Case 30 Open Wound: Upper Third of Leg

Reena A. Bhatt

Gustilo IIIB (see Table 30.1) injury with open wound involving the upper third of the right lower extremity
The proximal third of the anterior tibia is exposed and a bony defect with a spacer is in place

There is a comminuted fracture and significant soft tissue loss, without evidence of vascular injury

Table 30.1 Gustilo classification of open tibial fractures
Grade	Wound	Bony injury
I	<1 cm, clean, minimal soft tissue injury	Simple, with minimal comminution
II	>1 cm, moderate contamination, moderate soft tissue injury	Moderately comminuted fracture
IIIA	<10 cm, crushed tissue and/or contamination; local coverage usually possible	Significant contamination or segmental bone loss; possible vascular injury; highly contaminated wound; high velocity injury
IIIB	>10 cm, crushed tissue and/or contamination; inadequate soft tissue; requires regional or free flap	As above
IIIC	Major vascular injury requiring repair for limb salvage; in some cases, amputation is necessary	As above

Etiology
- Traumatic: Mechanism of injury
- Tumor resection: Extent of resection
- Chronic: Etiology of wound and history of previous management (e.g., history of osteomyelitis—cultures, antibiotics, debridement)
Age and comorbidities (diabetes, peripheral vascular disease, coronary artery disease, smoking history, steroid use, history of or planned radiation, malnutrition)

In acute trauma cases, evaluate ABCs
Assess wound
- Soft tissue injury: Size, depth, and zone of injury
- Degree of contamination and exposure of vital structures
- Vascular supply to lower extremity, bony defect, and periosteal injury
- Tendon exposure: Paratenon intact versus damaged
Vascular examination
- Evaluate pulses, temperature, color, and turgor
- Ankle-Arm Index (AAI) measurements and Doppler examination
Neurologic examination: Check for peroneal or tibial nerve injuries
Rule out Compartment Syndrome
- Tenderness over compartments involved
- Pain out of proportion to injury on flexion/extension of extremity
- Compromised neurovascular status (late finding)
- Absolute compartment pressures >30 mm Hg or difference between diastolic pressure and compartment pressure < 30 mm Hg