Major lower limb injuries where fractures are combined with extensive soft tissue damage should be assessed ideally within 24 hours of injury both by a plastic surgeon and an orthopaedic surgeon of consultant status who have special expertise in this field. There is unequivocal evidence that early closure of the wound over a severe compound fracture of the tibia can shorten the hospitalisation and fracture healing time by 50%, with great benefit to the patient and significant financial savings. This often requires sophisticated reconstructive techniques and the involvement of a plastic surgeon in the acute trauma team. This happens relatively infrequently in the British Isles and many patients are primarily treated without plastic surgical assistance.

The British Orthopaedic Association has recently collaborated with the British Association of Plastic, Reconstructive and Aesthetic Surgeons and a combined working party have made recommendations of good practice in a hand book published in January 1999. (The Early Management of Severe Tibial Fractures: The Need for combined Plastic and Orthopaedic management. A report by the British Orthopaedic Association and British Association of Plastic, Reconstructive and Aesthetic Surgeons, Working Party, January 1993. - available from either Association at the Royal College of Surgeons of England. BAPRAS: 020 7831 5161. BOA: 020 7405 6507)

It is recommended that centres for the treatment of patients with major lower limb injuries should be established, preferably associated with major trauma units. In these centres, such injuries can be assessed by both consultant orthopaedic and plastic surgeons.