Tibial fractures
Anatomy
 Tibia—85% of weight bearing
 Fibula—for muscle attachment and ankle stability, NWB bone
Tibial blood supply

Sources
1. nutrient artery
a. branch of posterior tibial artery, penetrates tibialis post
b. enters junction of upper and middle 1/3rd , traverses cortex over 5cm
2. metaphyseal vessels
3. periosteal vessels
a. derived from vessels of limb and run perpendicular to long axis of bone—
not interrupted in fractures if Periosteum intact
4. apophyseal – vessels from insertion of muscles/ligaments

nutrient artery and metaphyseal vessels are endosteal supply—linear pattern. These
are interrupted in fractures .

Cortical blood supply
o inner 2/3=endosteal supply
o outer 1/3=periosteal supply

Medullary(endosteal) supply is dominant in all healing phases of undisplaced fractures

Periosteal vessels alone are sufficient to support normal fracture repair

All veins drain to the periosteal surface
Classification
Gustillo 1976, 1984
Type I
Laceration: Less than 1 cm long.
Contamination: Clean puncture (Compound from within)
Soft-Tissue: Little damage. No crush
Fracture: Usually simple transverse or short oblique. V. little comminution.
Type II
Laceration: More than 1 cm long.
Contamination: Moderate contamination.
Soft-Tissue: No extensive soft-tissue damage, flap or avulsion. Slight or
moderate crushing.
Fracture: Moderate comminution.
Type III

Laceration: Extensive Skin damage
Contamination: High degree of contamination.
Soft-Tissue: Extensive soft-tissue damage to skin muscle and neurovascular
structures.
Fracture: Great deal of comminution and instability.
Includes(regardless of wound size):
High Velocity Trauma.
Gunshot injuries.
Farm injury.
IIIA
Adequate soft tissue coverage of a fractured bone despite extensive laceration
or flaps. High Vel Trauma with segmental or severely comminuted
fractures regardless of laceration size
IIIB
Extensive soft tissue injury with periosteal stripping and bony exposure.
This is usually associated with massive contamination.
IIIC
Open fracture associated with arterial injury requiring repair. Regardless of
wound size or soft tissue injury.
infection rates of: type I 0-2%, type II 2-7% and, type III 10-25% (Gustillo 1990)
Gustillo 1987
Sepsis rate
Amputation rate
IIIA
5% (7%)
2.5%
IIIB
28% (10-50%)
5.6%
IIIC
8% (25-50%)
25%


criticism of this classification
o interobserver variability - apart from the type IIIC injury, there are no absolute
rules that dictate that a specific injury falls into a particular class (60%
concordance rate)
To improve the accuracy of the classification of open fractures, the extent and severity of
the injury should be assessed only during surgery, after wound exploration and
débridement, and not at presentation in the emergency department.
Byrd 1985

In 1985, Byrd et al formulated a new and simplified classification of fractures, based on
the mechanism of the trauma and bone and soft tissue lesion. They recognized the
importance of both the direct and indirect traumatic forces responsible for the bony
lesions. Their classification is as follows:

Type I
o
o
o

Type II
o
o
o
o


Low-energy fractures
oblique or spiral fracture
clean-cut laceration smaller than 2 cm
Medium-energy trauma
displaced or comminuted fracture
laceration larger than 2 cm
myocutaneous contusion
Type III
o High-energy trauma
o severely displaced or comminuted fracture; segmental fracture or bone defect
o laceration larger than 2 cm
o loss of skin and muscle substance
Type IV
o High-energy bursting trauma
o crushing or avulsion with arterial damage requiring microvascular repair
Mangled Extremity Severity Score Johansen, 1990
Skeletal / soft-tissue injury
Low energy (stab; simple fracture; pistol gunshot wound)
Medium energy (open or multiple fractures, dislocation)
High energy (high speed MVA or rifle GSW)
Very high energy (high speed trauma + gross contamination)
Limb ischemia
Pulse reduced or absent but perfusion normal
1
2
3
4
1*
5
Pulseless; paresthesias, diminished capillary refill
Cool, paralyzed, insensate, numb
Shock
Systolic BP always > 90 mm Hg
Hypotensive transiently
Persistent hypotension
Age (years)
< 30
30-50
> 50
2*
3*
0
1
2
0
1
2
* Score doubled for ischemia > 6 hours


