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