Staged limb salvage of a Gustilo–Anderson type IIIC open distal tibial gunshot fracture using cross-leg pedicle flap and delayed intramedullary nailing with bone grafting: a case report

Introduction and importance Gunshot injuries to the lower limb can cause severe damage to both bone and soft tissues, particularly when the injury occurs at close range. Open fractures of the tibia are especially difficult to manage because of the limited soft-tissue coverage and the high risk of infection, non-union, and other complications. Gustilo–Anderson type IIIC fractures represent the most severe form, as they involve arterial injury that requires urgent repair. Successful limb salvage depends on early debridement, restoration of blood flow, stable fixation, and reliable soft-tissue coverage. In settings where advanced reconstructive options are not available, staged approaches may offer a practical alternative. Case presentation A 25-year-old previously healthy man sustained a gunshot injury to the distal right leg, resulting in a severe open tibial fracture with extensive soft-tissue loss, segmental bone loss, and injury to the posterior tibial artery. He underwent urgent irrigation, thorough debridement, primary arterial repair, and temporary external fixation. The tibial nerve was preserved. Serial debridements were performed until the wound was clean and well perfused. Soft-tissue coverage was then achieved using a cross-leg pedicle flap, with pedicle division performed after three weeks. This was followed by delayed intramedullary nailing, supported by a fibular strut graft and autologous iliac crest bone grafting. At six months, imaging showed progressive healing, and the patient regained full weight-bearing ability with independent ambulation and good functional recovery. Clinical discussion Managing severe open tibial fractures with vascular injury requires a carefully staged and multidisciplinary approach. Initial priorities include infection control and restoration of blood flow, followed by soft-tissue coverage and definitive skeletal reconstruction. Cross-leg pedicle flaps remain a reliable option when free-flap reconstruction is not feasible, particularly in resource-limited environments. In selected cases, staged bone reconstruction using grafts and stable fixation can provide satisfactory outcomes. Conclusion A staged treatment strategy combining vascular repair, repeated debridement, cross-leg flap reconstruction, and delayed intramedullary fixation with bone grafting can achieve successful limb salvage in selected patients with severe open tibial gunshot injuries, especially in resource-constrained settings.