According to Johansen’s study - a MESS score of greater than or equal to 7 had a
100% predictable value for amputation.
A prospective evaluation of the MESS (and also Limb Salvage Index (LSI); the Predictive
Salvage Index (PSI); the Nerve Injury, Ischemia, Soft-Tissue Injury, Skeletal Injury,
Shock, and Age of Patient Score (NISSSA); and the Hannover Fracture Scale-97 (HFS97)) by Bosse (J Bone Joint Surg Am 2001) did confirm that low scores could be used to
predict limb-salvage potential but failed to support the validity of the scores as predictors
of amputation.
Management
Early management considerations
1. patient
a. resuscitation
b. other injuries
2. injured limb
a. ischaemia – reduce fractures immediately
b. compartment
3. wound
a. priority is to prevent further contamination of the wound
b. avoid multiple dressing changes in ED - raises the ultimate infection rate by a
factor of 3 to 4
4. Fracture
a. Position limb safely and splint fracture
Importance of antibiotics
 Patzakis 1974 was the first to conclusively demonstrate the importance of antibiotics in
open fracture. In a randomised prospective trial he looked at 310 patients with open
fractures and divided them into three groups: The infection rate in Group I who received
no antibiotics was 13.9%, in Group II who received penicillin and streptomycin was 9.7%
and in Group III who received cephalothin was 2.3%. The difference between groups I
and III was statistically significant.
 The lowest reported infection rate with various systemic antibiotic regimens occurred
6




with combination therapy with a cephalosporin and an aminoglycoside.
Quinolones are a promising alternative to intravenous antibiotics because they offer
broad-spectrum antimicrobial coverage, are bactericidal, can be administered orally with
less frequent dosing than intravenous antibiotics, and are well tolerated clinically.
soon as possible after the injury occurs because a delay >3 hours increases the risk of
infection.
duration of therapy should be limited to 3 days, with repeated 3-day administration of
antibiotics at wound closure, bone grafting, or any major surgical procedure.
Local administration of gentamicin soaked PMMA (polymethylmethacrylate) beads
reduces the infection risk further. Advantages:
a. a high local concentration of antibiotics, often 10 to 20 times higher than that with
systemic administration
b. a low systemic concentration, which protects from the adverse effects of
aminoglycosides
c. a decreased need for the use of systemic aminoglycosides;
d. sealing of the wound from the external environment with film dressing.
Cessation of Smoking
 Clin Orthop Relat Res. 1999 Aug;(365):184-200.
 146 closed and Grade I open tibia shaft fractures treated with cast immobilization,
external fixation, or intramedullary rod fixation
 Two of the 44 patients who smoked had nonunions at the 1-year followup, whereas
none of the patients who did not smoke had nonunions.
 median time to clinical healing for patients who smoked (269 days) was significantly
greater than that of patients who did not smoke (136 days).
 There was a 69% delay in radiographic union in the group that smoked as interpreted
by a radiologist blinded to the two groups. Statistical differences in clinical and
radiographic healing rates
 The current data suggest that tibias of patients who smoke who require treatment with
intramedullary nailing or external fixation require more time to heal than do those of
patients who do not smoke.
 Am J Orthop. 2002 Sep
 retrospectively review of 105 patients with 110 open tibia fractures treated with
external fixator or intramedullary nail
 Smokers had a union rate of 84% (52/62), and nonsmokers had a union rate of 94%
(45/48), P = .10. For smokers in one arm of the study, time to union was significantly
longer (P = .01), and there were more complications (P = .04).
 Smoking decreased unions, slowed healing, and increased complications.
External bony fixation
 Because of the high risk of infection, Gustillo recommended external fixation against IM
nailing or plating.
 A recent meta-analysis of open tibial fracturesrevealed that nail fixation is associated with
lower reoperation rates, lower malunion rates, and lower infection rates than external
fixation. It must be noted that the data apply to all grades of open tibial fractures, not
necessarily Gustilo III’s as a separate group.
7
Early Flap coverage
 Marko Godina Early microsurgical reconstruction of complex trauma of the
extremities. PRS 1986
 532 patients with lower extremity wounds divided into 3 groups
 Group 1
coverage within 72 hours of injury
 Group 2
coverage between 72 hours and 3 months
 Group 3
coverage after 6 months
Group 1
Group 2
Group 3


