Acknowledgments

We would like to acknowledge the team from the Mzuzu Orthopaedic Support and Training program, including the local operating room staff (nurses, transport staff, anesthesia clinical officers), local orthopaedic surgery team (Bitiel Banda, MD, and orthopaedic clinical officers), program staff (Gomezgani Jenda), and the Foundation for Orthopaedic Trauma who funded this program. We would also like to sincerely thank the patient, who agreed to the filming and dissemination of this procedure and its details.