The man, who has worked as a driver since the age of seventeen, earns his living transporting people and goods in and around his hometown of Kabala, Sierra Leone.

During one of his trips, while working as an assistant driver, he was seated on the roof of a heavily loaded vehicle (Fig. 2). When the driver unexpectedly braked, he lost his balance, fell onto the road in front of the car, and was subsequently run over by the same vehicle.

He experienced immediate pain in his left lower leg, accompanied by a severe open wound. He remained conscious throughout. At the scene, an improvised splint was applied, and he was transported to Kabala Government Hospital.

There, he received an above-knee POP cast with a window for wound care. Recognising the severity of the fracture, the local clinicians advised referral to a higher-level centre. Fearing amputation, he declined and instead sought treatment from a traditional healer, where he received weekly herbal applications for three months.

His condition did not improve and there was a persistent severe angulation. Later he sought help at Masanga Hospital. He underwent surgery consisting of open reduction, debridement of the fracture, 3cm tibial shortening and a distal fibulectomy to correct for the angulation and to handle the shortened soft tissues. An external fixator was applied, but despite sixteen weeks of treatment and a subsequent six-week period in a below-knee POP, the fracture remained unstable.

The patient left the hospital and went to his village. He came back to Masanga Hospital the following year, when the visiting trauma team would return.

When the patient returned to Masanga Hospital he was alert with a GCS of 15, haemodynamically stable, non-anaemic, and without signs of systemic infection. 

Examination revealed an anterolateral ulcer and a smaller anteromedial ulcer with a chronic fistula at the medial side of the left lower leg, surrounded by extensive scarring (see Fig. 3–4). Distal pulses were palpable, motor function was preserved, and light-touch sensation remained intact.

The limb showed a pronounced anterior and valgus malalignment and rested in an equinus position. Upon manipulation of the proximal and distal bone ends, clear fracture movement was observed (see Video 1).

A radiograph was obtained, demonstrating a severe deformity with approximately 70 degrees of angulation of the tibia (see Fig. 5).

Initial evaluation and management in the ER

On the second day of admission, the patient was taken to theatre and underwent surgery under spinal anaesthesia. The planned procedure consisted of surgical debridement with the excision of the fistula, corrective osteotomy, and open fracture reduction with stabilisation using an external fixator.

Debridement and exploration

Access was obtained through an anterolateral incision, with additional opening of the scarred medial skin to improve exposure (see Fig. 6). The fistula led to the bone and was excised. The tibial non-union was thoroughly debrided, removing all non-viable bone until healthy, bleeding bone was encountered, resulting in an additional 2 cm of tibial bone resected. The medullary canal was opened and no purulence was observed. Deep tissue samples were taken for culture.

At the level of the previous fibular fracture, a new fibulectomy was performed to allow for adequate alignment.

Reduction and fixation

Stabilisation was achieved using an external fixator (see Fig 7). Two pins were placed proximally in the tibial shaft, cranial to the fracture site. Three pins were inserted distally: two anteroposteriorly oriented pins and one medial-to-lateral pin to enhance construct stability.

The two proximal pins were connected with a bar to form the proximal frame. Distally, the two anteroposterior pins were connected using a multiple pin-to-bar clamp. Bilateral oblique bars were then applied between the proximal and distal frames, completing the triangular delta configuration (see Fig 8).

Definitive fracture reduction was performed before the bar-to-bar clamps were fully tightened.

Estimated blood loss was 500 mL. Pulsations of the distal arteries were palpable after surgery.

Soft-tissue management

Through the anterolateral incision, a drain was positioned deep within the wound, after which the bone was covered with anterior tibial musculature, allowing this wound to heal by secondary intention. Despite the poor quality of the scarred medial skin, the medial wound was closed primarily without tension. 

Paraffin gauze dressings and compression bandages were applied.

Performing wound care

The patient continued on intravenous ceftriaxone while awaiting culture results. Analgesia consisted of paracetamol, diclofenac, and tramadol as required. A healthy, protein-rich diet was encouraged. A postoperative radiograph on day one (despite its limited quality) confirmed improved alignment (Fig. 9).

The limb was placed in a 90-degree backslab overnight, and the drain was removed after 24 hours. Pin-site care and daily wound care were initiated from the first postoperative day. A 4-cm heel lift was added to the left shoe to compensate for the leg-length discrepancy (Fig. 10). Mobilisation remained non-weight-bearing until radiographic evidence of consolidation.

Cultures results came out with gram negative organisms, multiresistant against all antibiotics available (including meropenem) in the hospital, after which the antibiotics were discontinued.

On day twelve, the patient underwent an additional debridement due to medial wound necrosis and local infection. The wound was kept wet for tissue granulation.

Follow-up after 4-7 weeks

At four weeks, the external fixator remained in situ. The wounds were granulating well, and no signs of infection were seen anymore (Fig. 11).

At week seven, radiographs demonstrated adequate callus formation and maintained alignment (Fig. 12). Gradual weight bearing was initiated with the external fixator in place. Pin sites remained clean, and the wound continued to improve.

Follow-up after 3 months

The external fixator was removed at week eleven due to pin loosening and increasing pain (Fig. 13). Mobilisation progressed to gradual weight bearing with crutches. Radiographs at week twelve showed ongoing fracture healing with residual valgus angulation (Fig. 14).

Follow-up after 6 months

At six months, follow-up was performed at the patient’s home. He was feeling well, his wounds had healed and he experienced no pain (see fig 15). He was able to walk 20–30 metres without crutches or a walking frame (Video 2). Radiographs demonstrated continued consolidation and maintained alignment of the tibia, slight valgus angulation was accepted (Fig. 16).

Follow-up after 12 months

At 12 months the patient was still walking independently without any aid. He returned back to work and experienced no complications in the past few months. A radiograph confirmed union of the tibia (Fig. 17), and a video shared by the patient showed him walking independently with a stable gait (Video 3).

Long treatment with multiple complications

To treat mal/non-unions in a limited-resource setting, expect long hospital admission, multiple surgeries and complications such as infections, extreme bone shortening and secondary malalignment. Patient should be informed about this and a primary amputation is a potential viable alternative because it his a shorter recovery period and often better predictable outcomes and quality of life.

Causes of impaired healing

In cases of non-union, ask yourself why the fracture is not healing? Evaluate the key causes of impaired healing: infection, insufficient mechanical stability, poor blood supply, soft-tissue interposition or bone loss, and relevant patient-related factors (smoking, malnutrition, diabetes, medication).

Addressing chronic infection

After identifying the contributing factor(s), address and eliminate them. In the discussed case, a chronic fistula and persistent wound indicated an ongoing infection, which was a major cause of impaired bone healing. Thorough debridement and creating a healthy biological environment are essential steps to allow bone healing to occur. Start antibiotics after debridement and adapt based on deep tissue cultures if possible.

Add extra stability to your construct

Using an additional pin to anchor a stabilisation rod can significantly increase the stiffness of the external fixator, to achieve adequate mechanical stability in complex non-unions.

Authors

P. Bongers, M.O. Kamara, R. Wierper.