Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Um We've got Dan here. He's an ST four T four. He's in Northwest one through your eyes. Great. Thank you very much. Sorry, I'm just turning the fan off on my laptop. It's really loud. Um Hi. Yeah, so I'm Dan Lasing me. I'm a plastic registrar in the Northwest. So I'm currently based at WIS Hospital. Um as Elaine said, um so I've been asked to speak about lower limb trauma. Um and the majority of lower limb trauma that we get involved in is open fractures. So the talk is mainly focused on that. Um I've just tried to do a couple of poll just so I can get an idea of the room. So you should have a poll coming up on your screen now. Um So if you could answer that if that's working, um speaking may answer 67. Ok. So I suspected all the other years seem to be on their Christmas break, so probably aren't engaging in webinars, but there's some fourth years who are might still be on placement. Um So about seven out of 30 responses, a bit of a mix. Ok. And then another pole just quickly is, are you a future plastic or orthopedic surgeon or you're not sure yet. Six responses. Nine, mostly plastics, which is good. Cos obviously, plastics is much, much better than orthopedics, but obviously I'm slightly biased. Um, but this talk is aimed at both. So there's bits of both what I understand in orthopedics and you need to know a little bit of both if you're gonna be dealing with lower limb trauma. Fine. So, um, let me share my screen. If you've got any questions throughout, then um if you just put them into the messages in the chat, um and then Elaine can interrupt me. I'm happy to be interrupted during it. Um Because when I share my screen, I won't be able to see anything. Um So um the things that I'd like to go over are um to aim this at the sort of medical student or junior doctor, sorry, resident doctor level is a sort of approach to lower limb trauma and specifically open fractures, how we might classify them. Um Looking at the bo guidelines which are our national guidelines for dealing with open lower limb fractures. Um A bit about anatomy reconstruction, some bit points on orthopedics and bone healing, flat monitoring and um how you deal with patients that have had free flap reconstruction and just a little bit about amputation. Um Please don't record or take any photos um because the images used in this haven't been cleared to be um shared widely Um, but if you have any questions throughout them, please let me know. Um, so first of all, just to give you a sort of quite a typical scenario when it comes to lower limb trauma, 30 year old lady knocked down by a car was crossing the road an hour ago. Um, you as the orthopedic sho and sometimes as the plastics sho registrar will be asked to call, er, attend the trauma call in A&E usually in recess. Um, so what's your approach to this situation? So just have a think about what, what would be going through your head. Um, I hope everyone's thinking at e because that is the correct answer. Um, you won't have done the ATL S but ATL S has advanced trauma, life support and it's a really, really excellent course. I think the way it's formatted now is um, lots of online learning and then a, a day face to face. It used to be two full days, face to face. Um, but essentially you all, we'll have all, you all know about a to e the main difference with trauma is you need to think about C spine. So it's C ABCD E. So C spine comes with the airways. So as you approach a patient that's been um sustained major trauma, you walk and you get taught a thing on the course called the C spine walk, which is you walk towards the patient like this. Cos the first thing you're gonna do is immobilize their c spine or if you're with other people, you get someone else to do that. But the first thing you should do is immobilize the C spine and assess the airway. I'm sure you all know how to assess the airway. So you're looking um for any facial trauma, um any foreign bodies um in the mouth, um or any neck trauma that could be affecting the airway. Um, And then you're protecting the c spine, like I said, the best way to do that is triple immobilization with um a cuff collar and blocks, um sorry, collar blocks, static fixation until we proper, clear their c spine. Um You then go on to your breathing and ventilation. So you're looking for equal air entry, chest expansion. Um looking at things like saturations or respiratory rate. Is there any evidence of blunt or sharp trauma to the rib cage or the chest? Um Do they have a flail segment? So a flail segment is when you've got ribs broken in more than one place and you get a separate segment that paradoxically rises as the chest is falling or vice versa. The other important major difference with trauma is when you're looking at circulation, you're looking for any massive hemorrhage. Um what it's important it's important to have in your mind where someone could be bleeding from and the way you remember this is four and fall and floor. So, um think about the chest cavity, um the abdominal cavity, the pelvis and the long bones. So that's your four and then the floor. So any external bleeding, are they bleeding from any limbs? Do they have any arterial bleed? Someone can lose. Um depending on where you read a liter and a half, 2.5 L of blood into their pelvis, for instance, if they've got a