SAWMA

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SAWMA SAON Joint Meeting

• Case Study May 2006

Ms Belinda Fowlie CNC Plastics
Orthopaedics Flinders Medical Centre
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• BL 24 year old male
• Fit and Well
• No significant PMH
• Moved from Tasmania to Adelaide to try out for
  Adelaide Crows
• Temporarily working in Naracoorte on a farm

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Work Accident

• Traumatic injury to lower legs 10/2/06
• his 24th birthday
• Lower legs trapped in mechanical irrigation
  wheel, while a hose attached to the wheel wrapped
  around his thighs giving a tourniquet effect
• Trapped for a number of hours
• Rescued
• Air lifted to FMC

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Sustained

• R Tibia comminuted shaft
• R Fibula transverse shaft
• No external STI
• L foot Lisfranc
• L distal Fibula
• Partial thickness dorsum foot de-gloving

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Treatment R leg

• R Tibia OT for IM nailing to.
• R Fibula conservatively managed
• R leg backslab for support
• Was allowed to WBAT on R leg with backslab
  support.

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Left Foot

• L foot Lisfranc conservatively managed
• L foot de-gloving debridement and STSG
• NWB on L leg with backslab for support.
• RIB 5 days post STSG

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Post Operative 6 hours

• Developed high compartmental pressures in all
  four lower leg compartments of R leg
• Diagnosed with compartment syndrome

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Compartment Syndrome

• A compartment is an area in the body where bone,
  muscle blood vessels are encompassed within a
  dense connective tissue band, called fascia
• Fascia thicker in lower leg to aid in venous
  return
• 4 compartments in the lower leg
• Anterior, superficial, deep posterior and lateral

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Compartments of the Lower Leg
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Pathophysiology of CS

• Compartment syndrome is high pressure in the
  muscle compartments, due to swelling from an
  injury
• Decrease in blood supply to the compartments,
  normally below the injury
• Hypoxia in cells of capillaries
• Capillary wall breaks down
• Fluid escapes (colloid proteins, metabolites)
• Increasing the swelling (compounding the problem)

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• Compartments can only distend so far due to tense
  fascia
• When compartment pressure rises to near or above
  intravascular pressure vessels collapse
• Pressure of 30-40 mm Hg are enough to cause
  venous breakdown and obstruction
• Increase in fluid escape from venous wall
  breakdown venous obstruction
• Compounding the problem further

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• Pressures of 55mm hg are high enough to decrease
  arterial blood flow.
• Breakdown of muscle, nerves, vessels..
• Nerves can last 2-4 hours of ischemia before
  dying, but can regenerate (slowly)
• Muscle 6 to 8 hours, once necrotic, unable to
  regenerate?fibrous scar? contraction

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Clinical presentation

• Five Ps
• 1) Pain, grater than you would expect from the
  injury
• 2) Paresthesia pins and needles
• 3) Paresis weakness in foot due to nerve
  compression
• 4)Pallor ? arterial circulation
• 5) Pulseless ness decrease or cessation of
  arterial flow

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Back to case scenario

• All Four compartments of BL leg were gt 55mmHg.
• A compartment pressure monitor was used to
  identify this
• Calculation of compartmental pressures P
  diastolic blood pressure-Intra-compartmental
  pressures. If P lt 30 mm Hg surgical intervention
  required.
• For example BP 120/80. Compartment pressure of
  55. 80-55 25.

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Treatment

• Returned to OT early next morning for emergency
  fasciotomy.
• Fasciotomy surgical opening of fascia which
  releases the pressure
• Usually a longitudinal lateral and medial
  incision is required to release all 4
  compartments
• Interesting point required a lateral fasciotomy
  only as tibia fracture had penetrated 1
  compartment, communicating it with another.

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Management Plan day 1 post Fasciotomy

• Daily Dressing with adaptic or jelonet / gauze /
  softban / crepe
• Strict RIB with high elevation
• Wait until swelling decreased for primary closure
  /- skin grafting.
• Continue with Cephazolin 1G IV until wound
  closure
• Hb 87 (? 142 pre op)
• CRP 213

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Management Plan Day 3

• Daily dressing continued with jelonet, gauze etc.
• Wound swab taken
• pseudomonas staphylococcus
• treated with IV flucloxicillin 2g 6/24
• Wound inspected daily by MOs
• Painful
• anaesthetics placed epidural catheter in for
  dressings on the ward.

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Day 5

• Further necrosis of muscle occurred, still looked
  clinically infected
• Returned to OT for debridement
• Tissue taken for MCS pseudo, staph and
  enterococcus
• ID consult, added Metronidazole
• Dressing changed to daily SSD dressings

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Day 6 - 14

• Infection continued, 2 more surgical debridements
• Massive muscle loss
• Returned to OT for debridement
• VAC applied on day 14 in OT to reduce deficit

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Day 20

• VAC insitu for 6 days
• many a discussion had with doctors
• Plan for free gracilis flap with STSG to cover
  deficit
• After VAC dramatic reduction in wound deficit.
• Returned to OT for primary closure with STSG to
  cover area where they couldnt close

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Meanwhile..back at the ranch

• L foot
• Day 5 STSG taken down 100 failure!
• ? Causes, mild smoker, ?infection (swab grew
  enterococcus), no evidence of shearing

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• After 30 days
• Allowed to get up and WB on R leg.
• Slow progress was made
• Eventually transferred to RGH to rehabilitation
  on day 38
• Spent 2 weeks in rehab
• Returned home to Naracoorte
• OPD 10/05/06

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• Walked up the ward to visit with aid of crutches
• Wounds healed
• Small area of skin around tendon not healed.
• Con mx