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Open fractures of the tibial diaphysis are often associated with severe bone and soft-tissue injury. Contamination of the fracture site and devitalization of the soft-tissue envelope greatly increase the risk of infection, nonunion, and wound complications. Management of open tibial shaft fractures begins with a thorough patient evaluation, including assessment of the bone and soft tissue surrounding the tibial injury. Classification of these injuries according to the system of Gustilo and Anderson at the time of surgical débridement is useful in guiding treatment and predicting outcomes. Administration of antibiotic prophylaxis as soon as possible after injury as well as urgent and thorough débridement, irrigation, and bony stabilization are done to minimize the risk of infection and improve outcomes. The use of antibiotic bead pouches and negative-pressure wound therapy has proved to be efficacious for the acute, temporary management of severe bone and soft-tissue defects.