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Fall 2007

Case Study: Collaboration Saves a Leg

John Keenan, a 53-year-old motorcyclist, was broadsided by a car; the collision cracked the engine block of the motorcycle. Unfortunately, Keenan's leg did not fare any better. He sustained a severely fractured right leg, a grade-IIIB open tibial shaft with extensive soft tissue loss. Keenan was rushed to the UCSF/San Francisco General Hospital (SFGH) Trauma Center, where the injury was evaluated in the busy, but experienced emergency department. Upon examination, the leg compartments were very tight due to swelling and Keenan had lost both his pulse and sensation in the leg.

Because of his limb-threatening injury and time-sensitive need to clean the wound, stabilize the bone and relieve the pressure in his leg, he required emergent operative treatment. He was taken immediately to one of the designated trauma operating rooms, where he underwent irrigation and debridement of his extensive wounds, intermedullary tibial nail placement and four compartment fasciotomies in his leg. As a result of these procedures, Keenan regained the pulse and feeling in his leg.

During this short time, he received multidisciplinary care from trauma specialists in general surgery, plastic surgery and orthopaedic surgery as well as evaluations by other physicians with expertise in trauma care, including the emergency physicians, radiologists and anesthesiologists.

While amputation was presented as a highly possible outcome of this serious injury, the surgical teams began a complicated treatment plan involving multiple, staged orthopaedic and plastic surgeries to salvage the patient's limb. After two subsequent surgical procedures to debride the contaminated wound, Keenan underwent staged procedures to place free muscle flaps from his back and abdomen with skin grafting to cover the massive open wound.

At the time of the flap placement, bacterial cultures were taken, which came back positive. Infectious disease experts assisted with the selection of antibiotics for a six-week treatment course. Fortunately, Keenan never developed an infection.

As is common with these severe, open fractures, however, Keenan's bone did not fully unite and he required an iliac crest bone graft six months after the accident. The operation was done in conjunction with the plastic surgery team, taking care not to disrupt the previously successful muscle flap.

Over the next year, Keenan had close medical follow-up and intensive physical therapy. He was instructed to gradually increase his activities according to his symptoms and the X-rays of his leg. After four months, the bone graft incorporated, his tibia healed fully and without an infection, and he regained full function of his leg. He has since fully resumed his pre-injury activities.

For more information, call the UCSF Department of Orthopaedic Surgery at (415) 206-8812.

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