SURGICAL TREATMENT OF MASSIVE INJURY TO SOFT TISSUES IN TRAUMATIC DISRUPTION OF THE LOWER EXTREMITY IN A PATIENT WITH POLYTRAUMA
Regional Clinical Center of Miners’ Health Protection,
Leninsk-Kuznetsky, Russia
Most traumatic detachments of the extremities are the result of railway injury, and, rarely, the result of injuries inside a car because of an extremity is compressed and injured with destructing parts of a motor vehicle. Another cause of traumatic amputations is impaction of moving mechanisms at the place of production [1]. More than 60 % of patients suffer from other injuries along with traumatic detachments. Commonly they are extensive wounds and fractures of other extremities, fractures of the pelvis, ribs and traumatic brain injury. Despite the fact that the problem of traumatic detachment has been researched during multiple centuries (mainly in military field surgery), it is still actual in peacetime. Traumatic ruptures of big segments of the extremities are life threatening injuries because of acute blood loss and infectious complications. The mortality is 11 %, with trend to decreasing [2].
The patient L., age of 38, was admitted with a reanimobile to Regional Clinical Center of Miners’ Health Protection. It was 12 hours after the industrial injury. From the history of the disease: an industrial injury – during underground service works his hand was impacted by the moving mechanism. After evacuation to the surface the patient was admitted to the nearest hospital. Then he received the emergent surgical preparation of the wound of the left hip, the perineum and the scrotum. After surgery the patient’s condition was estimated as extremely severe. During the first 12 hours after the injury the patient was transported with the reanimobile to Regional Clinical Center of Miners’ Health Protection. The transportation was realized with the special reanimobile over the distance of 200 km.
After hospital admission the patient received the X-ray examination, chest and abdominal MSCT. The diagnosis was made on the basis of the results of the examination: “Polytrauma. Traumatic detachment of the hip at the level of the proximal one-third. Tear-contused wounds of the perineum, the scrotum and the pubic region. Massive detachment of soft tissues in the gluteal and lumbar regions to the left. Acute blood loss. Traumatic shock of degree 3. ISS = 32. Blood loss of 40 % of total circulating volume of the blood”.
After collegial discussion the plan of treatment was developed on the basis of the integrative approaches in traumatology. First of all, it was decided to continue the anti-shock therapy for correcting the hemostatic disorders in the intensive care unit. Infusion therapy was realized with crystalloid solutions and donor blood components with 1:1 ratio.
On May 29, 2016, after hemodynamics stabilizing, the patient received the surgery – secondary surgical preparation of the wound in the region of the perineum, the scrotum, the residual left hip; laparoscopy, laparotomy, creation of hanging sigmostoma. The revision of the wound identified an extensive injury to soft tissues of the perineum with damages of the pelvic floor muscles, the injured scrotum, extensive detachment of the soft tissues of the left gluteal region and the left lumbar region with transition to the lateral abdominal wall, the left iliac region and the region above the pubic. There were no injuries to the rectum, the scrotum and cavernous bodies of penis. We identified ischemia in the skin flaps of the left hip and the gluteal region to the left (Fig. 1).
Figure 1Genera view of the wounds of the perineum, the marsupium and the left hip with regions of necrosis
Secondary contamination of the wounds was prevented with laparotomy and creation of the hanging sigmostoma in the left hypochondrium. During the postsurgical period the patient received the intensive care and antibacterial therapy for prevention of infectious complications.
As far as the regions of necrosis appeared, the patient received the staged necrectomy (Fig. 2).
Figure 2 The stage of necrectomy of the wounds of the perineum, the marsupium and the left hip
Daily dressings and necrectomy allowed preventing purulent processes in the wound and intensifying the processes of tissue regeneration in the wound. After preparation of the wound surface the autodermoplasty with the split-thickness skin graft (from the anterior surface of the right hip) was conducted(Fig3). The sigmostoma was closed after complete recovery of the wounds. Altogether the patient received 5 surgical interventions including laparotomy with creation of the sigmostoma, staged necrectomy, autodermoplasty and closure of the sigmostoma (Fig. 4).
Figure 3 Autodermoplasty of the left hip wound
Figure 4 Appearance of the wound of the perineum, the marsupium and the left hip
The patient was discharged from the hospital on August 12, 2016. His condition was satisfactory. The total duration of the hospital treatment was 76 bed-days including 45 bed-days in the intensive care unit. After 5 months the control examination showed that the patient could perform independent movements without crutches, as well as presence of erectile function.
The presented case of the patient with polytrauma showed that the results of the treatment were achieved by means of realization of the following materials:
- transfer to the specialized hospital was performed by the instant readiness team within 24 hours after the injury moment;
- the treatment was based on the complex approach including intensive anti-shock therapy, staged surgical sanitation of the infected wound.