Flap
failure
0.75%
12%
9.5%
Infection
1.5%
17.5%
6%
Time to
union
6.8months
12.3months
29months
LOS
No. operations
27 days
130days
256days
1.3
4.1
7.8
In a prospective review of open tibial fractures, Byrd advocated radical debridement of
bone and soft tissue with flap coverage in the first 5 to 6 days after injury (acute phase)
for the most severe injuries. The complication rate for Byrd Type III wounds averaged
18%. Fractures not treated by early muscle flaps predictably entered a colonized subacute
phase that extended from 1–6 weeks postinjury. Complications after treatment with flaps
during this phase averaged 50%. Some 4 to 6 weeks after untreated severe injuries, a
chronic phase begins that is characterized by a granulating wound, adherent soft tissue
and decreasing areas of infection. After soft tissue coverage, the complication rate for this
chronic group was 40%.
Issue is probably adequate debridement, copious irrigation and early coverage rather
than absolute time frame
Bony Reconstruction
 main aims of treatment are skeletal stabilisation, restoration of length and alignment, and
preservation of optimum function
 Segmental defects of greater than 2 cm are unlikely to heal spontaneously following
skeletal stabilisation alone.
 Those involving more than 50% of the circumference can heal spontaneously but often
require additional treatment to restore normal volume and strength.
 Bone loss in certain anatomical locations has a more favourable prognosis due to better
blood supply and corresponding osteogenic potential.
 Ways to bridge a bony defect
1. Bone Graft
2. Bone Shortening
3. Bone Transport
4. Vascularized bone
5. Alloplasts and growth factors
8
Bone Grafting
 Cancellous bone graft for small defects - often complicated by stress fractures if used for
larger defects
 Cortical bone grafts indicated for larger defects
1. A long period for revascularization is required. A long incorporating and
remodeling time, undergoing creeping substitution, is necessary. Spontaneous
stress fractures may occur late (reported to occur as many as 3 y after surgery).
2. late stress fractures causes pseudoarthrosis at the fracture site in approximately
33% of these patients.
 Early bone grafting recommended (<12/52 post injury and post flap coverage)—reduces
time to union
 Best for well vascularised defects <6cm treated with IM nailing although larger defects
have been grafted by some units
 Helps if fibula is intact—acts as a strut
Bone shortening and staged reconstruction
 For defects in excess of 6 cm, one option is to shorten the bone at the time of the initial
surgery, apply a circular frame and create a corticotomy through a healthy area of bone
away from the zone of injury.
 The bone can then be lengthened at the same time as obtaining bony union.
 Should be considered if the associated soft-tissue defect is shorter than that of the bone.
Shortening the leg will reduce the size of the soft-tissue defect and may avoid the need for
a free flap.
 In the upper limb, shortening of 2 to 4 cm may be tolerated without significant
functional impairment, obviating the need for subsequent lengthening.
Bone transport
 use of a frame to carry out callotasis or bone transport to bridge a defect
 Circular frames (Illazarov) are now more popular than uniaxial devices since they confer
greater stability and there is more flexibility in the configuration of the frame.
 Gap defects 16-20cm reported with success
 During the second operation for removal of pins, bone grafting is recommended for
around the docking site to prevent fractures
 Disadvantages
o Main problem is the lengthy external fixation time (1 month for each cm of
reconstruction)
o Pin site infections
o Stiffness of adjacent joints
o Pain, neuropraxia due to stretching
o Docking site fractures
9
Vascularised bone graft
 May be free or pedicled
 Free bone graft
o Fibula most commonly used
o Wei FC (PRS 2005) - One-stage reconstruction of composite bone and soft-tissue
defects in traumatic lower extremities using:
 vascularized fibula osteoseptocutaneous flaps
 vascularized iliac osteocutaneous flaps
 vascularized rib transfers with serratus anterior muscle and/or latissimus
dorsi muscle transfers
o can be used to bridge defects of up to 20 cm
o advantage is that soft tissue reconstruction achieved at same time
o disadvantages
1. usually a mismatch in size when used in the lower limb to bridge femoral
or tibial defects and the graft may fracture. Prolonged partial weightbearing may be required to minimise the incidence of this complication.
2. limited application for metaphyseal defects due to constraints in shape
o A recent comparison of this method with bone transport in the femur indicated
that superior results were obtained with the latter method (J Orthop Trauma 2003)
o Most useful for reconstruction of forearm defects, although creation of a one bone
forearm is another option
 Pedicled fibula (tibialisation of fibula)
o large graft of ipsilateral fibula is raised on a pedicle of peroneal and anterior tibial
muscles and peroneal vessels. It is aligned and fixed to the tibia along its posterior
long axis providing a sound mechanical and biological basis for union.
Alloplasts and growth factors
 as yet, there is no osteogenic or osteoinductive material of proven clinical value for the
treatment of significant post-traumatic bone loss in humans.
 Osteoconductive materials such as calcium phosphate cement have been used to fill small
bone defects following fractures, notably in the distal radius, the proximal humerus, the
tibial plateau and the calcaneum
10

