Case 32 Open Wound: Lower Third of Lower Leg



Marten N. Basta and Daniel Kwan

Case 32 Open Wound: Lower Third of Lower Leg

Case 32 The orthopedics service contacts you to assist in management of a 42-year-old male involved in a motor vehicle accident with an open comminuted tibial fracture of distal left leg. He has visible soft tissue deficit and areas of moderate periosteal stripping of bone.



32.1 Description




  • Gustilo grade IIIB (see Table 30.1) open comminuted distal tibial fracture



  • Full-thickness defect of anteromedial distal third of leg with inadequate local soft tissue

































    Table 32.1 Gustiloclassification 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




32.2 Work-Up



32.2.1 History




  • Mechanism of injury/Etiology of wound (traumatic, oncologic, vascular insufficiency, etc.)



  • Comorbidities of prognostic significance




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



  • Support network



32.2.2 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




    • Examine 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




    • Compromised neurovascular status



    • Tenderness over involved muscular compartments and pain out of proportion to injury on flexion/extension of extremity



    • Absolute compartment pressures >30 mm Hg or difference between diastolic pressure and compartment pressure <30 mm Hg



  • Potential donor sites



  • Fractures: 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 32 Open Wound: Lower Third of Lower Leg

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