pelvic fracture. So it's really important to identify that early. So that's one of the other major differences with ATL S compared to sort of standard B LS or I LS or A LS, you then move on to disability after you've got your circulation under control. Um and then exposure. So you're looking, you're gonna log roll and look for any injuries. So for us, for the purposes of this talk, we're really looking at exposure. Um there may be circulation problems but the vast majority of patients that sustain um a, a low limb trauma will be seen by paramedics and they may or may not put a tourniquet on to stem the bleeding. Um The only sort of significant bleed you can really have is the femur. So you need to check for any femoral fracture. So if someone comes in and they're unstable and they've had a significant mechanism of injury, they may have a femur fracture and they could be bleeding into their thigh and that again can take a liter or 2 L of blood. And depending on the size of the patient age of the patient, um whether they're on any blood thinners. Um So we'll be focusing mainly on exposure, but I just want you to have the ATS algorithm in the back of your mind. Um when thinking about lower limb trauma, um and the branches look horrendous and they're quite visceral images or it's quite a visceral scene when you see someone's foot pointing in the opposite direction and bones sticking out. But you really, really need to remember always be thinking ABCD um before moving on to that, that horrible looking injury, this is done to a different degrees um of um efficiency in different a and ESI worked in quite a few different hospitals and different A&E s different registrars or different consultants in A&E will have different approaches to this. Um It's really, really important in any trauma situation that you have one person standing back. Um That's sort of er, instructing the team about what, what everyone is doing and the order by stepping back, they can have an overall view of the picture of the patient. Um And another really important note is that when you do anything or change anything, you need to reassess or start back at the beginning, say c spine. Yeah, we've got that sorted airway, there's been no change there breathing, the respirate hasn't changed, et cetera, et cetera. Also consider that patients that are, for instance, picked up on a motorway that have open fractures may have been given things like ketamine or morphine by the paramedics. Um, ketamine won't affect breathing, but morphine will so they could have suppressed respiratory effort. Um, because of the drugs they've been given so that all forms part of the handover from the paramedics to be aware of um, of what, what's been given. Um, sorry to interrupt, but I don't think the slides are sharing. Are you on the ADL S one? No, I don't think they've come up. Sorry. That's because I didn't share. You see it now. There you go. Yeah, that's perfect. OK, so there's ATL S just been through that. I hope that makes sense. Um It would have made more sense if I was explaining it with a picture there. Um But if anyone's got any questions about ATL S or about this approach, then um then feel free to put a question in the chat. Can you see the slides moving? Yeah, that's fine. Great. Um So classification systems, there's different classification systems for um open lower limb fractures. Um And there are quite a few of them. So, um and Anderson, the one at the top um from the seventies is, is what we tend to use in the units that I worked in anyway. Um It's a way of determining how much soft tissue and bony damage that there will there will have been. And because of the injury, technically, you can only actually assess your only classify an open lower limb fracture, um, after debridement, after you've cut away the dead tissues after, you know what, what the extent of the damage is. You can go and read about the rest of these, but I'll focus more on and, and cos that's the one we use. Um, the, the NIS A score for instance, is, is far more in depth cos that looks at nerve injury, um, and takes into consideration a, a lot of different factors. Um Whereas the G Anderson is a bit simpler, it just looks at the wound. Um the mangled extremity sever the, the mass mangled extremity severity score um is a way of determining whether or not uh a limb should be amputated based on um the how much trauma there is ganga a hospital score, more recent ones, a Ganga hospital, there's a trauma reconstruction hospital in India. Um It's a sort of reconstructive surgery center for the in the world. Um Lots of people go there for fellowships to do microsurgery fellowships. Um cos they've got a trauma down to a tee cos unfortunately, they have a lot of trauma, there's lots of traffic through the door. Um The Bastian classification comes from Camp Bastion, um which was the British and American military base in Afghanistan during the war. Um cos they had multiple people coming in with open low limb fractures after stepping on improvised explosive device. So different parts of the world will have slightly different approaches because of the, the types of patients that they get in, in the UK, the vast majority of open low limb fractures are from road traffic accidents, um or from crush injuries um in industry. Um So to give you a brief overview of the Gut Anderson, so