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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
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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 – 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
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
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
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