L. Klein 1; P. Douša 2; R. Zajíček 1; I. Pafčuga 1; M. Tokarik 1
Dept. of Burns Medicine, 2 Dept. of Orthopedics and Traumatology, 3rd Faculty of Medicine and Teaching Hospital Královské Vinohrady, Charles University, Prague, Czech Republic
Vyšlo v časopise:
ACTA CHIRURGIAE PLASTICAE, 50, 1, 2008, pp. 17-22
presents a serious medical and social problem, due to the morbidity,
mortality and possible consequences in terms of a long-term
disablement or permanent invalidity. There are many various
definitions of these statuses whereas all with the common basic
characteristics of polytrauma: simultaneous injury to several (at
least two) body systems, one of which threatens the patient’s life.
In some cases, polytrauma can be considered also combined or
associated thermal injuries (burns) and mechanical injuries (for
example fractures of the locomotor system). Combinations of these
injuries are among the most severe ones. The overall condition of the
patient depends on how severe are the particular injuries. The
initial burn shock deepens and course of the acute burn treatment
period worsens, complications often occur, treatment time of
particular injuries extends. If there is a fracture of pelvis or
femur hemorrhagic shock develops among the burn shock and the blood
loss must be replaced even in the initial stages (in contrast to when
there is burn injury only). A complex approach to the treatment of
such patients is possible only within the scope of an
interdisciplinary cooperation of particular specializations that are
organized into trauma centers.
2006 at one o’clock in the morning a car accident occurred. A car
crashed into a tree and caught fire. There were two passengers in
the car, one died in the fire and the other, 23-year-old male was
rescued with severe thermal and mechanical injuries. The patient was
urgently treated on the spot, including endotracheal intubation and
he was transported by an air ambulance directly to the Burn Centre,
where he was admitted at 02.30 AM. Later, we have found from the
anamnesis that the injured man was previously healthy and he did not
suffer any internal illnesses. In his early childhood he underwent
a surgery for pes equinovarus on the right and at the age of 4 he
underwent bilateral prolongation of his Achilles tendons. The initial
treatment revealed that the patient sustained deep burns of upper
limbs, trunk, buttocks, genitals and lower limbs in the total extent
of 62% of the total body surface area (TBSA) (Fig. 1, 2). An
inhalation trauma of the airways was suspected. In the area of the
right orbit there was a hematoma and there was laceration of the
patient’s lower lip. Since there was disfiguration, mechanical
damage to the skin on the ventrolateral side of the thigh and the
whole lower extremity was positioned in an external rotation, we
suspected a compound fracture in the area of right femur. Venous and
arterial cannulations were completed, aggressive liquid resuscitation
was continued with the use of crystalloid and colloid solutions, and
frozen plasma was also given. A nasogastric tube was placed as well
as insertion of a permanent Foley catheter was performed, mechanical
lung ventilation was continued, and the patient was put on
antibiotics Tazocin. We have completed releasing escharotomy on the
right hand and forearm, suture of the lip wound and tetanus
prophylaxis by application of intramuscular TAT 0.5ml. Next, it was
necessary to complete diagnostics of possible skeletal injuries and
exclude possible injuries to the thoracic and abdominal cavities. The
appropriate X-ray and CT scans were completed. X-ray of the right
femur revealed ipsilateral fracture of the proximal end without
a significant dislocation and transversal dislocated fracture of the
diaphysis. Other bones were without any trauma. Head, chest and
abdominal injuries were excluded; on the contrary, bronchoscopy
confirmed inhalation injury of the airways. CT scan of the chest
revealed aĘpartial atelectasis of the lower lobe on the right side
and subsegmental atelectasis in the left lower lobe. Consequently,
the orthopedic team completes the first surgery - fixation of the
right femur diaphysis fracture with the use of external fixator (ZF
Mefisto) which allowed correcting the fracture into a satisfactory
position (Fig. 3). Due to the overall condition of the patient and
due to the type of multiple traumas we have decided to treat the
pertrochanteric fracture conservatively. Next, the treatment
continued on the Intensive Care Unit and was focused on mechanical
ventilation, liquid resuscitation, metabolic support and surgical
treatment of the burned areas. Surgical interventions then followed,
usually in 48-hour-intervals, consisting of releasing incisions (Fig.
4) or necrectomies. On the upper extremities and on trunk the
avulsion method was used. It concerns the so called epifascial
necrectomy, where we remove
skin and subcutis down to fascia (Fig. 5). The advantage of this
method is significantly lesser blood loss than in the tangential
(laminar) necrectomy by excisions when using Humby - or Watson - knife.
Overview of the main surgical interventions is listed in Table
the maximum effort to be gentle during manipulation with the patient
(transfers to and from the operating table, surgery on limb with the
external fixator in situ, bed changes etc.) the eighth day after the
osteosynthesis, there was loosening of the fixator and it was
necessary to reposition and fixate the femoral bone fragments again
(Fig. 6). The fracture was healing with a massive callus
particularly at the medial side of femur, however, the
pertrochanteric fracture gradually led to a varosity of the proximal
femoral fragment.Due to
angulated fragments of the diaphysis it was necessary on November
2006 (14 weeks after the injury) to complete an adjustment of the
external fixation. We have increased rigidity of the external fixator
by adding more screws. We have achieved satisfactory position; the
pertrochanteric fracture was at that time already healed. During the
course of the treatment the patient underwent intensive
physiotherapy, initially passive and later active with the goal to
prevent contractures of the small and large joints and to limit
muscle atrophy as much as possible and simultaneously maintain muscle
strength. Later rebandaging including showering was performed at the
standard unit. Owing to the then epidemiological situation at the
workplace bacteriological assessment of wounds several times revealed
a positive Methycilin-Resistant Staphylococcus
Despite that, through thorough local care and the overall treatment
we managed to prevent infection in the areas of pin sites (Fig.