um one is a small puncture wound. So it may be that the bone has punctured the skin and then gone back in. Um two is a wound that is slightly longer um but potentially will close directly. Two, the threes are then the more significant injuries that will probably require plastics input. Er I'll go more on to the guidelines in a second. But this if you have this in your mind, this is why plastics is important when it comes to open lower limb fractures because there may be soft tissue injury. Um a very wise orthopod that I worked with in Salford said that, ii know he didn't come up with it but define me. He, he asked me to define a fracture and a fracture is actually a soft tissue injury with a bony injury underneath soft tissues go through an immense amount of trauma if, if enough power has gone through to fracture the bone. So you have to consider the soft tissues when approaching anyone with a lower limb injury, lower limb open fracture. Um A three B means though there's periosteal stripping, so that bone is potentially devitalized. And three C means there's a um a vascular injury, so potentially um an unsalvageable limb depending on um the extent of the injury and how big the segment of, of the, how big the segment of the blood vessel is injured. Um There we go and there, there's just a bit more description of, of what the different um types of G and classifications are and just to reiterate when you see someone at A&E if you hear someone say this is a Gust Anderson two. Um Technically, they can't say that until the patient's been to theater and had the devitalized tissue derided. So you need to get rid of all the dead tissue to find out. Cos if you can imagine, you may have a very small puncture wound. But because of the, the force that's gone through the soft tissues, a set, an area of 10 centimeters squared might be devitalized because of the disruption of the blood tissue disruption to the, the skin and the blood supply to the skin. Um So have a look at Gut Anderson classification if you want to learn more about that. Um Now, in terms of take homes, this is the most important bit. Um we follow the best guidelines. So the British um orthopedic Association um in line with bare, which is the British Association of Plastic Reconstructive and Aesthetic Surgeons have got this guideline. So, it's last um published in 2017. Um You can Google it and find it on the B OA website or the bad website. Um, and it's, it's got a nice summary, which is just two pages long. If you're really bored over Christmas and you want to read the whole thing that's quite a bit longer. But, um, it's good to have an idea about this, just this two page summary. Um, and I'll go through some of the main points, um, about that. So, analgesia patients are gonna be in pain, these really hurt, that's pretty obvious you have to reduce the fracture and splint them. Often when people come in in A&E, there'll be in an inflatable, um, leg splint, um, for AAA tib fib fracture. Um, if it's a femur fracture, there may be an a toma splint or something similar to that which stretches, um, distracts the fracture and helps to prevent bleeding. Um, so you reduce the fracture and splint that's often done by orthopedics. Although obviously, we, we come in and give a hand usually under, um, some sort of conscious sedation in recess. So that may be with ketamine. It may be with propofol. Um, but you need someone then there that's airway trained. So that may be an anesthetist. It may be an A&E doctor A&E registrars or consultants, um, have to be airway trained. Um, you remove gross contamination. Um, it's really, really important that you don't try and do wash out in A&E because if you've got gravel and glass and things from the road if you start trying to jet, wash it out or spray it with saline, you may force, um, debris deeper into the wound and you don't want to do that. It needs to be controlled. And in theater, um, that's really, really common. You see people spraying sprinkling saline, um, onto the wound in A&E which isn't gonna do anything. Um However, if there's a big bit of tarmac or a big bit of glass, um that you could obviously see and you can remove safely, then you should do that photograph the wound. So from a plastics perspective, um it's really important for us for surgical planning to have photographs of the wound. Um This all A&E s that are trauma centers should have 24 hour provision of a camera um to take photographs. Um And this guideline is one of the main reasons for that. Um Similarly, for things like burns, we always like to have photographs. So photograph the wound, it's important that we see what the position of the limb is at the time of injury. So they may have been reduced at the roadside. But we get an idea then about the potential force that's gone through. Cos as you can imagine if someone's come in with an open lower limb fracture, it's them being reduced by orthopedics and A&E and then plastics arrive, we might think it doesn't look that bad, but the photo allows us to see how bad it was, how distracted were the tissues how much force went through it is the has the ankle was the ankle dislocated for instance. And the reason that's important is because we would then consider what reconstructive options are needed because of how much tissue may not survive. Cover the wound with a sterile saline soap