Open crushed Complex fracture dislocation of right lower limb with vascular injury

1. Case discussion
on
Open crushed Complex fracture dislocation of
right lower limb with vascular injury
Guided by Dr Ratnesh singh sir
Presented by Dr Shubhanshu singh

2. Patient detail and History
• My pt name is khusha prasad 37 year old male
• He is apparently alright before meet to road
traffic accident by collision between two auto
which hit directly on his right knee and thigh
in patna on 29/3/22 around 1pm.For that
problem he came to the paras hospital with
presentation of open crushed wound in right
knee and thigh in drowsy condition.

3. Limb examination
• Crushed contaminated wound present in Right
lower limb which extended from anterolateral
aspect of mid thigh to anterolateral aspect of
mid leg around 40*15cm with exposed bone ,
muscle, soft tissue and neurovascular
structure
• Right Ankle toe movement was absent
• Peripheral pulse was not asseseble
• Limb was cold

5. Emergency department management
• Firstly pt come to paras hospital in drowsy condition and our emergency team managed according
to ATLS protocol
• Bp= not recordable
• RR =30/ min
• HR=130/min
• Spo2= 90%
• Temperature =96.5 f/ 36 c
• Resuscitation done pt was not maintaining blood pressure so that After put two wide bore green
cannula and blood sample collect for cross matching and basic investigation then start 2 unit NS
with Norad 20ml/hr.
• prophylactic antibiotics injected on stat
• Tetanus toxoid injected
• Carefully wound examination done and found severely crushed and bleeding structure for that
compression dressing done, clinically present fracture of lower limb and stabilization done with
help of high groin above knee pop slab
• we arranged two unit blood for transfusion . information given to surgery , neurosurgery and ctvs
department for further assessment of vascular and internal injury
• Catheterization done
• 1 unit blood started
• After vitals stabilization head to toe examination done

6. Investigation
• Cbc
• Rbs
• S. electrolytes
• Liver/kidney function test
• ABG analysis
• PT-INR
• Trauma protocol X ray and CT
pelvis/abdomen/chest AP
• Viral markers

7. X ray pelvis both hip AP

8. X ray right knee ap/ lat

9. X ray right leg ap/lat

10. CT pelvis

13. Diagnosis
• After clinical , Hematological and radiological
examination my diagnosis was=
• Hypovolemic shock with complex crush injury of right
lower limb with Vascular injury..
• 1.Open fracture type 3b/c?(Gustilo Anderson)
• 2.Acetabulum associated type of posterior wall with
posterior column(Judet and letournal)
• 3. fracture distal femur type C 33-c2 (AO)
• 4.Posterior dislocation type 3(Thompson and Epstein)
• 5.Subtrochantric type 3b (Seinsheimer)
• 6.Floting knee type E (Lets et. al)

14. Treatment
• After complete Right lower limb assessment we
calculate Rajesekaran Ganga hospital score which is 18
• mangled extremity severity score is 9
• In 1st stage we perform above knee amputation as a life
saving procedure on 30/3/22 around 4am
• After two days we did wound debridement of
amputated stump on 1/4/22
• After once pt get Hemodynamically stable we go for
joint preserving procedure by posterior column and
wall of acetabulum plating and PFN for subtrochantric
fracture of right on 6/4/22

16. 1st Post op x ray

17. Pelvis with both hip ap post op

19. Complications
• At present pts Hb 8.5gm% after 6 unit of blood
transfusion (pre,intra and post op)
• Wbc count 16280
• Platelet count 6.17 lac
• Lactate 0.8mmol
• Pus culture shows klebsiella pneumonie intermideate
sensitive only for colistin
• Afebrile
• HR 90/mnt
• RR 24/mnt
• Now pts improve ………..!!!!