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
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