Search

This case report describes the management of a 27-year-old male who, after a quadbike accident, presented with an open, infected, segmental both bone forearm injury with significant bone and soft tissue loss including the radio-carpal joint. Limb salvage was accomplished in the form of a single bone forearm fusion utilising Masquelet's two-stage induced membrane technique to reconstruct the segmental bone defect. The patient proceeded to uneventful bony union by 6 months and returned to driving and riding a quadbike. Despite significant deep infection, successful salvage was achieved using the induced membrane technique. Critical to success was aggressive, repeated debridement alongside restoration of vascular supply and reconstruction of soft tissue defects. We highlight the multidisciplinary approach to management including relevant specialists with a particular interest in limb reconstruction.

To provide an overview of patient management and surgical technique regarded as best practice in optimising outcome following primary and secondary amputation in trauma patients. This is supported by evidence where available. There is increasing evidence that primary amputation may offer superior outcome to reconstruction in severe open lower limb injuries, particularly segmental trauma involving the foot and tibia. Similarly, patients considering complex reconstructive procedures for failed trauma management should be counselled that reported outcomes are equivalent or better following amputation and are achieved faster and with less complications. Patients should be fully informed of this when making decisions about management, though this needs to be individualised. Various surgical techniques have been associated with improved outcome and these are described herein. Careful peri-operative pain management has been associated with faster rehabilitation, better psychological response and a reduced risk of chronic pain. On discharge, patients should be linked to rehabilitation, prosthetic and clinical psychology services and these should be integrated where possible. A holistic, multidisciplinary approach is recommended in all aspects of care and should be available from the outset. Patients should be optimised medically and functionally, where possible pre-operatively. Psychological assessment and early information sharing are recommended. Where this is not possible due to acuity, these issues should be addressed as soon as possible post-amputation. Particularly where the limb is severely injured, careful planning and joint operating by senior Orthopaedic, Plastic and Vascular surgeons can achieve the best results.

Purpose With an ageing population, the incidence of trauma in those aged over 65 years is increasing. Strategies for dealing with these patients must be developed. At present the standard management of open tibial fractures in the UK is described by the BOAST4 guidelines (from the British Orthopaedic Association and British Association of Plastic & Aesthetic Surgeons). It is not clear to what extent these are appropriate for older patients. We describe our experience of managing elderly patients presenting with open tibial fractures. Method Patients were identified via prospectively collected national and departmental databases. These data were supplemented by review of the patient records and radiographs. Data collated included patient demographics, injury details, orthopaedic and plastic surgery operative details, and long-term outcomes. Results Between January 2013 and June 2016, 74 patients aged over 65 years were admitted with open lower limb fractures. 54 of these were open tibial fractures and these patients formed the study group. 19 patients required soft-tissue reconstruction for Gustilo and Anderson IIIB tibial fractures (age range, 67–95 years). In these patients, there were 7 midshaft (AO 42), 1 proximal (AO 41), and 11 distal (AO 43) fractures. 13 patients were treated with internal fixation and 6 with circular frames. The median length of hospital stay was 27 days (range, 4–85). 14 patients received loco-regional flaps and 5 underwent free tissue transfer with one requiring preoperative femoral angioplasty. There were no flap losses. Four patients had fasciocutaneous flaps, 3 tibialis anterior transposition, 2 an extensor digitorum brevis flap, 1 a hemisoleus flap, and 4 were skin grafted. All patients went on to unite and return to their premorbid weight-bearing status (4 using walking frames, 3 using sticks, and 12 walking independently). Conclusion Although the literature suggests a significantly higher complication rate in elderly patients with open fractures, we have demonstrated comparable rates of flap survival and bony union to those observed in younger patients. Challenges are presented in terms of patient physiology and these must be carefully managed pre- and postoperatively. These challenges are reflected in prolonged hospital stays.