Blast Injury to the Lower Limb	14
Paul H.B. Blair, Adrian K. Neil, and Christopher T. Andrews

A 40-year-old male was admitted to the emergency room approximately 1.5 h after sustaining a blast injury to both lower limbs. He had been resuscitated at his local accident and emergency department prior to transfer. On arrival, his pulse was 120 bpm and his blood pressure 80/40 mm Hg.

Examination revealed that the patient had sustained significant blast injuries to both lower limbs with no obvious torso injuries. The left leg had sustained neurovasculardamageaboveandbelowthekneewithconcomitantboneandsofttissueinjury; there was no tissue perfusion below the knee. On the right side there was a large wound in the thigh extending anteriorly to the knee joint with profuse bleeding; bony fragments could be seen in the wound and the right foot was pale with no palpable pulses and slight reduction in sensation.

Question 1

The priorities for the care of this patient include:

A.  Secureanairway,commenceoxygentherapyandobtainadequateintravenous(IV)access. B.  Complete a full survey of the patient before transferring for further management. C.  Wait for blood result before deciding on transfer out of the emergency room.

D.  Transfer the patient to theatre for definitive management during primary resuscitation. E.  Discuss treatment options with relatives.

Question 2

Which of the following are “hard” signs of vascular injury?

A.  Limb pain.

B.  Absence of pulses.

C.  Pallor or cyanosis.

D.  Cool to the touch.

E.  Bruit or thrill.

P.H.B. Blair ( )

Vascular Surgery Unit, Royal Victoria Hospital, Belfast, UK

G. Geroulakos and B. Sumpio (eds.), Vascular Surgery,	135
DOI: 10.1007/978-1-84996-356-5_14, © Springer-Verlag London Limited 2011

136	Adrian K. Neil et al.

Question 3

Which of the following statements relating to angiography are true?

A.  Angiography should be performed in all patients to target surgery.

B.  Angiography may be a useful tool in trauma patients with no hard signs of vascular injury.

C.  Angiography is reserved for stable patients.

D.  Angiography should only be performed in a radiology department.

E.  The patient’s pre-morbid condition should not influence the decision to perform angiography.

Question 4

For how long will the lower limb tolerate ischemia?

A.  20–30 min B.  90–120 min C.  6–8 h

D.  16–20 h E.  24–36 h

The patient was resuscitated as per advanced trauma life support (ATLS) protocol. Supplementary oxygen was administered in addition to obtaining additional IV access. Pressure dressings were applied to the open wounds and further assessment revealed an injury to the patient’s right hand; no other significant injuries were present. The patient was transferred to the operating theatre.

Question 5

What are the primary aims of surgery in such a case?

A.  To control life-threatening haemorrhage.

B.  To prevent end-organ ischaemia.

C.  To restore vascular continuity.

D.  To preserve limb function.

E.  To detect occult injuries.

Question 6

What factors will influence the decision to perform an amputation?

A.  Patient’s age

B.  Mechanism of injury

14  Blast Injury to the Lower Limb	137

C.  Time to treatment

D.  Degree of contamination

E.  All of the above

Question 7

Which of the following statements about complex vein repair are true?

A.  Complex vein repair should never be undertaken in the trauma patient.

B.  Complex vein repair should only be performed in the absence of major arterial injury. C.  Complex vein repair should be used to improve venous return in unstable patients. D.  Complex vein repair may prevent long-term limb dysfunction.

E.  Intraluminal venous shunting is an acceptable intraoperative temporising measure.

In the operating theatre, under general anaesthesia, the patient was placed in the supine position. The lower abdomen and both legs were prepared and draped widely and IV broad spectrum antibiotics were administered. Closer examination revealed that the left leg had sustained extensive injuries. The foot and distal calf were cold, pale and mottled. There was a compound injury to the left femur and tibia with complete disruption of the superficial femoral artery, superficial femoral vein and extensive injury to the sciatic nerve. It was decided that primary amputation of the left limb was required. On examination of the right leg there was complete disruption of the distal superficial/popliteal artery, a ragged laceration of the popliteal vein and significant bruising to branches of the sciatic nerve. There was a shrapnel injury to the right hand involving the thumb and middle finger.

Immediate surgical steps were as follows: (a) a proximal thigh tourniquet was placed on the left leg to arrest haemorrhage prior to formal amputation. The laceration to the right lower leg was then extended distally to facilitate exposure of the neurovascular structures. Control of the superficial femoral and below-knee popliteal artery was obtained and a careful distal embolectomy performed. A Javid shunt was then placed between the right superficial femoral artery and right below-knee popliteal vessel (Fig. 14.1). Significant bleeding from a large defect in the popliteal vein occurred following shunt insertion; this was repaired using a lateral suture. The long saphenous vein was harvested from the left leg, prior to performing above-knee amputation. While the left above-knee amputation was being performed, the orthopaedic surgeons carefully assessed the right lower limb and placed a temporary fixation device traversing the right knee joint (Fig. 14.2). Having obtained bony stability, with an external fixator device, the temporary intraluminal shunt was removed and a definitive bypass performed using reversed left long saphenous vein graft. Formal fasciotomy was performed of the right lower leg using a standard lateral and medial approach; distal pulses were confirmed in the right foot. Further debridement of necrotic muscle was performed and the wound on the medial aspect was partially closed; the anterolateral wounds were debrided and irrigated, as were the fasciotomy sites, with sterile dressings being applied to both.

138	Adrian K. Neil et al.

Fig. 14.1  Extended wound, medial aspect of right leg with a temporary intraluminal shunt between superficial femoral and below-knee popliteal arteries

Fig. 14.2  A multidisciplinary approach. Bony stabilization of right leg (after temporary intraluminal shunt placement) by the orthopaedic surgeons, simultaneous with left above-knee amputation by the vascular surgeons

Question 8

In the absence of obvious haemorrhage, when is it appropriate to reinspect the wounds in the postoperative period?

A.  1–2 h B.  4–6 h C.  12–16 h D.  24–48 h E.  5+ days

Postoperatively the patient was transferred to the intensive care unit where the right limb was elevated to reduce swelling. The right foot was left exposed to allow access for pedal pulses. Broad spectrum IV antibiotics were continued in addition to standard prophylaxis for deep vein thrombosis, and urine was checked for myoglobinuria. The patient was returned to the operating theatre within 48 h for wound inspection and change of dressing. Eventually skin coverage of the right limb was obtained using a combination of split skin grafting and healing by delayed primary intention. Over the next few months the patient

14  Blast Injury to the Lower Limb	139

required complex orthopaedic surgery including the use of an Ilizarov frame device (Fig. 14.3). He was fitted with an above-knee prosthesis for his left leg and is now fully independent (Fig. 14.4).

Fig. 14.3  Recovery. Healed traumatic and fasciotomy wounds after skin grafting; Ilizarov frame still in place

Fig. 14.4  Rehabilitation. An excellent result for limb salvage (right leg) and learning to function with a prosthesis (left)