Salvage After Patient-Driven Delayed Conversion From External Fixation to Intramedullary Nailing in an Open Tibial Shaft Fracture: A Case Report.

Abstract

Background: Open tibial shaft fractures require timely management of both skeletal instability and soft-tissue injury. Temporary external fixation is useful for early stabilization, but prolonged retention without progression to definitive fixation may increase the risk of delayed union and other complications. This case illustrates a patient-driven delay from the preferred staged pathway and subsequent salvage after restoration of mechanical stability and biological support.

Case presentation: A 40-year-old man sustained a Gustilo-Anderson Type II open fracture of the right tibial shaft with an associated fibular fracture following a road traffic accident. He presented approximately 40 min after injury with a clean 2 cm wound over the anteromedial midleg and intact distal neurovascular status. Immediate preoperative radiographs before initial stabilization were unavailable because the case was reviewed retrospectively. After resuscitation and optimization, irrigation, debridement, primary wound closure, drain placement, and monolateral external fixation were performed on November 22, 2024. Serial follow-up radiographs showed maintained alignment but limited progression toward union. Early conversion to intramedullary nailing was advised, but the patient initially declined further surgery for personal and socioeconomic reasons. On February 12, 2025, the external fixator was removed and intramedullary interlocking nailing with autogenous bone grafting was performed as a salvage procedure. Follow-up radiographs showed progressive callus formation and solid union at late follow-up on March 27, 2026. No postoperative wound complication or deep infection occurred.

Conclusions: This case should not be interpreted as supporting delayed conversion as routine practice. Rather, it illustrates a cautionary salvage scenario in which patient-driven delay disrupted the preferred staged pathway, and union was achieved only after definitive restoration of stability and selective biological support.