» Although timely irrigation and debridement within six hours after
injury has been established as the standard of care in the management
of open tibial fractures, current evidence does not support such
practice. The ideal irrigation solution and pressure remain equivocal.

» Antibiotic prophylaxis should be commenced as soon as possible. All
patients should receive antimicrobial coverage against gram-positive
bacteria, typically with a first-generation cephalosporin. Gustilo and
Anderson type-III injuries require additional coverage, and it is
reasonable to use an aminoglycoside, although the optimal regimen
has not conclusively been established. Local antibiotic administration
at the site of injury, as an adjunct to systemic prophylaxis, considerably
reduces the risk of infection, and the benefit is most pronounced for
type-III injuries.

» Both reamed and unreamed intramedullary nailing are reasonable
options for fracture fixation of open tibial fractures and have
demonstrated comparable outcomes. Although external fixation
should not typically be used as definitive fixation, it is a useful
temporizing measure in more severe injuries when it is used for a short
duration of time (i.e., twenty-eight days or less).

» Primary wound closure is recommended for fractures with less severe
soft-tissue injury, allowing for tension-free closure. For those injuries
requiring delayed closure, definitive coverage should not be delayed
beyond seven days, even in the setting of negative-pressure wound