Complex Limb Injury. Exceptional healthcare, personally delivered

Transcription

1 Complex Limb Injury Exceptional healthcare, personally delivered

2 Complex Limb Injuries Introduction This information booklet aims to help you to understand the nature, treatment and outcome of your limb injury. North Bristol NHS Trust is a recognised centre in the South West for the treatment of complex injuries to the limbs. Such injuries require input both from orthopaedic surgeons who look after the healing of broken bones and plastic surgeons that look after the rest of the soft tissue injuries. This combined approach along with input from nurses, physiotherapists and occupational therapists is designed to ensure the best treatment for patients like you with such complex injuries. Our goal is to assist you in achieving the best possible outcome following your injury. With your help we will try to heal your injury and enable you to carry on with your life. It is however important to understand that your injury is serious and potentially limb threatening and this is the reason why you have been referred to our unit. We may not be able to turn back the clock but we will try to get you back to your normal routine or as close to it as possible. Your Injury The reason for your referral to our service is that not only have you broken one or more bones but you have also damaged the tissues overlying the bones. These types of injury normally involve considerable force such as in a car or motorcycle accident or following a fall from a height. The bones are usually broken into several pieces which have to be fixed back together and cannot just be treated in a plaster. The muscle and skin over the bone or bones is torn and damaged to such an extent that it cannot normally simply be sewn back together. 2 Complex Limb Injury

3 Diagram 1: Open Fracture Complex Limb Injury 3

4 Assessing the Bony Injury We use a combination of x-rays and scans, both CT and MRI scans, to assess the bony injury. These scans enable us to develop a plan of how to fix the bones. There are several ways of fixing the bones. External fixation: - This involves either: n A single rod held with several pins drilled into the bone, or n Applying a frame to hold the bony fragments in the correct position. n Ensure you follow instructions about pin site care to reduce the risk of infection The external fixator is removed once the bone is fully healed and this can be a number of months after the injury. 4 Complex Limb Injury

5 Diagram 2: External fixation Complex Limb Injury 5

6 Internal fixation: - This involves stabilising the bones with either: n A plate placed directly on the bone, or n A special rod known as an intermedullary nail, which is inserted down the shaft of the bone. Internal fixators are usually left in place after the bones are fully healed. Diagram 3: Internal fixation 6 Complex Limb Injury

7 X-Ray photos: Complex Limb Injury 7

8 Assessing the Soft Tissue Injury Whilst we can get a good idea about the extent of the damage to the skin and muscle by looking at x-rays and scans we also need physically to inspect the injured tissue. We need to assess the damage to the skin and muscle and decide if the soft tissue will recover from the injury. Reason for Assessment When tissue is subjected to a high speed impact it can be crushed and torn to such an extent that it no longer receives blood from the body. In this case the injured tissue must be removed. Failure to remove it will result in the wound becoming infected and this in turn will prevent the bones from healing. Trip to the Operating Theatre We will normally need to give you an anaesthetic to put you to sleep whilst we inspect your injury and remove all of the skin, muscle and bone that will not heal if left in place. We will also wash your wound to remove any dirt and debris which may cause infection. This process also allows us to decide on the best way to cover your wound with healthy tissue to allow it to heal. Other Examinations Because the flow of blood to the damaged area is extremely important we may send you for a special x-ray scan called an angiogram to look at the blood vessels in the limb before deciding the best way to treat you. You may need an injection to allow us to see the blood vessels clearly but you do not need to be put to sleep for this test. This scan is normally carried out in the days between your first operation and any further operations. 8 Complex Limb Injury

9 Further Surgery There is normally a delay of several days between the first assessment and cleaning of your wound and you returning to the operating theatre for the bones and soft tissues to be repaired. Sometimes we will stabilise the bones and cover the wound with healthy tissue at the same time and sometimes you will go to the operating theatre more than once for this to be carried out. Methods Used to Cover your Wound To allow your broken bones to heal not only must they be stabilised but they must also be covered with healthy tissue. There are a number of ways in which we can do this. The method chosen will normally be determined by your age and your general health and fitness as well as the extent of your injury. Direct Closure The simplest way to cover the wound is by directly sewing the skin tissues together and allowing them to heal. This however is not normally possible as the area of injury is too large. Complex Limb Injury 9

10 Local Skin Flap This involves moving a healthy flap of tissue next to the wound over the wound to cover the exposed bones. This is shown in diagram 4. This method may cover the wound but will normally leave a new wound that need to be covered with skin tissue. This is usually 10 Complex Limb Injury

11 Diagram 4: Local skin flap Complex Limb Injury 11

12 Skin Graft A skin graft is a shaving of skin, often taken from the thigh and placed on a raw wound to speed up the healing process. Unfortunately this does not work well on exposed bone. We use these grafts on top of a muscle flap or to cover the raw area left when a local flap of tissue is rotated to cover a wound. See diagram 5. Diagram 5: Skin graft 12 Complex Limb Injury

13 Local Muscle Flap We will sometimes use a muscle to cover an exposed bone or joint. Muscles have two attachments and one can be cut and the muscle rotated to cover a wound. This can only be done in certain circumstances, normally in injuries around the knee joint. Diagram 6: Local muscle flap Complex Limb Injury 13

