Case 1: This 21-year-old male was involved in a motor vehicle collision at approximately three o’clock in the morning. His initial evaluation in the Emergency Room revealed the following injuries: small subdural hematoma, complex facial fractures, a closed left subtrochanteric femur fracture, a complex left tibial / talar body / calcaneus fracture with a stellate open fracture wound of 6 centimeters on the plantar aspect of the foot, and a right open Type II (4 cm) open tibial fracture (Figure 34-5a-d). The patient underwent aggressive resuscitation with warm intravenous fluids, warm blankets, and intubation and sedation. His laboratory numbers at individual time periods are shown in Table 34-6. The laboratory values therefore were indicative of a coagulopathic, under-resuscitated patient.

The left lower extremity was felt to be a severe injury with regards to the displacement of his tibia, the accompanying soft tissue (muscle, tendon, nerve) injury, and the plantar wound associated with the exposed tibial articular surface.

Because of the severity of his left lower extremity injuries, this case was placed in the emergent/urgent category, with plans for initial debridement and stabilization within the next several hours. Close communication with the General Surgery and Anesthesia teams was maintained, and the severity of the injury was explained. A short operative intervention was planned, with the goal of debridement of the open wounds, possible intramedullary nailing of the right tibia, and reduction of the left tibial shaft fracture. Realizing that the patient was not well resuscitated, the plan was to not address the left proximal femur in the first surgical intervention, but to come back to the operating room in the next 24 hours for definitive repair of his left proximal femur fracture and possibly the left tibia. Additionally, if the patient had any significant deterioration in the operating room, we were prepared to perform DCO by external fixation of all injuries. The initial operative intervention lasted two hours beginning at approximately 7:30 am, during which time several procedures were accomplished: 1. Irrigation and debridement of the right tibial wound; 2. Intramedullary nailing of the right tibial fracture; 3. Irrigation and debridement of the left plantar wound; 4. Open reduction to the tibial shaft displacement on the left; and 5. Splinting of the left lower extremity (Figure 34-5e-g). Two surgical teams worked on the left and right lower extremities at the same time. No intervention was made on his left proximal femur fracture, although external fixation of this injury (pelvis to proximal femur) was a consideration. Additionally, external fixation of the left lower extremity was also a consideration (rather than splinting) but was difficult because of the calcaneus and talus fracture. The patient underwent ongoing resuscitation during the operating room intervention, with fluid resuscitation, fresh frozen plasma, packed red blood cells, platelets and calcium replacement. His laboratory values after the surgical intervention indicated need for further resuscitation, but we had not “lost ground” and had accomplished our initial urgent orthopaedic trauma goals. If the patient had significantly deteriorated intra-operatively, consideration to immediate left below knee amputation would have been reasonable.

The patient stabilized over the next 18 hours, and his coagulopathy and acidosis improved. He was therefore taken back to the operating room on Post-Injury Day 1 and had: 1. Repeat irrigation and debridement with closure of his left plantar foot wound; 2. Open reduction and internal fixation of his left subtrochanteric femur fracture; 3. Provisional fixation of the medial malleolar ankle fracture to gain ankle stability; and 4. Splinting of his left lower extremity (Figure 34-5h,i).

The patient slowly stabilized over the next three days, and had his facial fractures fixed on Post-Injury Day 7. Definitive fixation of his ankle, talus, and calcaneus fractures was deferred until Post-Injury Day 15 (Figure 34-5j). The delay was to allow time for him to recover from his initial trauma, and to allow time for the swelling about his lower extremity to decrease.