CLINICAL OBSERVATION OF SUCCESSFUL TREATMENT OF A PATIENT WITH POLYTRAUMA AND OPENED FRACTURE OF UPPER ONE-THIRD OF LEFT LEG BONES OF TYPE IIIB ACCORDING TO GUSTILO-ANDERSON Blazhenko A.N., Kurinny S.N., Mukhanov M.L., Afaunov A.A.
Kuban State Medical University, Krasnodar, Russia
Unfortunately, the current incidence of infectious complications after Gustilo-Anderson type IIIB opened fractures is 10-67 % according to various authors [1-4].
In its turn, if infectious complications develop, then chronic osteomyelitis appear in 8-25 % of cases, and 40 % of patients demonstrate some disorders of fracture union, resulting in disability in almost half of patients with such injuries [2, 4].
According to some authors [1, 5], most poor outcomes of treatment are determined by mistakes in primary surgical preparation (PSP), recurrent surgical preparation (SP) of opened fracture wounds.
Objective – to discuss the features of staged surgical treatment of patients with polytrauma, including severe opened fractures of limb bones type III by Gustilo-Anderson.
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and the Rules for Clinical Practice in the Russian Federation (the Order by Health Ministry of RF, 19 June 2003, No.266), with written consent for use of the data and approval from the local ethical committee of Kuban State Medical University (the protocol No.69, 26 October 2018).
MATERIALS AND METHODS
The clinical case presents the surgical treatment of the patient K., female, year of birth 1998, case history No.28561, with high energy injury as result of road traffic accident (collision of two cars, the patient was a driver). She was admitted to the nearest level 2 trauma center [6] for realization of medical care (primary admission hospital) 30 minutes after injury.
The diagnosis was: “Polytrauma (severe associated injury to the head, abdomen and lower extremities)”:
- a dominating injury – abdominal injury: splenic and hepatic rupture, ongoing bleeding into abdominal cavity, hemoperitoneum – 1,000 ml (AIS = 5);
- closed traumatic brain injury, brain concussion. Closed abdominal injury. Splenic and hepatic rupture (AIS = 1);
- Gustilo-Anderson type 3B opened fracture of the left leg in the upper one-third (Fig. 1); a contused wound of the upper one-third of the right leg with penetration into the knee joint (AIS = 2).
Figure 1
The patient K.: X-ray image of the tibial fracture to the left, performed after admission.
Polytrauma severity according to AIS/NISS – 30 points (polytrauma with probable lethal outcome).
The life-threatening consequence of the injury was traumatic shock of degree 2, massive hemoperitoneum, ongoing bleeding into abdominal cavity.
Stages of surgical treatment
The first stage: urgent surgical interventions for arresting bleeding in abdominal cavity were carried out in the primary admission hospital: laparotomy, abdominal cavity revision, splenectomy, liver rupture suturing; then, traditional primary surgical preparation (PSP) [1, 5] of the wound of Gustilo-Anderson type IIIB opened tibial fracture was conducted; it was completed with suturing (sealing) of the wound and with application of the external fixing apparatus (EFA). PSP for the wound in the upper one-third of the right leg with penetration into the knee joint was realized; it was completed with suturing (sealing) of the wound and application of plaster bandage.
After achievement of relative stabilization of the patient’s condition, 19 hours after trauma, she was transferred by the sanitary aviation reanimobile to the regional multi-profile hospital (Research Institute – Regional Clinical Hospital No.1, Krasnodar) for arrangement of specialized medical care.
The second stage:
- recurrent surgical preparation (SP) of the wound of the Gustilo-Anderson type IIIB opened fracture of the left leg was conducted 2 hours after transfer to the regional multi-profile hospital, or 21 hours after the injury. The sealing sutures were removed. The regions of formed necrosis of covering tissues were dissected. As result, a defect in covering tissues appeared. VAC-dressing was applied (Fig. 2, 4) [1, 7, 8].
