Tibial nailing in a lateral decubitus position facilitates simultaneous harvest of scapular flaps for single stage definitive orthoplastic management

Open tibial fractures can be challenging to manage because of the paucity of soft tissue available locally to cover any wound post debridement. They commonly require both skeletal stabilisation and complex soft tissue reconstruction. This combined approach to manage open tibia fractures is the foundation upon which orthoplastic care is based. The optimal method of managing these patients is to perform a debridement on day one and then a combined “fix and flap” procedure no more than 7 days later.

We present three patients who underwent suprapatella tibial nailing in a lateral position purely to facilitate ease of access to the back so scapular and para-scapular flap could be harvested. These flaps are usually pliable, conformable and hair free with a reliable, long and large calibre pedicle which allows a relatively rapid flap harvest. To use scapular flaps the plastic surgery surgeons would have to wait for the orthopaedic surgeons to complete supine tibial nailing prior to commencing flap harvest. For a “fix and flap” procedure, this could mean performing microsurgical anastomosis late in the evening when surgeons may be tired. Therefore, other flaps with less reliable pedicles were used.

Stabilising open tibial fractures that require intramedullary tibial nailing and a free flap in a lateral position promotes orthoplastic teamwork. It facilitates the harvesting of a relatively straightforward flap in a time efficient manner as both surgical teams can operate simultaneously. This increases surgical efficiency, promotes orthoplastic teamwork and utilises a more reliable flap giving the best chance of recovery for these complex injuries.