Overview
An open fracture with soft-tissue loss is hard to manage well because the goals are the same as for any limb injury: return the patient to optimum function quickly and avoid complications. Outcomes depend on planning at system level rather than case-by-case improvisation. The orthoplastic approach, in which orthopaedic and plastic surgeons jointly debride, fix and reconstruct, is the model described in Rockwood. Experience with microsurgery varies between centers, so the best approach has to account for local resources. (Rockwood)
Timing and Models of Care
Historically, open fractures were debrided and temporarily stabilized by orthopaedic surgeons, and soft-tissue cover then depended on local resources. (Rockwood)
Godina's 1986 report associated free flap cover within 72 hours of injury with much lower flap failure, and a rapid rise in failure once surgery slipped beyond about 7 days. The interval between definitive fixation and flap surgery was not assessed in that study. (Rockwood)
Reports of combined orthoplastic care found lower infection when definitive reconstruction was done in the same session (4.2% in one study) than when fixation and soft-tissue reconstruction were separated. (Rockwood)
In the UK, concentration of open fractures in major trauma centers produced a national deep infection rate of about 7%. (Rockwood)
The GOLIATH group meta-analysis found infection risk rises as time from injury to debridement increases. Evidence that debridement within 12 hours lowers infection is weak, but debridement within 24 hours has moderate support, especially in more severe injuries. (Rockwood)
Studies looking at each interval separately (injury to first debridement, definitive fixation, flap cover) found the interval between definitive fixation and flap closure to be the most important predictor of infection. Definitive fixation and flap cover in the same session performed best in open tibial shaft fractures. (Rockwood)
Initial Management
Resuscitate and treat life-threatening injuries first, following general trauma principles.
Reduce and stabilize the limb to reduce pain and bleeding and restore anatomic position. Do a neurovascular examination to identify any need for urgent revascularization or decompression.
Photograph the soft-tissue defect and obtain plain and cross-sectional imaging, so that orthoplastic planning can proceed.
Compartment syndrome can occur even with an open wound, so assess the compartments clinically.
Cover the wound with saline-moistened gauze before any splint. Remove gross contamination, but ED wound "washout" does not replace timely, thorough debridement in the operating room.
Give IV antibiotics early for all open fractures. Delays beyond 1 hour were linked to higher infection, particularly in Gustilo–Anderson type III fractures. Regimens follow local policy and generally cover gram-positive organisms. For type III injuries, add gram-negative cover and consider broadening cover during surgery for nosocomial risk.
Preoperative CT angiography helps map regional vascular anatomy and plan reconstruction. It can be done at the initial assessment (to find vascular injuries needing urgent action) or after initial debridement and temporary stabilization, to allow vasospasm to resolve.
Perform a medical review and physiologic optimization (correct anemia, restore hemodynamics, prevent hypothermia and dehydration). Consent should include the risks of donor site morbidity.
In more severe injuries, discuss limb salvage vs primary amputation.
Debridement in high-energy fractures often needs a wide exposure: extend the wound proximally and distally until healthy tissue is reached. Ideally bone and soft-tissue reconstruction are closely coordinated and done in the same session. (Rockwood)
Patient factors
Diabetes and smoking raise the risk of nonunion and infection.
In patients with vascular disease, angiography is recommended at admission. Local flaps such as the medial plantar flap may be preferable to skin graft or free tissue transfer. Orthopaedic strategy can be adapted, for example tibial shortening or ankle fusion, to allow tension-free closure over healthy skin. (Rockwood)
The Reconstructive Ladder
Rockwood describes the "reconstructive ladder" or "elevator": consider all options and let patient and injury factors move the choice up or down. More than one method can be used in the same operation, for example a local flap plus a skin graft for its donor site, or a muscle flap covered with skin graft. (Rockwood)
1. Supportive measures
After adequate debridement, simple occlusive dressings can suffice for superficial skin defects.
Negative pressure wound therapy promotes wound healing and is widely used between initial debridement and definitive fixation and closure. There is no evidence supporting it as definitive soft-tissue treatment of open fractures. (Rockwood)
2. Direct closure
When skin and soft tissue meet without undue tension, direct closure is usually the best option.
Bone shortening can allow direct closure, especially in high-comorbidity patients. It eases tension in transverse defects but can make longitudinal wounds harder to close, because shortening widens a longitudinal wound in the cylindrical soft-tissue envelope. (Rockwood)
3. Skin grafts
A graft has no blood supply of its own and depends entirely on the recipient bed. Healthy muscle is an excellent bed.
