Case Examples – severe lower limb injuries

March 2014Trauma Conference

Andy GrayNewcastle Hospitals

Example 1

• 42 year old fit and well male• RTA – 28th March 2013 (1 year ago!)• Transferred to RVI • A,B,C normal. GCS 15• Pan CT scan – no significant injury to head,

neck, thoracolumbar spine, chest, abdo etc

Secondary survey

• Bilateral distal femoral shaft fractures • Left thigh wound • Both kneecaps damaged• Classic ‘dashboard’ injury• Hips and pelvis fine• Arterial line being inserted into wrist during

secondary survey• Ortho trauma theatre free (consultant led)• On call consultant going to fracture clinic

Theatre

• Stable patient / base excess OK (no acidosis)• Debridement and irrigation of wound• Bilateral retrograde nailing• Left performed / supervised by consultant 1• Right performed by consultant 2• Transferred to ITU/HDU after surgery

Day 1 post op

• Left wrist pain• Pins and needles

median nerve• Going to theatre for 2nd

debridement and DPC of open femur – plastics present

• Dislocated IP joint big toe

Additional surgery

ARDS / Fat embolus Syndrome

• Aeitilogy after major trauma– Haemodynamic (Crowel 2000) –occult

hypovolaemia– Embolic – Coagulative – Inflammatory – Injury Severity Score– Associated injuries (e.g. chest)

Over next 2 weeks

• Recovered from ARDS• Began rehab on ortho trauma ward• Repatriation to local DGH near Manchester

Transferred to hospital closer to home

• As per national guidelines• Case discussed with receiving team• Good communication• Patient spent 1 week in hospital before

requesting re-transfer back to RVI

Issues

• Receiving unit critical of care received• No ownership of patient -no consultant review• K wires removed from toe deformity recurred• Critical of position of wrist plate• Critical of missed screw• “How old was your treating surgeon?”

• Worried and confused patient.

2 months after surgery – wound infection left anterior knee wound

Admitted – wound debridement and exchange nail

9 months after injury – femurs healed and doing well apart from toe!!

Issues for discussion

• Importance of repeating the secondary survey• Repatriation of patients– In theory everybody agrees with this– ? Dealing with complications – ? Patients need secondary procedures– Ownership of the patient– Avoiding criticising treatment of patient – ‘I would have managed this differently’

Case 2- 35 year old male / MBA / isolated lower limb injury / 22 stone

Spanning ex fix applied 2.5 weeks

Definitive fixation – 2 incisions

Infection / wound necrosis / plastics and salvage / rotational flap to distal tibia / free lat dorsi flap over knee

6 weeks later – lifted flap / bone graft / reattached extensor mechanism

Discussion points

• Expect the unexpected • Importance of having allied specialties

(plastics/vascular) available on-site• Development of a gold standard regional

service for open fractures and complex lower limb reconstruction

Thank-You