A 17 years old male patient sustained road traffic accident where his right knee was badly crushed between a cement wall and a speedy car.
The injury was closed, but there was severe soft tissue swelling all around the distal thigh, knee and proximal leg with markedly contused skin circumferential. The distal pulses were well palpable and no signs of nerve injury. The swelling was rapidly increasing and it was obvious that there was an internal extensive degloving injury of the skin and subcutaneous tissue.
X-ray Right knee showing; comminuted ipsilateral distal femoral and proximal tibial epiphyseal fractures
CT-SCAN: Right knee sagittal view showing, comminuted ipsilateral distal femoral and proximal tibial epiphyseal fractures
Challenges and questions:
1. Very comminuted epiphyseal fractures in skeletally immature pt patient who is swimming champion! What to do next?
2. What will be the methods of fixation? and why?
3. Very severe soft tissue injury and marked swelling, extensive hematoma and skin degloving that preclude any formal anatomical open reduction and fixation.
4. No available local tissue for plastic reconstruction.
5. Very limited options for proper rigid fixation in view of the bad soft tissue condition.
6. Long duration is expected for the soft tissue to heal adequately to allow safe further surgical bony reconstruction.
7. Very high chance to end up with badly stiff or ankylosed joint!
8. Risk of infection is a formidable sequel!
9. Lengthy spanning external fixator is very detrimental for future knee function.
Any suggestions or novel ideas?
Dr. Ashraf Khalil, FRCS, MD
Consultant Orthopedic Surgeon,
King Fahad Hospital,
Medina, Saudi Arabia
Management and treatment:
Intraoperatively, there was huge clotted subcutaneous hematoma all around the knee, distal thigh and proximal leg, which was initially evacuated through small skin incision. Because of the bad skin and soft tissue condition, the decision was taken to perform minimal percutaneous reduction of the epiphyseal elements with percutaneous cannulated screws fixation and trial of aligning the distal femoral and proximal tibial articular blocks as near anatomical as possible and maintaining that alignment with spanning external fixator. The tibial reduction and fixation was more satisfactory than the femoral one which showed some residual malalignment.
2 days later skin necrosis and gangrene were established which necessitated formal extensive debridement by the Plastic Surgeon who found uncovered lateral femoral condyle due to subcutaneous tissue sloughing. It was necessary to remove the distal femoral hindering pin and the lateral femoral condyle was partially covered by the lateral head of gastrocnemius flap. Then repeated debridement and wound care sessions were performed by the plastic surgeon in operating room followed later on by vacuum dressing till satisfactory granulation tissue was formed. Next, split thickness meshed skin graft was performed. And we are still waiting for healing of the skin grafting to consider further management.
Dr. Ashraf Khalil would like to thanks all for commenting and discussion on this case.