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26 Jul 2025
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Open Tibial Shaft Fracture with Fibular Instability Managed by Intramedullary Nailing

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Clinical Details

Clinical and radiological findings:  A 45-year-old female with a history of schizophrenia, currently homeless, was struck by a vehicle traveling at 45 mph. The patient sustained a type 3a (possibly 3b) open tibial fracture, classified as AO/OTA 42-B3, with a transverse tension-type laceration extending across the anterior and lateral compartments of the leg. Initial radiographs confirmed the tibial fracture and a displaced fibular fracture at the level of the soft tissue injury. No compartment syndrome was present. A stable head bleed was noted, with no additional injuries.

Preoperative Plan

Planning remarks:  The preoperative plan involved urgent irrigation and debridement (I&D) to remove gross contamination, followed by stabilization of the tibial fracture using intramedullary (IM) nailing. Due to the instability of the fibular fracture and its potential impact on soft tissue healing, retrograde flexible nailing of the fibula was planned using a guidewire from a humeral nailing system.

Surgical Discussion

Patient positioning:  The patient was positioned supine on the operating table, with the affected leg prepared for anterograde tibial nailing.

Anatomical surgical approach:  A longitudinal incision was made over the patellar tendon for access to the proximal tibia. The entry point for the tibial IM nail was established at the anterior edge of the tibial plateau. Following adequate debridement of the open wound, an intramedullary nail was inserted into the tibia. For fibular stabilization, a small incision was made distally over the lateral malleolus to facilitate retrograde insertion of a flexible nail.

Operative remarks: 

The surgical team noted that stabilization of the fibula was crucial in enhancing soft tissue healing and preventing further trauma during mobilization. The decision to use a guidewire from a humeral nailing system for fibular fixation was based on cost-effectiveness and availability. The wound closure was achieved with some tension, raising concerns about potential wound healing complications.

Postoperative protocol:   Postoperatively, the patient was placed in a splint with non-weight bearing (NWB) instructions for 6 weeks to allow for initial soft tissue healing. Progressive weight bearing as tolerated (WBAT) was planned after this period, contingent on wound healing and radiographic evidence of fracture consolidation.

Follow up:   Not specified.

Orthopaedic implants used:   Tibial intramedullary nail, retrograde flexible nail (humeral guidewire).

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