Management of Grade 3C Compound Injury of Lower Limb with Floating Knee – Salvage versus Amputation (Case Series)

Abstract

Introduction: Severe open injuries of limbs, especially of the femur and tibia when associated with vascular injuries, present major challenges in management. The decision to amputate or salvage can often be a difficult one even for experienced surgeons. Mangled lower extremity results due to high-energy trauma, especially due to motor vehicle accidents, and is defined as injury to three of the four systems in the extremity that is soft tissues, bone, vascular, and nerve. Open fractures are classified by Gustilo and Anderson’s classification in which type 3B is an injury where soft-tissue loss and primary closure of the wound are not possible and type 3C is any open fracture with vascular compromise. Case Report: We report a series of six ipsilateral fractures of the femur and the tibia treated at the Department of Orthopaedics, Sri Ramachandra Medical College and Hospital, Chennai, Tamil Nadu, over a 3-year period (2014–2017). The mean age of our patients was 30 years old, and there were five men and one woman. The right side lower limb was frequently involved (five cases), and the main etiology was road traffic accidents (six cases). Articular involvement was found in six cases. Skin wounds were noticed in all cases (type III C of the Gustilo classification). Urgent wound care, fluid replacement, and antibiotic therapy were undertaken for open fractures. According to modified Fraser classification, all six cases was classified under type II-C. Mangled extremity severity score for five cases was 7 and for one case it was 8. Ganga Hospital Open Injury Severity Score was also used which was found to be in borderline range of 16 score for three cases, 15 score for two cases, and 14 score for one case. All six cases were managed with serial wound debridement + Ilizarov fixator + soft-tissue repair with involvement of orthopedic, vascular, and plastic surgery team. Limb salvage was done for all six cases after considering all the factors. Postoperatively, rehabilitative

Analysis of the Risk Factors for Free Flap Necrosis in Soft Tissue Reconstruction of the Lower Limbs

“…According to the modified extremity severity score, shock duration and limb ischemia after injury are determinants of one-stage amputation. 20 Post-injury shock implies a high degree of injury and is often associated with major arterial injury of the lower extremities. 21 Theoretically, post-injury shock is associated with free flap necrosis.…”