Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table to facilitate access to both the femur and tibia.

Anatomical surgical approach:  An extensile lateral approach was utilized for the femur, allowing for thorough debridement and irrigation of the open fracture site. For the tibia, a medial approach was employed, using a distractor to restore length after fibular fixation. This approach also facilitated access for vascular repair and fasciotomies.

During femoral fixation, devitalized bone segments were used as templates before being discarded post-nailing. The anterior intercalary fragment retained good muscle attachment, suggesting potential for healing, though bone grafting may be necessary. Intraoperatively, upon achieving tibial length restoration, a vascular injury occurred, managed with digital pressure and a sterile tourniquet until vascular surgery performed a sidewall repair. Fasciotomies were completed prior to final fixation.

Postoperative protocol:   Postoperatively, the patient received a split-thickness skin graft (STSG) for fasciotomy wound coverage. The leg remained well perfused.

Follow up:   Not specified

Orthopaedic implants used:   Intramedullary nail for femur fixation, bridging plate for tibial fixation, distractor for length restoration, sterile tourniquet for vascular control.