Limb threatening injuries

I've been struggling to come up with a clinical topic for the blog, but a comment in the notes from one of the physiotherapists gave me an idea. It was "limb-threatening injury. High risk of significant contractures of elbow and shoulder". The patient is a 20 year old lady, who has a child of 6 months. She suffered a full thickness burn to her non-dominant arm, which was managed expectantly at another hospital for three weeks. As could have been predicted, the wound did not heal and she started to scar with her arm stuck straight at the elbow and in at her side. Since her arrival, we have excised the burn and grafted the arm. It was also splinted, but she removed it because of discomfort (twice) and so she is starting to develop more contractures.

Major limb threatening injuries are something we see quite commonly at SFH. They are either due to comminuted open fractures with significant tissue loss, massive soft tissue trauma or burns. The first two are normally due to traffic incidents. In the UK, I have had limited exposure to these injuries, as they are managed by teams of surgeons (plastic, orthopaedic and vascular) in tertiary centres, with most operations done by consultants. Open fractures are graded from 1 to 3, depending on the degree of soft tissue damage. Fresh grade 1 fractures can be cleaned, sutured, placed in plaster and given antibiotics. All others need cleaning, fixation (often externally) and sometimes skin flaps or grafts to cover the defect. Infected open fractures need external fixation and scrupulous wound management, as well as antibiotics.

What we are able to do here is more limited than at home, but still normally saves the limb. I was discussing with a visiting orthopaedic consultant from Addenbrooke's what he would do differently in the UK, as he operated on a comminuted open knee fracture. Interestingly, the only big differences were the need for vascular imaging to rule out an arterial injury, and intra-operative radiology. So, we have the majority of the kit needed to do things properly, and the skills (Prof is trained in trauma surgery), what often hampers us is the level of understanding in our referral centres, or even junior staff.

One of the things I have been trained in since arriving at SFH is application of external fixators, and I have now operated on quite a few open fractures. The very pleasing ones are those that come early, with limited infection or soft tissue loss, who can then be fixed and discharged with the fixator after a week or so. Others are more of a challenge. We have one young man in hospital at the moment, who had a huge devolving injury of his leg, with an open ankle fracture (following an assault). He was sutured and put in plaster by another hospital, and came here after two weeks, with a huge soft tissue defect and pus pouring out of his ankle. After two weeks of external fixations and wound care, we have now grafted his leg and expect to be able to put a flap on his ankle in the next month or so. What was very much a limb-threatening injury appears to be salvaged.

There is however a lot of dogma associated with open fracture management (and limb burns, which I will touch on later). One of our difficult patients at the moment presented with a fresh grade 1 (open) tibia fracture (it is in fact in four pieces), and the on call debrided the wound and placed it in plaster. Unfortunately, despite the instructions in the notes, and the assistant saying the fracture should be sutured, the wound was left open, with exposed fracture at the base. Essentially an iatrogenic grade 3 fracture. We then had to apply an external fixator and make a fasciocutaneous flap to cover the defect. When asked why he had ignored the departmental policy and written instructions, I was just told that open fractures should never be closed. The patient will however keep his leg, and regardless of how it was fixed, he is going to be a long time recovering (we are considering plating his tibia in the next few weeks).

We do have some failures. One recently discharged patient had an infected open ankle fracture sutured, and needed external fixation and a flap to save the leg. The fixator has just been removed (it became infected) and the fracture does not look well healed. He is however a very elderly man, so I suspect that having a leg that partly works is acceptable, and we are going to see how he does. We have also amputated a few terrible open fractures in the last few months, that for reasons of infection or vascular compromise were just not salvageable.

Returning to the first case, the burnt arm, I suspect she will always have a poorly functioning arm. Ideally, earlier grafting and splinting would have made things much better. The policy in a lot of hospitals of referring only when burns do not heal means we start trying to save the limb a step behind where we would like to be. Patients do seem more likely to remove dressings and splints than at home, so compliance is also a major issue. But, working within the limitations of our skills, and the available kit, I think we do alright!