these materials are only suitable for use in relatively small contained metaphyseal
defects since they have poor resistance to torsional, shear or bending stresses. These
physical limitations and the absence of any osteoinductivity or osteogenicity render them
unsuitable for use in the presence of extensive bone loss.
Complications of Fractures
11
1. avascular necrosis
2. delayed union
a. Inadequate blood supply
b. Infection (and in any open fracture)
c. Insufficient splintage
d. Distraction of fragments (traction, intact fellow bone)
3. Non union
a. Excessive motion
b. Gap
c. Poor blood supply
4. Malunion
a. Primary – fracture never reduced
b. Secondary – reduction not held
c. Malunion in a child will remodel provided the fracture is near a bone end and
not mal-rotated.
Articular Reconstruction
 Small defects can probably be ignored if there is no instability of the joint.
 Larger defects will require consideration of the use of an allograft or an arthroplasty, in
small joints of the fingers, consider arthrodesis
 Fresh articular allografts following trauma have mainly been described in the knee,
usually for fractures of the tibial plateau (defects of more than 3 cm in diameter and 1 cm
deep) - indications for allografts are limited to younger patients with significant defects
 Arthroplasty is available for most joints and is indicated in older patients. For some joints,
such as the ankle, wrist and interphalangeal joints, fusion is a reasonable alternative.
Soft Tissue reconstruction
Principles
1. Early soft tissue coverage (3-7 days) after adequate debridement and fixation
2. Muscle that is traumatized, crushed, or affected by a compartment syndrome should not
be transferred; free muscle transfer should be used instead.
3. Fasciocutaneous flaps are useful when dead space is minimal, when the flaps are pliable,
and when they facilitate tendon gliding. They may restore sensibility to the affected area if
the flap remains innervated.
4. in the presence of severe osseous injury, use of rotational flaps was notably more likely to
lead to wound complications compared with free flaps
Musculocuneous vs random flaps for risk of infection
12