gauze in a semi occlusive film dressing. So you want to seal off to the air every time you do anything, whether that's manipulating it, dressing it, um removing gross contamination, you should repeat your neurovascular examination. Is that limb um alive that can be difficult to assess sensation if the patient is on, is either drunk um on drugs or they aren't quite with it because of the drugs we've given them. So try and get an idea about the sensation. Have they got any altered sensation? You can imagine if someone's foot is at 90 degrees to their ankle, the sensation might be affected. So then you manipulate it and then you check to see whether the sensation starts to, to return and that could be could be number four and then goes to pins and needles. It. Everyone's sort of falling asleep on their arm in an awkward position. So, you know what that feels like. Um if you can't feel a pulse, then it's parti then potentially more of an emergency procedure in terms of the speed that we get into theater. Um if you can't feel a pulse, um then you can get a Doppler out. So a little handheld Doppler and you can put that where the dorsalis pedis or the posterior tibial is. Um, and see whether you can hear a pulse with that. So IV antibiotics should be given within an hour of the injury. Um, that will depend on your local guidelines. So for instance, at the minute we give Coamoxiclav um the good paramedics, if they're able to give drugs, um, will give the antibiotics at the scene. So they'll get pain relief and they'll get antibiotics at the scene. Once they've got a cannula in, they should all have a tetanus booster, you know, regardless of their status, cos these are dirty wounds. Um And you wanna get an X ray. Um If an ankle is grossly distorted, you're not gonna wait for an x-ray to relocate it. Um That will vary depending on who you speak to. But if you've got a devascularized limb and a, a very, very um uh distracted ankle, you want to put it back in position before you start to get scans and things X rays are very useful um as are CT scans and CT angios if you want to check the vascular supply, but do not delay reducing the fracture um to get imaging and that's basically it. So that's both for initial management. Um The, the next points are about the ongoing management. So that's things like having a consultant and a consultant, plastic surgeon and consultant orthopedic surgeon in the first visit to theater. Um The reason that's important is the guidelines used to say a senior orthopedic registrar, at least or senior um, plastics registrar. However, how do you define seniority? Um The number on someone's badge doesn't necessarily represent how much experience they've had with open fractures. So their new guidelines say it needs to be a consultant. Um, quite often, I mean, one I managed a few weeks ago in Alder Hay and the consultant came into theater, plastics, consultant came into theater, but he didn't scrub, he was happy with what I was doing. They just need to be in theater and cast an eye over the wound, um timing of surgery. So within 24 hours, um like I said, consultant, plastic and orthopedic surgeons should be on a planned trauma operating list. The reason for that is um you are more likely to get a consultant in theater. If it's on a planned list, you don't want to be doing things at four in the morning when people are tired and you're on minimal staff if you don't have to. So within 24 hours, but you can imagine if this happens early in the morning by the time it gets to the next day, it you may breach the 24 hours. So you have to take all that into consideration when planning, there are some exceptions to the rule. So gross contamination. So agricultural, aquatic or sewage. So um if someone, you know, has fallen over on their farm, for instance, then you would get taken to the theater straight away. Um If they've got any signs of compartment syndrome, so even in an open tib fib fracture, you can still get compartment syndrome because there's more than one compartment in the leg. If the limb is devascularized, devascularized, um then obviously, you need to go to the theater sooner. It may be that the, the limb starts to go pink once you've reduced the ankle. However, sometimes, um, you, it still warrants exploration um urgently rather than waiting till the next day if they've got another injury, um requiring immediate surgery. So for instance, if they've got er, their, if their tummy needs to be opened or their chest needs to be opened, um, and they go into theater anyway, then orthopedics and plastics should join the general surgeons or the cardiothoracic surgeons um to do the initial debridement of the leg. Um And the other one that can be slightly confusing is within 12 hours of an injury. Um for solitary high energy open fractures, what this means is if someone's been in a high energy injury, um and all they've got is the open fracture. You, you would tend to try and get them in within 12 hours. Now, you've got to think how much force is needed for a young fit person to sustain an open fracture versus an elderly person. And I've seen elderly people that have literally stepped off the curb and sustained an open fracture. Whereas young people, it tends to be higher energy injuries. So all of these things have to be taken into consideration what the patient factors, the injury