The Mangled Extremity Team at The Denver Clinic for Extremities at Risk was contacted about a young man who had been injured in an accident where he was pinned between the bumper of two cars causing severe fractures of both legs. He was transported from the accident to a local hospital where he was cleared of other trauma, then taken to the operating room for debridement and stabilization of the his lower leg fractures with external fixation devices. After the fractures were stabilized he was transferred to Presbyterian/St. Luke's Medical Center for further management.

On arrival, he was taken to the OR for evalutation of his legs. The right leg was most severely injured with fractures just below the knee joint (tibial plateau) and in the middle of the leg bone.  There was a large open area at the outer part of his knee, and he had damage to the nerve that runs along the outer aspect of the leg (peroneal nerve). The ligaments on the outer side of his knee and the vessels to the foot were injured as well. The team felt the injuries to his right leg were too severe for surgical intervention so an amputation of the lower leg was done.

The left leg injury was similar to the right but with less damage to the ligaments and blood vessels.  The team felt that the left leg could be reconstructed so all the damaged tissue was removed and the external fixator adjusted to improve the alignment of the fractures. He returned to the O.R. several times over the next few days for continued cleaning of the area, and placement of antibiotic beads. This was in preparation for covering the open area with a free muscle flap. In additon, the external fixator was extended to support his foot.

10 days after the accident the team felt the wound was clean and it was appropriate to cover the area.  The plastic surgeon used the muscle from one side of the patient's back (latissimus) to cover the open area.

Intraoperative photo after the latissimus flap has been placed over the wound. The external fixator can be see as well.

3 weeks after his original injury he was taken back to the operating room to revise the fracture stabilization from an external fixator to a ring fixator (Taylor Spatial Frame). The team felt this new fixation would be better because it would allow movement at his knee and allow the surgeon the opportunity to correct any deformity that might occur as the fractures were healing.  In addition, this type of fixation would allow the patient to put weight through his leg.

Xray of Taylor Spatial Frame after external fixator was removed.

He was followed closely after his hospitalization with frequent CT scans to assess bone healing, and to assess the free tissue transfer. He steadily increased the amount of weight bearing on the left without difficulty, and was fit with an above knee prosthesis on the right. He worked closely with a physical therapist on strengthening, range of motion and gait, and was able to progress to walking without any assistive device.

CT scans at 8 months post-injury revealed that his left tibia was in good alignment and there was significant bone formation but not complete fracture union. His latissimus free flap healed without any complications. It contracted as anticipated, and was not a limiting factor to knee range of motion. 

Photo after the Taylor Spatial Frame was removed. Shows the area where the latissimus flap was placed to cover the wound from the original injury.

Less then one year after his accident he was full weightbearing on both his right amputated leg and the left severe tibial plateau fracture.