Mathes PRS 1990 – canine model
o bacterial counts were significantly lower in the musculocutaneous flap wound
o phagocytic activity of the leukocytes within musculocutaneous flap wound was
1.5 times greater than the leukocytes in the random-pattern flap
o intracellular bacterial killing ratio of the musculocutaneous flap leukocyte was 83
percent versus 26 percent in the random-pattern flap leukocyte, a significant
difference.
Musculocuneous vs fasciocutaneous flaps for risk of infection
 Mathes PRS 1986 - Canine model
o Area of skin necrosis secondary to bacterial inoculation was similar in the two flap
types.
o In wound spaces formed by the deep surface of the two flap types, a greater degree
of inhibition and elimination of bacterial growth and more collagen deposition
was seen in the musculocutaneous wound space than in the fasciocutaneous flap.
 Gosain PRS 1990 – canine model
o Muscle flap showed superior tissue ingrowth, rapid early augmentation of blood
flow during first 24 hours
o most rapid decline in bacterial counts at the undersurface of both flaps occurred
within 24 hours, dropping significantly lower within musculocutaneous flaps.
Musculocutaneous vs cutaneous flaps for bone revascularization
 Fisher PRS 1987
o muscle of the musculocutaneous flap had a blood flow three times that of the skin
of the cutaneous flap.
o muscle flap was superior to a cutaneous flap in revascularizing isolated bone
segments at 4 weeks.
Tissue expansion
 The primary application is to resurface areas of unstable soft tissue or unsightly scar.
 Because of high infection rates (5-30%), TE is more difficult in the leg than elsewhere.
 Good results can be expected in the buttocks or thigh, but below the knee, Manders
reports a failure rate of 50%.
 Expanders are usually placed subcutaneously (just above the fascia) and inflation
pressures should not exceed 40 mmHg to avoid compartment syndrome.
 Use as big an expander as possible.
 Plan for transverse, not axial advancement of tissue.
 The ankle and foot are not suitable for TE.
Thigh coverage
1. local transposition
a. muscle flaps - gracilis, vastus lateralis, TFL, rectus abdominis, rectus femoris
b. fasciocutaneous flaps – medial thigh, lateral posterior thigh, anterolateral
Proximal 1/3rd
1. keystone flap
13
2. vastus medialis
3. distally based vastus lateralis
a. partial necrosis not infrequent
4. medial/lateral gastrocnemius flap
a. disadvantages
i. volume of the distal part of the muscle is small and sometimes is unable to
provide enough coverage for large defects around the knee joint,
particularly at the suprapatellar region or across the midline (need both
gastrocnemius)
ii. knee stiffness
iii. bulky at pivot point
5. distally based anterolateral thigh flap
a. flap is centered in the middle of a line connecting the anterior superior iliac
spine to the lateral border of the patella (between rectus femoris and vastus
lateralis).
b. circle with a 3-cm radius is centered in the middle of this line. The majority of
perforators is in the inferior external quadrant of the circle.
c. based on the anastamoses between the descending branch of the LCFA and the
lateral superior genicular artery in the knee region.
d. a second perforator should be preserved as a precaution if based distally
e. advantages:
i. greater flexibility of size and shape
ii. better color and texture match
iii. less bulkiness
iv. allows for early mobilization – less stiffness
v. donor site closed primarily if the width < 8 cm
f. disadvantages
i. technically difficult – 40% of the perforators septocutaneous; 60%
musculocutaneous, coursing through vastus lateralis
ii. 5% have no identifiable perforator
6. proximally based soleus
7. saphenous artery flap (for above knee defects)
Middle 1/3rd
1. medial gastrocnemius flap (upper part of middle third)
2. soleus flap
a. workhorse flap
3. tibialis anterior turnover flap
a. Type IV muscle
b. For small defects involving subcutaneous border of tibia
4. others - FDL, EDL, EHL,FHL, PT, PB
Distal 1/3rd
 Beware using local flaps in diabetic patients with vascular disease
a. partial graft and flap loss is the rule rather than the exception.
 Challenging as skin here is tight, frequently oedematous and bone/tendon lies
subcutaneous
14

