A 30 year old male fell off of a motorbike and sustained a fracture tibia and fibula. The following is a clinical image of his leg.
I would review the patient immediately, ensure satisfactory primary and secondary survey.
Documentation of NV structure. If vascular concern discuss with vascular surgeons and consultant on call.
Treat according to BOAST guidelines, Abx until closure, washout/debridement within 24 hours, tetanus, saline soaked gauze and application of an above knee plaster of Paris.
Discussion with plastics, ? Exfix
- Compartment syndrome
- Vascular injury
- Gross contamination
- Multiply injured patient
Objective criteria used to predict amputation. It includes:
0) Little or no soft tissue injury
1) Superficial abrasion with contusional damage to skin or muscle
2) Deep contamination with local contusional damage
3) Extensive contusion or crushing of skin or destruction of muscle.
1) Clean <1cm
2) 1-10cm no extensive soft tissue damage
3a) Contaminated wound (high-energy, gunshot, farm yard) or extensive periosteal stripping with large skin wound (>10cm)
3b) As 3a but requires flap coverage (plastics)
3c) As 3a but requires vascular repair (vascular)
Injuries should be classified at surgical debridement after wound excision rather than on initial presentation.
Owens et al. Performed in sheep and at 48 hours the group treated with low pressure lavage and saline showed the lowest rebound in bacterial counts.
In an appropriately marked and consented patient.
I would extend the wounds along fasciotomy lines. I would debride the wound edges.
I would deliver the fracture edges. Devitalised bone would be removed (tested using the tug test).
I would debride all devitalised tissue clockwise from superficial to deep
Subsequently irrigate with saline solution (low pressure should be used)
Type 1 3L
Type 2 6L
Type 3 9L