Highenergy gunshot wound to tibia Case History 2

High-energy gunshot wound to tibia Case

History • • • 2 26 -year-old healthy male Gunshot wound (M 16, 5. 56 mm bullet) 1 hour prior to admission Isolated leg injury No pulses noted Tibial and common peroneal nerves nonfunctional

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What to do? • • 4 Amputate? Salvage?

Day of admission • • • 5 Vascular exploration and temporary vascular bypass Debridement and temporary stabilization with external fixator Vein graft reconstruction—popliteal to tibial artery bypass Temporary soft-tissue coverage Broad spectrum antibiotic coverage

After external fixation and vascular repair 6

Day 2– 3 Second look surgery and re-debridement 7

Day 4 • Local gastrocnemius flap • Definitive fixation - Ring fixator—“Hexapod” 8

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Follow-up over 18 weeks • Soft-tissue healing but a small intermittent sinus continues over anterior medial side of leg • When patient receives antibiotics swelling and sinus resolve • Plan - Continue with correction as regenerate will “burn out the infection” 10

18 weeks 11

Rationale for waiting in the face of continued infection • • • Fixation stable Fracture showing signs of healing Patient not threatened by sepsis • Plan - Wait for fracture to heal then deal with infection 12

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24 weeks fracture seems healed radiologically but sinus much worse 14

24 weeks: decision making • Need to address infection • • Hard- and soft-tissue debridement Free flap for soft-tissue cover • 15 Eradication of dead space and blood supply

Day of reconstruction 16

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What is the diagnosis? 18

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Retained sponge • • • 20 Sponge removed at site of proximal vascular anastomosis Debridement Negative pressure (vacuum-assisted closure) dressing

• • • 21 Soft tissue and bone healed No sensation on sole of foot Persistent peroneal nerve palsy

Take-home messages • • • 22 Always look at the whole x-ray Take nothing for granted Trust only yourself