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Lower limb reconstruction and open fractures
In an open tibial fracture time is tissue: antibiotics within an hour, early debridement and definitive soft tissue cover within 72 hours — and the flap is chosen by the third of the leg: gastrocnemius for the upper third, soleus for the middle, and a free flap for the lower third and foot.
Why it matters in the exam
Gustilo-Anderson classification: I — wound under 1 cm and clean; II — 1 to 10 cm with moderate damage; III — over 10 cm or high energy: IIIA — adequate soft tissue cover, IIIB — periosteum stripped and a flap required, IIIC — arterial injury requiring repair. Per BOAST: antibiotics within an hour (cefazolin, adding gram-negative cover for severe injuries), debridement within 12 hours in high-energy injury and immediately with agricultural or marine contamination, and definitive cover within 72 hours — ideally "fix and flap" in the same operation. Delayed cover raises infection and non-union. Reconstruction by thirds: upper — medial gastrocnemius flap; middle — soleus; lower, ankle and foot — free flap (ALT, gracilis) or a pedicled reverse sural flap.
The choice between salvage and amputation is hard: the LEAP study showed similar outcomes two years after salvage and amputation, and that loss of plantar sensation on arrival is not a reliable predictor and amputation must not be decided on it alone. Severity scores such as MESS help but do not decide alone; factors favouring amputation: IIIC with prolonged warm ischaemia, extensive muscle crush, multilevel injury and severe comorbidity. Exposed hardware can sometimes be salvaged when it is stable, without infection and with early cover. For a bone gap, the Masquelet technique (induced membrane — a cement spacer for some weeks, then bone graft), a free fibula flap, or the Capanna technique — a vascularised fibula inside a cadaver bone allograft — is used. In every severe leg injury compartment syndrome is sought, treated with two-incision fasciotomy of all four compartments.
Key points
- Antibiotics within an hour; definitive cover within 72 hours.
- Gustilo IIIB — flap needed; IIIC — arterial repair.
- Upper — gastrocnemius; middle — soleus; lower — free.
- LEAP: salvage and amputation — similar outcomes.
- Bone gap — Masquelet, fibula, Capanna.
Summary table
| Gustilo | Wound and tissue | Reconstruction need |
|---|---|---|
| I | Under 1 cm, clean | Primary closure in most |
| II | 1 to 10 cm, moderate damage | Closure or graft |
| IIIA | Over 10 cm or high energy, adequate cover | Closure, sometimes graft |
| IIIB | Periosteum stripped, exposed bone | Local or free flap |
| IIIC | Arterial injury requiring repair | Vascular repair and flap |
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Sources
- BOAST and BAPRAS Standards for the Management of Open Fractures, 2017 (updated 2020) — Timing of antibiotics, debridement and soft tissue cover
- Gustilo-Anderson classification of open fractures, 1976 and 1984 — Types I to IIIC
- Lower Extremity Assessment Project (LEAP), 2002 — Amputation versus limb salvage
Sources are given for further reading; the text is written afresh and not copied from them.
Reviewed by the Examqo AI Professor · 2026-11-06. The text may contain errors; when in doubt, check the source.