factors. Um, and also what time of day it is and what what facilities you have available these injuries do sometimes get managed in district general hospitals that don't have plastics and orthopedics and that, that is incorrect. I mean, it's just, it's just bad management. Um, patients unless they're severely unstable should be transferred to a trauma center. Um not to a district general unless they need life saving um resuscitation. Um even if that is the case, they should have the life saving saving resuscitation in a district general and then be transferred into a trauma unit with both available. Um I can only speak for locally but for instance, in Manchester trauma centers are sod and MRI. MRI has onsite plastics, but only during working hours and then out of our support from the consultants covering with insurer. Salford has plastics. I don't think they've got a full on call rota yet where I work in Winston, it's not a major trauma center but Aintree is so we have consultants that will cover er, Aintree every day of the week but not out of hours. So if it was out of hours, it needs to be the on call consulting going there. Um So there's lots of politics involved. And that's part of the way that um, different areas are funded. There will be some set ups around the country where they have plastics, orthopedics within the trauma center, which would be ideal, but I've just not been lucky enough to experience that yet. Um So any questions about the boo guidelines or anything like that so far? Are there, are there any questions in the chat? Yeah. So what are the, the principles of surgery? So to extend the wound, explore and excise, excise just means cut away dead tissue. You've gotta consider the viability of the skin. Um And there's a classification for that, that you can have a look at the muscle. So we look at the color contraction, consistency and capacity to bleed. So the four CS um color is obvious contraction. You can pinch it or buzz the muscle to see whether it contracts. That gives you an idea about whether it's devitalized and whether it's still got a nerve supply, the consistency. Is it nice and plump and moist? Um or does it look dry and sort of as if it's treading apart? Um and does it bleed? Is there blood going into that muscle? Have any of the vessels been trapped? Then look at the bone, the tug test, which is quite a rudimentary test where if you see any fragments of bone, pick it up at your forceps and give it a little tug if it comes out um then that bone is gonna be devascularized. So you set that to one side. Um, high pressure, pulse, pulse lavage is not recommended. So, um, that's basically like a power hose in theater. And if you use that, you can push it, push debris down deeper into the tissues. Um Depending on where you work. Different preferences, you should probably be talking at least between four and eight um liters of, of sodium chloride to wash out the wounds. Um It's just about volume. You just need to get lots and lots and lots of fluid through that. Sometimes if you've got bits of um er tarmac or debris or bits of glass within the wound, you just need to cut them out. Um You can't rinse them out because you get sort of that staining that tattooing if you've ever seen someone that's hit the road, um they get, they get tarmac and, and dirt and stones lodged into the tissues and sometimes you just need to cut it out photographs, as I said. So photographs in A&E or at the time, sometimes paramedics take photos of what it looks like on the road. Um Photographs are on attendance to A&E and then photographs um in theater um at every stage so that we can plan reconstruction. So this talk originally was designed for sort of small classrooms. So we do a little bit of an anatomy quiz but I've taken off the, the things but you can look at the anatomy in your own time. So, it's important to understand that, um, there's three major arteries, um, supplying the lower limb, depending on the patient's age, their smoking status, whether they've got any preexisting vascular, um, vascular injuries or, um, disease, you may have worse, uh, blood supply to the leg. These all things all need to be taken into consideration. Um, you can find this out when they come in using an ample history. I'm sure you've all heard of that. So that's allergies, um medications past medical history, last meal and the events leading up to the injury. So always have it in your mind. Um What the baseline of the patient is both medically and socially as well. Someone that comes in with an open leg fracture that is normally wheelchair bound may be managed in a very different way to someone who's a young athlete, for instance. Um and also consider the nervous supply. Um So there's a nice picture of the vessels um coming down into, into the leg. You can get a CT angio to assess the vasculature um after, after um significant lower limb trauma. So fasciotomies, fasciotomies are used in Compartment syndrome or if you're worried that compartment syndrome is going to happen. So it's really, really important when fasciotomies are done, they're done in the presence of a plastic surgeon because we have to consider the perforators. So these vessels come out at 5, 10 and 15 centimeters medially on the leg. Um and they may be used, they come out towards the skin. Um and this skin can then be cut and isolated