Limb Salvage – A Beneficial Alternative to Amputation
Brig Gen Prof Dr M A Mannan, Dr Masum Billah
The limb salvage has advanced since the time of the Civil War, when nearly all severely traumatized limbs were amputated. The primary goal of limb salvage is to restore and maintain stability & ambulation. The decision to salvage the critically injured limb is multifactorial and should be individualized along with definitive indications. Limb salvage is more cost-effective than amputations in the long run, so early detection and management is beneficial for the patients. A 39 year old Chinese male patient was admitted in United Hospital through Accident & Emergency department with history of blast injury (Air Conditioner blast at work place) severe lacerated injury in his left thigh and leg with burn injury of both hand and face with multiple abrasion in the right leg with pain and active bleeding. X-ray of left lower limb revealed open segmental fracture of upper 3rd and severely comminuted fracture of lower 3rd of left tibia with bone loss from middle 3rd of left tibia and comminuted fracture of middle 3rd of left fibula. He had no other medical co-morbidity. His clinical presentation indicated:
- Open contaminated and lacerated wound from postero-medial aspect of left thigh to lower leg, with exposed bone (Tibia). Lower 1/3rd of the left lower limb was swollen and painful with active bleeding. Loss of skin and sub-cutaneous tissues, also medial head of gastrocnemius, Tibialis Posterior, Extensor Hallucis Longus and Soleus muscles were lost. Movement of left lower limb was restricted. No neurological deficit of left foot was present. Left Arteria Dorsalis Pedis (ADP) was palpable and he could move all toes actively.
- Left heel was swollen, bruised and had blisters.
- Multiple abrasions in the medial aspect of right thigh and leg with tenderness. Movement of right lower limb was painful and restricted. No neurovascular deficit of right lower limb was present. Right ADP was palpable. Could move all toes actively.
- Severe burn injury (Superficial burn) of both hands including all fingers, wrist joint with dorsal and volar aspect of both hands. The range of movement (ROM) of both wrist joints were painful and restricted. Radial pulse was palpable with no neurological deficit.
- Superficial burn was present on whole face, both ears, scalp, eyebrow and eye lashes. No injury was found in eyes though inhalation burn was present.
Surgical toileting, wound debridement and immobilization were done by uni-axial external-fixator on first day. Then series of operations were performed to save the limbs, these being: a) Local flap mobilization to cover bony area b) Muscle flap mobilization of lateral head of gastrocnemius muscle and lower end of medial gastrocnemius muscle to cover anterior aspect of tibia c) Split thickness skin graft with flap mobilization done by Plastic Surgeon d) After controlling the infection and proper healing of the wound, uni-axial external fixator was removed and application of ILIZAROV external fixator done e) Burn dressing done by Plastic Surgeon in between the series of surgical procedures routinely Post-operative rehabilitation was done under supervision of physiotherapist to improve movement of all joints, restore stability and ambulation. The patient has gone back to China, in follow up communication he has informed that doctors in China have assessed and appreciated the treatment given here and also agreed with our next plan of treatment which is transportation of tibia to fill the gap by ILIZAROV.