Requires good durability to resist shear and friction by walking/footwear
1. Ponten superflap (Type A fasciocutaneous flap)
2. Perforator adipofascial flap
a. Based on peroneus, posterior tibial perforators
b. lowermost perforators of the peroneal or posterior tibial artery were identified
preoperatively, and a straight incision through skin only was made proximal to this
perforator. With the skin flaps reflected, the adipofascial flap was than raised in
the subfascial plane. The perforators to be retained in the base were located and
the flap was then turned over to cover the defect, followed by application of a
split-thickness skin graft over the flap.
3. lateral supramalleolar flap
a. terminal perforator of the peroneal artery always emerges from the groove
between the tibia and the fibula, perforating the interosseous membrane
approximately 5 cm above the lateral malleolus, and then it divides into two
branches: an ascending cutaneous branch and a descending branch
b. flap based on this ascending branch and can be designed on the lateral aspect of
the lower leg, with an axis along the anterior border of the fibula.
designed on the lateral aspect of the lower leg, with an axis on the anterior border of the fibul, he
peroneal flap (PF), for reference, is designed more proximally, with an axis on the posterior border of
the fibula.
15
4. lateral calcaneal artery flap
a. LCA is a branch of the peroneal artery
b. exits from beneath the deep fascia 1.5cm proximal to the tip of the lateral
malleolus and 3.5cm posterior to the mid coronal plane of the fibula.
c. proceeded distally, passing 1.5cm anterior to the posterior superior corner of the
calcaneus
d. may be used for posterior heel defects <5cm
e. can be designed as a short (8.0 x 4.5 cm in the adult) vertical flap or a long (14.0 x
4.5 cm) flap that curves forward to the base of the fifth metatarsal.
5. dorsalis pedis flap
a. bad donor site
6. EDB flap
16
a. Defects <4cm2
7. reverse sural artery flap
a. based on the median superficial sural artery
b. better for lateral defects
8. reverse gastrocnemius
a. has been reclassified by Taylor as Type 2 flap with the additional supply by both
posterior tibial and peroneal vessels to the distal muscle belly.
9. soleus flap
a. Type II muscle
b. has three territories. The proximal part of the muscle is supplied by the branch(es)
of the distal popliteal artery. Distally, the medial aspect of the muscle receives
branches from the posterior tibial artery, which enter the deep surface of the
muscle, whereas the lateral aspect of the muscle receives branches from the
peroneal artery, which again enter the deep surface of the muscle
c. proximally based more reliable but less reach - epimysium can be scored to extend
the flap length
d. distally based – high risk of necrosis
10. distally based peroneus brevis
a. a type 4 flap – but has been reported for lateral ankle defects
b. location of distal pedicle within 6 cm from the lateral malleolus
11. free flaps
12. cross-leg flaps when microsurgical flaps are not feasible
a. At present cross-leg flaps are transferred as fasciocutaneous tissue units with a
length:width ratio of 3:1 or 4:1
b. Tend to have a high necrosis (40%) and infection (28%) rate.
17
Plantar reconstruction
 Requirements
1. Durability – need to tolerate shear forces
2. Preferably sensate
o Cutaneous sensation has not been shown to be critical in cases of plantar
reconstruction where the deep pressure sensation is intact.
o No difference in incidence of complciations has been found between
innervated and noninnervated flaps
 Options
1. Transposition, rotation, and V-Y skin flaps
o For defects <3cm2
2. Partial toe fillet and web space flaps
o based on digital arteries
o useful for small distal defects
3. Local muscle flaps
o Indicated for small defects only (<2-3cm)
o Most commonly
 abductor digiti minimi
 workhorse flap
 useful for lateral ankle and calcaneal defects.
 abductor hallucis
 useful for medial midfoot, heel, and ankle defects.
 extensor digitorum brevis
 anterior ankle defect
 flexor digitorum brevis
 useful for plantar heel defects.
 flexor digiti minimi muscles.
o base these proximally – most are type 2.
4. Medial plantar artery flap
o medial plantar artery emerges deep to the abductor hallucis muscle, then
travels between this muscle and flexor digitorum brevis muscle, continues
along the medial border of the foot, and anastomoses with the first plantar
metatarsal artery
o medial plantar nerve runs alongside and lateral to the artery
o Proximally based good for heel defects
 Requires neurolysis of medial plantar artery
 Division of abductor hallicus adds additional length
o Distally based
 supplied in a retrograde fashion by the communications with the deep
plantar arch.
 Disadvantage - lack of sensibility, the possibility of inadequate
retrograde arterial perfusion or retrograde venous drainage and its
potential limited anterior reach.
o Cross foot instep flap
 Reserved for complicated sole reconstruction
5. Plantar flap
o Based on lateral plantar artery and FDB
18
o for coverage of the heel, Achilles tendon, medial and lateral malleolus.
6. Free muscle flap and SSG
o For larger defects, has been the method of choice over fasciocutaneous flaps
 Sonmez PRS 2003 disputes this and found fasciocutaneous flap more
durable and more sensate than muscle/SSG.
19
o May PRS 1985
 muscle and SSG reconstruction – all patients ambulatory
 cutaneous sensibility may not be necessary for successful
reconstruction of the weight-bearing surface of the foot
o in general - Muscle flaps preferred for the deep and irregular defects or
chronic, open infected wounds.
o Main problem is interface between SSG and plantar skin
o prone to extensive tissue fibrosis and skin breakdown, particularly after a
period of weight bearing and improper care
Limb Amputation vs limb salvage
Indications for amputation:
 when functional result of reconstruction is inferior to amputation
1. severe crush with segmental composite defects
2. unreconstructable sciatic nerve/posterior tibial nerve loss
3. severe vascular injury
 Absolute
when limb threatens life eg myoglobinuria etc following crush
 Relative
Other injuries eg spinal or head injury
Age – children do better
Other medical conditions
Limb motor function and distal sensation
 Delayed leg amputation is considered a relative treatment failure, as this outcome
suggests possible errors in the initial treatment rationale. Furthermore, delayed
amputation has been linked to increased hospital costs, more operations, and increased
20



patient disability, including sepsis and death.
IIIC associated with a 25-61% amputation rate
Contraindications for salvage of IIIC fracture
1. warm ischaemia>6hours
2. severe medical illness
3. tibial loss >8cm
4. posterior tibial nerve injury in adults
5. severed limb
Indications for lower limb replantation
1. amputation at single level, clean transaction without crush
2. warm ischeamia <6hours
3. child