as we'll see in some of the flap reconstruction in order to, to cover up the defect to cover up the bone. And I'll explain why that's important. Shortly. You can see on this nice picture here, you've got this lovely perforator coming out there. Um These need to be preserved, which is why the blue line is where you cut for fasciotomies to release the compartments to release any potential pressure. As soon as an injury happens, you get swelling, that swelling increases the compartment pressure. And imagine the compartment is as a fixed her volume. If the pressure goes above the the BP, first of all, it's gonna stop venous return, which means blood will be going in but not coming out. And eventually, if it's left for too long, it can cut off the arterial supply and start to damage nerves. So you can potentially lose, you can lose a limb. If you don't diagnose and treat compartment syndrome in an open lower limb fracture, because of the high energy, we almost expect that they're gonna get compartment syndrome. So if we're going to extend the wounds to find normal tissue, we'll extend along the fasciotomy lines. Again, this is a really important picture to understand um where the different structures are within the like you can see here. So this is where how we make the fasciotomy. So we describe lower than fasciotomies. We do as a two incision for compartment release. So the anterolateral incision, it's done about a centimeter away from the lateral border of the, the tibia. You cut into this compartment. Here, the anterior compartment move along under the skin and then release uh the the perineal or lateral compartment. And this is done up and down the length of the leg and then move over to the posterior medial incision. Um So you release the superficial posterior compartment and then the deep posterior compartment through the same incision. So that's why it's called a two incision, four compartment release. So, considerations for reconstruction, think about what sent to you're in. Is there a plastic surgeon available? Um Do they have a microscope? Do they do free flap reconstruction injury factor? So, is immediate definitive bony stabilization possible. What I mean by definitive could either be outside the outside the body or inside the body inside the body would be in the form of a plate screws or a nail quite often tibias have uh an intermedullary nail put in. Um or is this patient gonna be man? Is it, have you got such a severe fracture that there's nothing to put the pin through? So they need to have um uh an external frame. I'll talk more about that in a sec them in a second. Do we fully understand the fracture configuration? Um do they need to have a CT scan is the zone of injury well defined. Do they need multiple trips to theater to debride? They should just need one good debridement at the beginning. However, sometimes in crush injuries, you may find that tissues look ok within 24 hours and then 48 hours later, more starts to die away just because of the nature of crush. Do they have recipient vessels? So if we do a free flap reconstruction, which involves taking part, taking tissue from elsewhere and plumbing it in to cover up the bone, we need a vessel to plumb that onto. So if someone has vascular disease and they only have one vessel supplying in their leg, which is quite common, um It may change the reconstruction we do that can be found out using a CT angio. What flaps are available if they're a polytrauma patient, if they've had a femur fracture, you can't take an anterolateral thigh flap. For instance, if they've got trauma on that side, you could take one from the other side though. So you've got to consider what flaps are available and we'll talk more about flaps shortly. Patient factors doing free flap, microsurgery can last anywhere between six hours and 12 hours depending on the complexity of it who's doing it. Um And how long it takes for orthopods to do the bony fixation? So, is the patient stable enough to withstand such a long operation? Have they had significant blood loss. Have they been on HD U? Are they requiring organ support? So these are all things that we're thinking about when it comes to reconstruction? Is it an isolated injury? Are there more life threatening or limb threatening injuries that need to be managed prior to us doing the reconstruction? Would we put the patient at a disadvantage by giving them a long anesthetic? Would we put them at risk of things like clots? For instance, think about things that affect wound healing, smoking status, diabetes, steroid, use their general compliance. You don't want to do high tech operations on low tech patients. Um That's what we always have in our heads when it comes to hand trauma. Um And it's certainly the same for lower limb trauma. Lots and lots of patients that sustain open, lower limb fractures have either been, well, a lot of them have been doing something they shouldn't have been doing speeding, driving, drunk, climbing over things, jumping off things. So you have to consider, um, will that patient comply with our instructions afterwards? The free flap procedure might take, take eight hours, but they're gonna have months of recovery after that and you need to know they can behave themselves. Um Luckily a lot of them are immobilized afterwards, so they have to stop smoking cos they can't get out of