Case Examples – severe lower limb injuries

1. Case Examples – severe lower limb injuries March 2014 Trauma Conference Andy Gray Newcastle Hospitals

2. 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

3. 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

4. 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

6. 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

7. Additional surgery

10. ARDS / Fat embolus Syndrome • Aeitilogy after major trauma • Haemodynamic (Crowel 2000) –occult hypovolaemia • Embolic • Coagulative • Inflammatory • Injury Severity Score • Associated injuries (e.g. chest)

11. Over next 2 weeks • Recovered from ARDS • Began rehab on ortho trauma ward • Repatriation to local DGH near Manchester

13. 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

14. 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.

17. 2 months after surgery – wound infection left anterior knee wound

18. Admitted – wound debridement and exchange nail

19. 9 months after injury – femurs healed and doing well apart from toe!!

20. 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’

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

22. Spanning ex fix applied 2.5 weeks

23. Definitive fixation – 2 incisions

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

25. 6 weeks later – lifted flap / bone graft / reattached extensor mechanism

27. 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

28. Thank-You