Grafting onto bare periosteum is possible but not recommended, because of desiccation and necrosis risk and an unstable, unsightly scar.
Debride the wound fully before grafting. Colonization with organisms such as beta-hemolytic streptococci, staphylococci or Pseudomonas impairs take.
Split-thickness grafts are preferred for the large areas in most trauma reconstruction. Full-thickness grafts suit small areas where contracture must be minimized, such as the hand and over joints.
Consider immobilization or splinting for 3–7 days to limit shear that prevents take.
Dermal matrices (bovine-derived or fully synthetic) can improve scar appearance and durability, but they also need a well-vascularized bed and a skin graft. (Rockwood)
4. Local and regional flaps
A flap carries its own blood supply. Flaps are classified by location, by vascular pattern (random or axial), by tissue (skin, fasciocutaneous, muscle) and by movement (advancement, transposition, rotation, propeller). (Rockwood)
Random-pattern flaps: in the lower limb, the length-to-width ratio is 2:1 or even 1:1 to avoid tip necrosis. Ponten's "super flap" (1981) showed that including the deep fascia allowed longer, narrower flaps to survive.
Perforator-based fasciocutaneous flaps rely on predictable perforators from the axial vessels.
Medial leg: posterior tibial artery perforators, usually 5–10 cm proximal to the medial malleolus in adults. Locate the perforator with Doppler. A "reverse planning" trick uses sterile gauze to mimic flap dimensions: stretch it from the posterior flap edge to the far edge of the defect, then rotate that length back onto the donor site. The donor site needs a split-thickness graft, and long flaps risk tip necrosis. This can be done in one session along with definitive internal fixation before the local flap.
Lateral leg: peroneal artery perforators. Used less because of limited rotation to cover open tibial fractures, and the superficial peroneal nerve is at risk.
Propeller flaps: islanding on the perforator allows rotation up to 180 degrees when drainage veins are carefully dissected. Islanded medial and lateral flaps with rotation beyond 90 degrees have reported tip necrosis up to 25%. A literature rate of 11.3% partial flap loss and 8.1% venous congestion is reported even with careful technique.
Reverse sural artery flap: based on the vessels accompanying the sural nerve. It needs a 4-cm-wide subcutaneous band with the nerve, which is sacrificed proximally, and a tunnel wide enough for the flap and postoperative swelling. Partial necrosis of up to 21% limits its use to well-selected cases.
Medial sural artery perforator flap: transmuscular perforator from the medial gastrocnemius, usually in the first third of a line from the popliteal midpoint to the medial malleolus. It can be a pedicled flap for the anterior knee or a free flap for foot and ankle defects, when the donor site can be closed primarily.
Medial plantar artery flap: a local axial fasciocutaneous flap (or free flap), mainly used locally for open ankle fractures.
5. Local muscle flaps
Select by Mathes–Nahai vascular type. Type IV muscles cannot be isolated on a pedicle for transfer. Type I are ideal, and types II, III and V can be used if the other pedicles are controlled to prevent bleeding. Consider the functional loss. (Rockwood)
Gastrocnemius flap (proximal third of the leg). The workhorse local muscle flap, relatively easy to dissect. The medial head is a type I muscle on the medial sural artery. It can be released from its origin above the femoral condyle for more arc, or partially cut through its fascia for more length and width. It needs a skin graft and causes donor morbidity. It rarely reaches above the joint line of the knee. The lateral head is smaller, limited by the fibular head and puts the peroneal nerve at risk. Preserve the great saphenous vein and nerve, and watch the pes anserinus, which can block the arc of rotation.
Soleus flap (middle and distal thirds). Type II muscle with several dominant pedicles: proximal (popliteal), and distal branches from the posterior tibial and peroneal arteries. It can be used as a whole muscle or hemisoleus flap, proximally based for the middle third and distally based for the distal third. It is reliable and robust but dissection is harder, the arc is smaller than gastrocnemius, and it may be damaged by the injury. Consider it for smaller tibial defects where the muscle and pedicle are intact.
Rockwood's authors prefer to do definitive internal fixation at the time of definitive soft-tissue reconstruction.