the hospital. The guidelines are that we need to do definitive cover with a vascularized with vascularized soft tissue and that should be achieved within 72 hours. I very rarely see that happen in the UK, to be honest, because of the set up the way that trauma is set up quite often, these have been managed in the trauma center which might not have plastics and then, um they will then be transferred over to the plastics unit. They'll wait for a bed, they'll get into a bed, then they'll have to wait for theater space. There's lots and lots of delays, but ideally, it should be within 72 hours. After the first procedure, we often temporize the wound with a VAC dressing. So I don't know whether anyone's seen negative pressure, wound therapy. So you put a VAC onto the wound that helps to take off excess tissue, er, excess fluid, sorry. It uh um also allows for granulation on the wound bed um and helps to try and prevent infection. So, one thing to consider when you're reconstructing an open low limb fracture. So the patients come in, they've had their debridement. Everything looks nice and clean. The orthopods have got a plan to fix the bone and they say to you, right? Ok. We need you to cover up the bone that we're gonna fix. You've gotta consider what you need. So do you want muscle or no muscle? Some of the pros fasciocutaneous flaps. So that's taking skin, subcutaneous tissue and then the first layer of fascia, um muscle flap is taking all of that plus some muscle or just the muscle itself and that will become more clear in a second. So fas cutaneous flaps are easier to re elevate for secondary bone reconstruction. Sometimes bone needs to be shortened in significant trauma. So if you've got a smashed bone, they may need to shorten it in order to fix it. Then later on, they come back in for lengthening procedures, for instance, to help them walk better. If that's potentially going to happen, then a fasciocutaneous flap will be better because it can be easily lifted off because it has that layer of flap fascia, which is almost that like cling filmy layer, which is nice to be able to peel off muscle when it's put into bone fractures, integrate into it, clots off and then scars down. It may be sensate. So if you can take it with a nerve, you might be able to maintain s um maintain sensation, minimal donor site morbidity, you're not taking any muscle away. So hopefully, it wouldn't have any functional impact, aesthetically superior. So you can imagine the front of the ankle is very thin skin on the side of the ankle is very thin skin. So if you've got a fas cutaneous flap, it's much thinner and therefore, it will look better and think about things like them getting shoes on. So they'll be able to wear shoes um that aren't like the big sort of uh orthotic um sandals muscle flaps can form better to cavity. So if you've got a hole and then the bottom of the hole is a fracture, the muscle, the muscle will sink into that. And there's lots of studies on muscle macrophages. So muscle flaps potentially reduce the chance of infection. They've got a very rich blood supply there for um more white cells, more macrophages that could potentially reduce the chance of infection and osteomyelitis uh experimental data to demonstrate to improve bone healing. Um the muscle thins over time, but when it's over time, it's quite a long time. So I've seen patients 6, 12 months after a muscle flap and they still need to go back in and have a debulking procedure where the plastic surgeon will come in and, and reduce some of that bulk so that they can do things like, like I said before, like put shoes on. Um another classification for you if you want to look it up is mas and I, and that looks at what, what the blood supply of a muscle is. So um the D stands for dominant pedicle and M stands for minor pedicle. So you can see that different muscles have got different types of blood supply. And with this in the back of our mind, we can then know um which, which type of muscle flap we need and whether if we're leaving any behind, what's the blood supply gonna be. So we're taking it with its blood supply we have to consider what would be keeping the rest of that muscle alive. And you can remember this by two graceful glute to sit on the la. And so these are just examples of the different types. So type one would be tensor, tensor, fascia lata, type two B, gracilis and glu sartorius doi with LA Dorsa for instance, because it has these minor pedicles, you can take part of the muscle away as a lat dorsal flap on the dominant pedicle. And then what's left will still be supplied um by the minor pedicles, sartorius, you can take segmentally. So you could cut a couple of sections of this and then flip it over for instance to cover um structures in the groin and so on. So a bit about orthopedics. So early skeletal stabilization is important because it restores alignment. It eliminates gross movement and that helps with pain and it also limits further soft tissue damage. If you imagine if you've got a fractured bone and you've got a vessel or a nerve sitting into it. If you reduce that fracture, making sure the the vessel or the nerve is out of the bone and then it's fixed back in, in its anatomical position, the the vessel and the nerve can't then slip back into the fracture. If you're in a situation where the bone is off and you've