7-10). Since the patient had a significant psychological support
from the staff, clinical psychologist, and a good family support,
healing course of both types of injuries (thermal and mechanical) was
positive. After five months from completion of the osteosynthesis we
have dynamized the external fixator and the patient was allowed
partial weight bearing on the limb. The patient started
verticalization and gait training and gradually progressed to a full
weight bearing. The patient’s overall condition at the end of the
sixth month allowed for transfer to a surgical unit in the area of
the patient’s residence so he could continue with rehabilitation.
Transplanted and harvested areas as well as both fractures continued
to heal well and on March 8th,
2007, eight months after the injury, during an out-patient visit it
was possible to remove the external fixator (Fig. 11). The
pertrochanteric femoral fracture healed in varus angulation, however,
in this case we consider the position satisfactory. Fracture of
diaphysis healed with a massive callus with a slight angulation.
The result was shortening of the limb by 2 cm which proved to be
positive due to the plantar flexion in the ankle joint. The patient
thrives physically and mentally and is motivated to continue with
gait training and overall self care training (Fig. 12).
combination of thermal and mechanical injuries can be divided into
two types: one when the fracture is localized elsewhere than the
burned area or within the burned area. This situation represents
a critical factor which must be taken into account during the choice
of possible treatment procedures. Basic possibilities of therapeutic
algorithms are shown in Table 2.
of short bones fractures, vertebral and skull fractures are treated
conservatively, which allows to fully concentrate on the treatment of
burns. Complications are caused by circular burns, when the patients
must be turned. Most frequently the combination of fractures and
burns occur on upper or lower extremities. Fractures without
dislocation of fragments can only be treated with a classical
plaster cast if it is outside the burned area. Some workplaces may
prefer the open-method treatment of the burn when using skeletal
traction. However, the method of skeletal traction can not provide
a perfect immobilization of the fractured fragments because there is
a need for frequent rebandaging of the burned area. Metal material
used for traction should not run through the burned area, because
sooner or later it leads to an infection and loosening of the wire.
The same reasons lead to certain reservations regarding the use of
external fixators. Despite that, some authors recommend external
fixators in open fractures or in an area with severe burns. When the
skin is healed it is possible to change the external fixator to
internal osteosynthesis. The most convenient treatment of fracture in
the area of burn is a stable osteosynthesis that allows for a good
manipulation with the extremity. However, due to severe burns in the
area of thigh we have not in this case used the internal femoral
fracture osteosynthesis with a reconstruction nail, which we use in
cases of solely mechanical injuries. Osteosynthesis after dislocated
fractures should be completed as soon as the patient’s status
allows. Preferably, it should be completed within 48 hours after the
injury, because later than that danger of infection in the burned
area increases and there is aĘrisk of infection transmission from
skin into the bone.
on surgical treatment of fracture through the burned area vary.
In burns of 2nd
degree where the incision runs through the burned area it is possible
to sew the incision after osteosynthesis and treat the burn as usual.
Experimental works on
dogs in Houston tried the possibility to perform the osteosynthesis
24 hours after the necrectomy and covering of the area with
autotransplants. However, the use of this method in human medicine is
not further mentioned by authors.
In comminuted fractures
it is recommended to complete the necrectomy, bloody reposition with
rinsing of the fracture site with antibiotics and subsequent suture
of soft tissues and closure of the defect with autotransplants
or temporarily with a biological cover (allotransplants,
Some workplaces recommend
proceeding radically with the use of early two-team surgery method.
Within two days after the injury, or preferably even the same day of
admission after the patient is prepared, a team of two surgeons
erudite in the treatment of burns complete a necrectomy according to
the judged depth of necrosis and with the evaluation of transplants
type. Concurrently, they harvest dermoepidermal autotransplants,
which they expand by the use of meshdermatom. After that the trauma
surgeon completes aĘstable osteosynthesis. Final closure of the
wound is again completed by the team specialized in the treatment of
burns. The subsequent treatment plan follows as usual.
In particularly severe
comminuted fractures with derangement of the blood supply and damage
to the soft tissues it is necessary to consider an amputation as
a lifesaving treatment. Particularly, if the fracture is associated
with a critical extent of the burn when there is danger of sepsis or
in patients who would not cooperate in the treatment of combined
injury due to other illnesses, in elderly patients or after a mass
accident in exceptional situations. It is recommended to complete an
exarticulation in the most distal joint rather than amputation
through the burned area and bone due to the possibility of infection
traits associated with the combined thermal and mechanical injuries,
particularly the treatment course, treatment method, and prognosis of
the status require an individual approach to particular patients
based on evaluation of factors, which describe seriousness of the
burn trauma. Based on our experience we move towards more active and
early surgical solution of these complicated traumatic statuses.
Particularly, considering that despite not a very high absolute
number of the total injuries (up to 5% of thermal and mechanical
injuries) these injuries concern mainly young individuals in
a productive age and who can be this way saved and returned back to
work was completed within the scope of the research project supported
by the grant IGA MZ NR 8853-4/06.
Prof. Leo Klein, M.D., PhD.
of Burn Medicine
34 Prague 10
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