14 Free Tissue Transfer This method is often the best treatment. A piece of tissue is taken, in most cases from the back or thigh, and detached with its artery and vein intact. It is placed over the wound and its artery and vein are re-attached to the local blood vessels. The wound left from taking this tissue is normally directly closed with stitches. Diagram 7: Free tissue transfer 14 Complex Limb Injury

15 Free Muscle Transfer In this method we take a muscle and completely detach it along with its artery and vein. This is then placed over the wound and re-attached to the local blood vessels. Often a skin graft is required to cover this muscle. The place where the muscle is taken can be directly closed with stitches. Complications of Surgery Although normally you will have more than one operation we will always try to stabilise the broken bones and cover the wound with healthy tissue at the same time. Because the methods we have to use are complicated, your surgery can take many hours to perform. There is always the possibility of complications from such surgery and these can occur in theatre and afterwards once you are back on the ward. Bleeding Two of the main complications following surgery are infection and bleeding. Both of these can prevent your wound from healing. Bleeding can cause a collection of blood under the flap and this can mean the flap is at risk of failing. When this happens we may take you back to theatre to remove the trapped blood and stop the bleeding. Infection The other main complication besides bleeding is infection. A deep seated infection within the wound can not only stop the soft tissues from healing but also prevent the bones from healing. We will monitor you closely for any signs of infection after your operation by checking your wounds, your temperature and taking blood samples. You may be treated with antibiotics and often these are given through a direct line (tube) into a blood vessel. You may need antibiotics for some time after we have covered your wounds. Complex Limb Injury 15

16 Flap Failure When we use a free tissue transfer we rely on the blood vessels to work once they have been reconnected. Sometime they do not and there are signs we look for to tell us if this is happening. We will look at the flap every half hour in the early period in order to check its colour, consistency and to look for swelling. We will try to keep the limb as warm as possible and try to keep up the blood flow through the flap by fluid into your veins through a drip. We also need to monitor the amount of urine you are passing and we tend to use a catheter to do this. We may also listen to the flap with a probe placed on the skin to check the blood is flowing. On the first night after your operation you may have a disturbed night s sleep, as we carry out these checks every half hour. If there are problems with the flap we may need to return you to theatre to explore it more thoroughly. This can happen at any time over the first few days. We will keep you in bed for the first four days during this critical time. If the flap does fail we may have to take it away and carry out another operation to replace it. Several factors can reduce the flap s chance of success by constricting the blood flow within it. These are cold, caffeine and cigarettes. We will keep the flap warm but you must avoid smoking (including passive smoking) and food or drinks containing caffeine for at least two weeks after your surgery. There is also a greater risk of a blood clot forming in the leg, known as a Deep Vein Thrombosis (DVT); this is particularly the case in smokers. 16 Complex Limb Injury

17 Pain Injuries such as yours are painful. We are very mindful of this and will attempt to provide you with the correct amounts of pain killers. Normally some of these can be directly controlled by you. We can top this up with further pain relief as required. We work closely with a specialist pain team who can advise us on the best treatment for you. You may continue to need pain killers when you have left hospital and the pain team can advise us on these as well. Recovery The orthopaedic doctors will take x-rays after your surgery but only after a four day period of strict bed rest has passed. This way they can assess the bone healing. After four days we will start the process of getting you out of bed and increasing your mobility. We take this very slowly at first. Initially we only let you dangle your leg out of bed for a few minutes at a time. We will then gradually build this up and under the guidance of our physiotherapists we will help you to get out of bed on crutches. Initially you cannot put weight on your affected leg but gradually you will be allowed to place some weight on your leg. This may not happen immediately and depends on the type of bone fixation you have had and the rate of healing. Loss of your Limb Whilst we always do our absolute best to save your leg it is extremely important that you are aware that we may not be able to so. We will always discuss with you and your family the possibility of an amputation and will only perform an amputation after such discussion has taken place and you have given your consent. If we recommend an amputation this is because based on our experience of your type of injury this is the only option available to you. Complex Limb Injury 17

18 Post traumatic Stress Disorder (PTSD) In some people traumatic experiences set off a reaction that can last for months or years. This is called Post Traumatic Stress Disorder. The symptoms can start immediately or within 6 months of the traumatic event. Many people feel griefstricken, depressed, anxious, guilty and angry after a traumatic experience. They can also suffer from other non-specific symptoms such as muscle aches and pains, irregular heartbeats, diarrhoea and headaches. All these symptoms may lead to depression, social isolation, overuse of drugs, alcohol and smoke. Just as there are both psychological and physical aspects to PTSD, so there are both physical and psychological treatments for it. Leaving Hospital When we need to carry out free tissue transfer you can expect to be in hospital for at least ten days. When the surgery is less complex you may be able to leave sooner. Once you leave hospital we will continue to monitor your progress in our dressing clinic and in our lower limb clinic where you will see plastic and orthopaedic surgeons and physiotherapists. We will monitor your progress and look for any signs of your bones failing to heal. We can carry out further surgery to improve this healing if needed. We may also want to adjust your flap if required, for example if it is too bulky. 18 Complex Limb Injury

19 NHS Constitution. Information on your rights and responsibilities. Available at constitution Complex Limb Injury 19

20 If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice. North Bristol NHS Trust. This edition published May Review due May NBT002377