PREOPERATIVE DIAGNOSIS: Right open grade 2 tibia-fibula (tib-fib) fracture, with multiple facial lacerations.
POSTOPERATIVE DIAGNOSIS: Grade 2-3 open tibia-fibula (tib-fib) fracture, with multiple facial lacerations.
SURGICAL PROCEDURE: Right leg wound irrigation and debridement, and reduction of the tib-fib fractures, with application of external fixator and three compartment fasciotomies.
INDICATIONS: The patient is a 50-year-old homeless alcoholic, who while on a bicycle was struck by a motor vehicle, injuring his right leg and face as he impacted the car. He was extracted from the windshield by the EMTs who were called. Evaluation in the emergency room revealed open injuries to the right leg, with bone exposed. Given this, I was asked to see the patient. After discussions with both the patient and his sister, consent for emergent irrigation, debridement, and realignment with external fixator to the right leg was performed. In the emergency room, the patient had grossly intact sensation over the dorsum and plantar aspect of the foot, but demonstrated dorsiflexion to the toes. He had 2 lacerations overlying the anterior and proximal aspect of the tibia, that were approximately 2 cm in length, and then distally a larger laceration of approximately 6-7 cm in length. Exposed bone was noted through the wound. Some debris was noted on the ends of the bones, consistent with contamination.
DESCRIPTION OF THE PROCEDURE: The patient was brought to the operating room, and placed on the operating room table. While awake, his cervical collar was removed. He was asked to move his head with rotation and flexion/extension, and demonstrated no pain. After administration of a general anesthetic, with the patient's C-spine held in neutral alignment, intubation was easily achieved. A proximal tourniquet was applied to the right upper thigh, and the patient's leg was prepped and draped free in the usual sterile fashion.
Again, we began by inspecting the wound, after irrigation with 3 L of fluid through it, to remove any gross debris. Inspection of the ends of the wound revealed material that was impregnated within the cancellous bone several centimeters up the intramedullary canal that appeared consistent with a sock material. No other debris was encountered. Clot and loose bone fragments were removed, and fortunately were small. Significant large segmental pieces were noted in the distal fragment. The leg was quite unstable, and the proximal long oblique fracture point had come anterior to the posterior tibia tendon and buttonholed through the skin and fascia. Once the wound had been cleaned again with more pulsatile lavage, relocation of this exposed bone within its normal bed was achieved with longitudinal traction. Inspection of the soft tissue stripping revealed a fair area of degloving that extended several centimeters circumferentially, but primarily anteriorly proximally around the open wound.
Extension of the laceration 2 cm above and below this was performed to enhance irrigation and debridement. Irregular swelling in the anterior compartment was noted proximal to this, just lateral to the other laceration, and expression of anterior compartment musculature out this wound could be achieved. Essentially, this was transected internally. Extension of this wound was performed to 3-4 cm, to allow removal of any devitalized tissue, and copious irrigation was performed here, as well. No foreign debris was encountered in this location. Given the extensive soft tissue and bony injuries, it was felt fasciotomies would be appropriate, and so through the distal and proximal incisions, fasciotomy of the posterior and anterior compartments was performed, respectively. Later, a lateral incision would be made 4 cm in length, through which fasciotomy was performed here. Much of the fascia had been disrupted laterally, and just proximally was extended with finger dissection. In the medial wound, what appeared to be the saphenous vein had been transected. The posterior tib appeared to be quite shredded, but intact. Identification of the posterior tibial artery and nerve were not performed, but no significant arterial bleeding was encountered. The tourniquet was left up throughout. Next, 2 pins were placed from anterior to posterior, between the 2 lacerations and just proximal by 3 cm to the proximal fracture on the tibia. These pins were placed perpendicular to the bone, bicortical in nature, and were pre-drilled. A multi-pin clamp was then assembled over this, and a through-and-through pin was placed on the calcaneus proximally 2-3 cm anterior to the posterior edge of the tuberosity, and 2-3 cm dorsal to the plantar surface of the tuberosity. This was well posterior and inferior to the neurovascular bundle. A stab incision was made, and blunt dissection made through the skin, down to bone. This was pre-drilled, and the Steinmann pin with central pins was then inserted, passing this through the lateral side of the heel. An incision was made over the tip of the pin, and this was extended to the central portion of the pin. A medial bar was then applied with a pin-to-bar clamp distally, and a second bar was placed with a pin-to-bar clamp distally and through the proximal pin, to provide a delta construct. With longitudinal traction and manipulation at the fracture site, gross alignment could be achieved. This was a very unstable fracture pattern, and given the obliquity of the fracture, it easily displaced. However, with some tedium we were able to maintain overall gross alignment in both coronal and sagittal planes. A small fixator pin was then placed in the first metatarsal perpendicular to its surface bicortical. This was attached to the lateral bar through a bar-to-bar clamp, and then from a bar-to-pin clamp. This allowed the foot to be stabilized in neutral dorsiflexion. A lateral compartment fasciotomy was completed, as previously noted. Copious irrigation was again performed using antibiotic bug juice deeply, with approximately 10 L of fluid being irrigated through the wounds at various times. Attention was taken off of the pin site locations, and dressing with Xeroform over both the wounds and the pin sites was completed without difficulty. The 4x4s, Kerlix, and Ace wraps were used to dress the wound.
The patient was reversed from the general anesthetic, and returned to the recovery area in stable condition.
There were no complications, blood loss was 250 cc, and overall the patient tolerated the procedure.