Download Case discussions Knee Course

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