Lower Limb

Question 1

Pt comes in with Gustilo IIIc tibial injury- how do you manage them?

Answer 1

My management of this pt is based on BOA/BAPRAS guidelines and evidence from Glass & Nanchahal paper on management of IIIc injuries (JPRAS 2009)

• Obtain AMPLE history
• Assess the pt according to ATLS principles to exclude any immediately life-threatening injuries
• If isolated injury:
  Assess leg incl wounds and distal NV status (clinical/doppler)
  Photographs
  Remove gross contaminants
  Saline soaked gauze dressing
  X-rays
  Reduce
  Splint
• Needs 1.2g augmentin (or 600mg uv)
• Tetanus

Vascular compromise is indication for immediate surgery - ensure anaesthetist/theatre aware
Take to theatre - joint orthopaedic case
NO indication for pre-op angiography - causes significant increase in ischaemia time without appreciable advantage in terms of limb salvage
Social pre-scrub
Standard prep
Exploration - site and nature of vascular injury usually evident but can use on-table angiography if unclear e.g multilevel injuries.
Insert vascular shunt e.g paediatric feeding tube or commercial shunt
Permits re-evaluation of viability and facilitates decision re salvage v amputation
If non viable after shunt then primary amputation
If salvaging - use of shunt prior to skeletal fixation and definitive vascular repair can significantly reduce ischaemia time
Formal debridement
Skeletal stabilisation usually ex-fix
Definitive vascular reconstruction - direct repair if possible or reverse long saphenous vein graft
Selective fasciotomy when indicated e.g crush mechanism, prolonged ischaemia time >3-4hrs
Gentamicin beads and temporary dressing e.g NPWT

Second look, debridemement, definitive skeletal stabilisation and flap coverage in timely manner

Question 2

How do you classify degloving injuries?

Answer 2

Arnez, Khan and Tyler described a classification of soft tissue degloving in limb trauma (JPRAS 2010)

I - limited degloving with abrasion or avulsion of soft tissues
II - non circumferential single plane degloving
III - circumferential single plane degloving
IV - multiplanar degloving

Fundamentally they recommend types I-III should undergo radical primary debridement and single stage reconstruction
- accept that may excise more tissue than required but avoids dessication of underlying structures and achieve good primary healing

However, type IV injuries represent high energy trauma and had low rates of primary healing with single stage approach therefore recommend serial wound excision prior to reconstruction.