Case 31 Open Wound: Middle Third of Lower Leg



Marten N. Basta and Daniel Kwan

Case 31 Open Wound: Middle Third of Lower Leg

Case 31 A 35-year-old male presents to the Emergency Department after motor vehicle accident, resulting in tibial bone loss and extensive overlying soft tissue damage.



31.1 Description




  • Open wound of the middle third of the right leg




    • Gustilo IIIB (see Table 30.1): Comminuted bony defect with extensive overlying soft tissue defect (>10cm) without vascular injury



    • 30 cm×12 cm soft tissue defect; large area of comminuted tibial shaft exposed and stripped of periosteum



31.2 Work-Up



31.2.1 History




  • Etiology




    • Traumatic: Mechanism of injury; evaluate for concomitant injuries



    • Tumor resection: Extent of resection



    • Chronic: Etiology of wound and history of previous management



  • Comorbidities of prognostic significance




    • Peripheral vascular disease, cardiovascular disease, diabetes, smoking history, nutritional status, steroid use, and radiation treatment



31.2.2 Physical Examination




  • In 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 and 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



31.2.3 Pertinent Diagnostic Imaging Studies




  • X-ray films: Evaluation of bony injuries



  • Computed tomography angiography (CTA)/Angiography indications: Preoperative planning for free flap reconstruction in patients with risk factors for peripheral vascular disease or concerning physical exam


Classification: When a fracture is involved with the injury




  • Gustilo Classification System of Open Tibial Fractures (see Table 30.1)

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Jul 17, 2021 | Posted by in General Surgery | Comments Off on Case 31 Open Wound: Middle Third of Lower Leg

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