case examples – severe lower limb injuries
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Case Examples – severe lower limb injuries. March 2014 Trauma Conference Andy Gray Newcastle Hospitals. Example 1. 42 year old fit and well male RTA – 28 th March 2013 (1 year ago!) Transferred to RVI A,B,C normal. GCS 15 - PowerPoint PPT PresentationTRANSCRIPT
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Case Examples – severe lower limb injuries
March 2014Trauma Conference
Andy GrayNewcastle Hospitals
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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
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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
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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
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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
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Additional surgery
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ARDS / Fat embolus Syndrome
• Aeitilogy after major trauma– Haemodynamic (Crowel 2000) –occult
hypovolaemia– Embolic – Coagulative – Inflammatory – Injury Severity Score– Associated injuries (e.g. chest)
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Over next 2 weeks
• Recovered from ARDS• Began rehab on ortho trauma ward• Repatriation to local DGH near Manchester
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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
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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.
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2 months after surgery – wound infection left anterior knee wound
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Admitted – wound debridement and exchange nail
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9 months after injury – femurs healed and doing well apart from toe!!
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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’
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Case 2- 35 year old male / MBA / isolated lower limb injury / 22 stone
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Spanning ex fix applied 2.5 weeks
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Definitive fixation – 2 incisions
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Infection / wound necrosis / plastics and salvage / rotational flap to distal tibia / free lat dorsi flap over knee
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6 weeks later – lifted flap / bone graft / reattached extensor mechanism
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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
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Thank-You