Figure 2
The patient K.: sutured wound (a) of Gustilo-Anderson type III opened fracture of the left tibia with the emerging area of necrosis of covering tissue; (b) the sutured wound of the upper one-third of the right tibia.
Figure 3
The patient K.: the wound of the upper one-third of the right shin (a) penetrating into the cavity of the knee joint after removal of seams.
Figure 4
The patient K.: sutured wound after recurrent surgical treatment and drainage of the knee joint (a), the wound of the upper one-third of the right tibia, (b) VAC dressing placed on the wound of an opened fracture of the left tibia.
- recurrent SP of the wound in the anterior internal surface of the superior one-third of the right leg with penetration into the knee joint cavity; wound revision (Fig. 3), wound toilet with antiseptic solutions, active draining of the cavity of the right knee joint; considering the satisfactory condition of soft tissues of the wound, the layer-by-layer sutures were applied.
The third stage: after 48 hours, the planned recurrent SP was conducted. It was directed to dissection of the formed necrosis of soft tissues, to wound toilet, change of VAC-dressings. The wound discharge was examined for presence of microflora (the result was negative, microflora growth was not identified).
The fourth stage: on the fifth day after transfer, in absence of signs of covering tissue necrosis and negative result of presence of bacterial flora in the wound discharge, the covering tissue defect in the anterior internal surface of the upper one-third of the leg was closed by means of myoplasty for the covering tissue defect with use of the tissues of the medial head of gastrocnemius muscle, with split skin autografting (Fig. 6, 7) and simultaneous internal osteosynthesis of tibial fracture with the angle stability plate (Fig. 5, 8).
Figure 5
The patient K.: the implementation of the semi-enclosed bridge osteosynthesis of the tibia plate with angular stability (а).
Figure 6
The patient K.: performance of myoplasty of the defect of covering tissues of the upper one-third of the left shin with the medial head of the calf muscle, (a) calf muscle before closing the defect of cover tissues.
Figure 7
The patient K.: the condition of the wound after the closure of the displaced head of the gastrocnemius muscle, split skin graft, (a) state after dermatomes plastics defect of the skin split graft.
Figure 8 The patient K. radiograph of tibial fracture, after performing bridge osteosynthesis with a plate with angular stability.
RESULTS
After the multi-staged surgical treatment, the wound of Gustilo-Anderson type IIIB opened fracture of the left tibia completed without complications; the processes of bone reparative regeneration were not disordered. The figures 9 and 10 show the result of treatment in 3 months (X-ray images and condition of covering tissues in the fracture site). The patient could walk without a cane.
Figure 9
The patient K.: radiographs of the patient in 3 months after completion of surgical treatment, signs of the forming fusion of fragments are determined.
Figure 10
The patient K.: the limb of the patient after 3 months after the completion of surgical treatment (a) the covering tissues in the area of the former defect in a satisfactory condition
CONCLUSION
1. The treatment of patients with polytrauma and Gustilo-Anderson opened fractures of long bones should be performed in level 1 trauma centers. The transfer of such patients from primary admission hospitals is realized within 24 hours after trauma for the purpose of realization of staged specialized surgical management.
2. Traditional PSP with wound sealing for Gustilo-Anderson type IIIB opened fractures promotes the disordered blood circulation and necrosis of covering tissues in the fracture site; it can lead to exposure and necrosis of the bone and to development of infectious complications.
3. The planned recurrent SPs with staged necrectomy and vacuum assisting for prevention of infectious complications and correction of covering tissue defects in the fracture site should be initiated immediately after transfer to the level 1 trauma center. It decreases the necrosis square and sizes of a covering tissue defect, prevents osteonecrosis in the region of bone exposure and creates the conditions for realization of final internal osteosynthesis.
4. In absence of signs of soft tissue necrosis in the fracture site, negative results of wound discharge for presence of microflora, it is possible to perform internal fixation simultaneously with plasty for a covering tissue defect.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.