Muscle vs fasciocutaneous flaps
Muscle flaps fill dead space and conform to the defect. Theoretically their vascularity supports bone healing, but clinical evidence is unclear. They need a skin graft, are harder to monitor, have more donor morbidity and are much harder to re-elevate for secondary procedures such as bone grafting. Fasciocutaneous flaps give skin-to-skin closure, better scar quality and usually lower donor morbidity, contract less, and may need later thinning. The choice should fit the patient. (Rockwood)
Free Tissue Transfer (Rockwood)
Prerequisites for success:
A well-prepared patient. Assess lower-limb vascularity with CT angiography (for example peronea magna, where the peroneal artery is the dominant supply). Recipient vessels near the zone of injury often have subclinical injury, so examine them first, re-excise the wound if needed, and decide whether to anastomose proximal or distal to the defect. Plan a backup that the first plan does not compromise. Position the patient so orthopaedic and plastic teams can work together. Agree the plan with anesthesia. Avoid inotropes and fluid overload, and use urine output as an indirect marker of perfusion, aiming for 0.5 mL/kg/h.
A comprehensive plan including alternative options if the first flap fails.
A well-equipped operating room with room for the microscope, sharp microsurgical instruments, regularly checked clamps and experienced staff. Many centers use two teams, one raising the flap and the other preparing the recipient site.
A safe postoperative environment for a prolonged, complex case.
Postoperative care
Monitor flap temperature, color, turgor, capillary refill and Doppler signal. Other options are thermography, implantable Doppler, laser Doppler and plethysmography. The method must detect both arterial insufficiency and venous congestion.
Most salvageable problems occur in the first 24–48 hours, so monitoring is most intense then. Salvageable problems have been described up to day 4, so continue regular monitoring until then. Use a flap chart and a face-to-face handover.
Elevate the limb and keep the patient warm to promote vasodilation. Avoid vasopressors such as nicotine and caffeine.
Lower-limb free flaps are sensitive to venous congestion when dependent, so many surgeons use a staged "dangling" protocol after a few days of bed rest. Correctable vascular problems are rare after day 7, and discharge is often possible then.
Splinting for soft-tissue rest can usually stop at 2 weeks, longer if the flap needs protection from tension (for example a functional muscle transfer).
Free flaps for the lower extremity (Rockwood Table 19-2)
Anterolateral thigh (ALT) flap. Perforator flap on the descending branch of the lateral circumflex femoral artery. Skin islands up to 25 × 35 cm, but widths over about 8–13 cm probably cannot be closed primarily and need a graft. Pedicle 8–12 cm. Surface markings: anterior superior iliac spine and lateral patellar border, with the main perforators within a 4-cm circle at their midpoint (mark with Doppler). Usually thin, good contour, can be raised at the same time as fracture fixation, low donor morbidity.
Scapular flap. Circumflex scapular vessels. A fully cutaneous flap with a constant anatomy, skin islands up to 10 × 20 cm closed primarily, low donor morbidity. Still preferred by the Rockwood authors for open fractures in small children. Pedicle 7–10 cm if limited to the circumflex scapular vessel. Needs lateral or prone positioning, which makes synchronous surgery harder.
Radial forearm flap. Up to about 8 × 16 cm, thin and pliable with a long pedicle, but sacrifices the radial artery (check the ulnar supply with an Allen test), leaves a notable donor scar, risks damage to the superficial radial nerve and causes cold intolerance.
SCIP flap. Superficial circumflex iliac artery perforator flap, thin and long, with a short pedicle but limited donor morbidity and a hidden scar.
Latissimus dorsi. Muscle (with or without a skin island), up to 20 × 40 cm, on the thoracodorsal artery. Needs lateral positioning and a skin graft. Potential for functional loss.
Gracilis. Muscle, about 6 × 20 cm, medial circumflex femoral vessels, short pedicle. Can be used as a free functional muscle transfer. Needs a skin graft.
Rectus abdominis. Muscle (with or without skin island), up to 10 × 30 cm, on the deep inferior epigastric vessels. Donor morbidity includes functional loss and hernia risk.
Complications
Flap failure or partial loss (tip necrosis, venous congestion). Rates are higher with delay, poorly planned pedicles, rotation beyond 90 degrees in islanded flaps and long random flaps. (Rockwood)
Infection, strongly linked to the interval between definitive fixation and flap cover. (Rockwood)
Donor-site morbidity: graft loss, scar, cold intolerance (radial forearm), nerve injury (sural, superficial peroneal, radial), functional muscle loss. (Rockwood)
Graft failure on periosteum, infected beds or shear. (Rockwood)
References
Khan U, Kelly MB, O'Grady E, Al-Hourani K. Soft tissue coverage for injuries and fractures. In: Tornetta P III, Ricci WM, Ostrum RF, McKee MD, Ollivere BJ, de Ridder VA, eds. Rockwood and Green's Fractures in Adults. 10th ed. Wolters Kluwer; 2024. Chapter 19 (Turkish edition: Erişkin Kırıkları).