Treatment of the Low Extremity Severe Mechanical Injury with Uncompensated Ischemia (Case Report)

Abstract

Relevance. Discussion of the criteria for decision making “amputation vs. preservation”, when viability of the extremity is uncertain, has been continuing. The case description. The lower extremity of a serviceman was injured by a caterpillar tractor. The severity of the damage was determined by the following conditions: open segmental fracture of the femoral diaphysis, 5 cm traction-compression damage of the popliteal artery, acute thrombosis of the popliteal and tibial arteries, sciatic nerve damage, circular detachment of the thigh skin, acute hemorrhage, II degree shock, and uncompensated lower extremity ischemia throughout 24 hours. The MESS score of the injured extremity was 8 indicating that an amputation would have been considered. Nevertheless, we choose the organ preservation solution with the revascularization of the injured limb segment. A multi-stage treatment was carried out including stabilization of bone fragments, primary reconstruction of the popliteal artery to restore the arterial blood flow in the injured extremity, reperfusion injury and myoglobinuria elimination, intensive kidney protection therapy, infection management, skin defects replacement, orthopedic surgery. As a result of the treatment, the injured limb was saved. The femur fracture healed allowing the patient to walk without assistance. Conclusion. The use of the programmed surgical treatment for severe mechanical injury of the lower extremity, an individual multi disciplinary approach, assessing the severity of systemic disorders, and timely use of extracorporeal detoxification made it possible to avoid amputation, perform organ preservation surgery, and create favorable conditions for restoring the supporting function of the lower extremity.

About the authors

V. V. Khominets

Kirov Military Medical Academy

Email: fake@neicon.ru

Vladimir V. Khominets — Dr. Sci. (Med.), Professor, Head of the Military Traumatology and Orthopedics Department

St. Petersburg

Russian Federation

A. V. Shchukin

Kirov Military Medical Academy

Author for correspondence.
Email: ossa.76@mail.ru

Aleksei V. Shchukin — Cand. Sci. (Med.), Head of the Traumatology and Orthopedics Clinic’s Unit

St. Petersburg

Russian Federation

S. V. Mikhailov

Kirov Military Medical Academy

Email: fake@neicon.ru

Sergei V. Mikhailov — Cand. Sci. (Med.), Assistant Professor of the Military Traumatology and Orthopedics Department

St. Petersburg

 

Russian Federation

D. A. Shakun

Kirov Military Medical Academy

Email: fake@neicon.ru

Dmitrii A. Shakun — Cand. Sci. (Med.), Senior Professor of the Military Traumatology and Orthopedics Department

St. Petersburg

 

Russian Federation

M. V. Endovitskaya

Kirov Military Medical Academy

Email: fake@neicon.ru

Maria V. Endovitskaya — Vascular Surgeon of the Military Traumatology and Orthopedics Department

St. Petersburg

Russian Federation

M. V. Zakharov

Kirov Military Medical Academy

Email: fake@neicon.ru

Mikhail V. Zakharov — Cand. Sci. (Med.), Deputy Head of the Department of Nephrology and Efferent Therapy

St. Petersburg

Russian Federation

References

  1. Абышов Н.С., Алиев Э.Н. Результаты х ского лечения сочетанных травм сосудов и костей конечностей. Хирургия. Журнал им. Н.И. Пирогова. 2007;(9):54-58.
  2. Губочкин Н.Г., Гайдуков В.М., Микитюк С.И. Лечение пострадавших с огнестрельными ранениями и повреждениями сосудов конечностей. Медико-биологические и социально-психологические проблемы безопасности в чрезвычайных ситуациях. 2015;(4):38-41.
  3. Самохвалов И.М., Рева В.А., Пронченко А.А., Петров А.Н. Оказание догоспитальной помощи пострадавшим с повреждениями магистральных сосудов конечностей в мегаполисе. Врач скорой помощи. 2012;(9):17-23.
  4. Clouse W.D., Rasmussen T.E., Peck M.A., Eliason J.L., Cox M.W., Bowser A.N. et al. In-theater management of vascular injury: 2 years of the Balad Vascular Registry. J Am Coll Surg. 2007;204(4):625-632. doi: 10.1016/j.jamcollsurg.2007.01.040.
  5. Owens B.D., Belmont P.J. Combat orthopedic surgery: lessons learned in Iraq and Afghanistan. Thorofare: SLACK Incorporated; 2011. 328 p.
  6. Covey D.C., Born C.T. Blast injuries: mechanics and wounding patterns. J Surg Orthop Adv. 2010;19(1):8-12.
  7. Самохвалов И.М., Рева В.А. Вклад профессора В.А. Корнилова (1937-1993) в сосудистую хирургию. Ангиология и сосудистая хирургия. 2014;(3):142-144.
  8. Заболевания артерий нижних конечностей: к ские рекомендации. 2016. Режим доступа: https://racvs.ru/clinic/files/2016/Diseases-lower-limb-arteries.pdf.
  9. Савельев В.С., Затевахин И.И., Степанов Н.В., Кошкин В.М. Клиническая классификация ишемии конечностей и тактика лечения при острой эмбологенной артериальной непроходимости. Вестник хирургии им. И.И. Грекова. 1974;(11):7-13.
  10. Schirò S.R., Sessa S., Piccioli A., Maccauro G. Primary amputation vs limb salvage in mangled extremity: a systematic review of the current scoring system. BMC Musculoskelet Disord. 2015;(16):372. doi: 10.1186/s12891-015-0832-7.
  11. Bosse M.J., MacKenzie E.J., Kellam J.F., Burgess A.R., Webb L.X., Swiontkowski M.F. et al. A prospective evaluation of the clinical utility of the lower-extremity injuryseverity scores. J Bone Joint Surg Am. 2001;83(1):3-14. doi: 10.2106/00004623-200101000-00002.
  12. Гуманенко Е.К., Козлов В.К. Политравма. М.: ГЭОТАРМедицина; 2008. с. 71-73; 86-95.
  13. Клиническая ангиология : руководство для врачей. Под ред. А.В. Покровского. Москва: Медицина; 2004. Т. 1. 808 с.
  14. Новак И.Е., Федоров К.С., Савчук А.В. Алгоритм л чения вывиха голени, осложненного повреждением подколенной артерии. В кн.: Актуальные проблемы экспериментальной и клинической медицины. Волгоград; 2018. с. 148-149.
  15. Султанов Д.Д., Усманов Н.У., Курбанов У.А., Баратов А.К., Курбанов Н.Р. Хирургическая тактика при травматических повреждениях артерий голени. Ангиология и сосудистая хирургия. 2003;9(2):111-117.
  16. Костырной А.В., Потапенков М.А., Аргунова А.Э., Чорнобрывый В.И. Выбор тактики хирургического вмешательства при травматическом повреждении сосудов. Вестник науки и образования. 2017;(1):95-97.
  17. Султанов Д.Д., Усманов Н.У., Баратов А.К., Гаибов А.Д., Курбанов У.А., Курбанов Н.Р. Травматические повреждения подколенной и берцовых артерий: особенности ишемии конечности и вопросы хирургической тактики. Ангиология и сосусосудистая хирургия. 2004;10(3):104-113.
  18. Catalano M. Epidemiology of critical limb ischaemia: north Italian data. Eur J Med. 1993;2(1):11-14.

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