got some tubular structure where there's a vessel or a nerve in there and the bone moves you could potentially then sever that vessel, especially in context of trauma, cos everything will be edematous and potentially you already damaged, um decreases the risk of further bacterial spread. So you've got the bone ends. I see a line the blood supply to the um is restored to the bone um through the the improved blood flow and venous return. Um And as I said, it reduces the pain, the edema, the stiffness. So options external fixator, as I mentioned before. So outside locking into mago nails, um and they can be reamed or unreamed plates and screws. Um So, first of all, would you look at a little bit about the physiology of bone healing? Um So you get hematoma formation and then you get callus formation, fibrocartilaginous and callus formation, then bony callus formation and then bone remodeling. This is what happens when a bone has slight movement in it. So it's been reduced, but it has slight movement, you get that callus forming. So if you want to look more into bone healing, then you're very welcome to. But essentially having an awareness of the stages of the different um bits of bone healing um can be important for you to think about the recovery process. So, primary bone healing is by adversity and remodeling. So it heals without callus formation. Um It's fixed with absolute absolute stability. So that is if you had two bones and you had a plate bridging over the top of it, it's completely stiff and still. So the bone remodels and connects back together, um It's basically tricked into thinking it was never fractured. So you've got a stable fixation. Um And then the bone will do its usual turning over. Um And that's how the fracture heals. Secondary bone healing is endochondral ossification. So that's when it's not rigidly fixed. So that's for instance, someone that's in a plaster. So in a plaster, you'll get microval at the fracture site, you get that hematoma and that color formation. So just to give you an idea about the different types of um fixation. So that's an im nail. So they would have gone in through an incision just inferior to the knee, gone down into the tibia. Um And you can see that there's callus formation here, which means that it wasn't absolutely completely fixed cos there's been a hematoma that's formed um which has then formed a callous an X fix. So this is quite a nice example of the X fixes that we tend to use here. You've got the fasciotomy wound. So imagine the tibia is running underneath the pins here. And then like I said, you've got fasciotomy, fasciotomy and the perforators will be preserved in this area here. Frames can be uni player and biplanar or multiplanar. Um And there's lots that goes into the, the, the biomechanics of frames. Um And if you want to know about more about that, you're best off speaking to an orthopedic surgeon. Um But it's just important to know that there's different types from a plastics point of view. Our most important factor is knowing that the frame will be out of the way of our reconstruction. So if they are going to use a frame, can they out leave a window um on the medial side of the leg, because most likely we're doing a free flap, we'll be plumbing the free flap into the posterior tibial artery which we access from the medial side. Or we might want to get to those perforators on the media side. So more often than not, we ask them to leave a window and they will rearrange the frames in order to do that or if they've got rings, they've got certain rings that they can take off. Um and the structure will still be stable enough for um us to do our operation and the rings go back on at the end. But this is why it's so important for good communication between orthopedics and plastics. Um And you can see that the different frames are either non weight bearing or weight bearing. So this isn't an ilizarov frame. So that's a a circular frame um that goes outside and you can see that there's callus formation starting there. So this wasn't absolutely fixed. So this is secondary bone healing er there and then, and there's a Hexapod frame which has slightly different angles. So this can be used if you're trying to manipulate a fracture, so if you need it to be lengthened out, um you can adjust the pins and adjust the direction and the force is moving on it. So moving on to the plastic bit flaps. So this will be a little bit of a whistle stop tour just to give you an idea about all the different types of flaps that we use. Um So I'm not gonna go into detail about how we do them, but this just gives you an idea about the different things we can do. Um So medial artery, medial, serial artery perforator flap. Um So this is the medial seral artery coming off the popliteal. You can take a muscle part and a skin paddle. Um and you can use that. So if you've got an open fracture here, you can take this flap, raise the flap up here and you can see the pedicle coming off there, you would then tunnel it underneath the bridge of skin and stitch it in. So this is a pedicle flap. So it's not a free flap. It's kept attached to its blood supply when it's moved. Uh reverse postural neurocutaneous flap. So this is taken based off the sural nerve um and essentially it's flipped over. So you take it off its blood supply there, clip the vein here and then it gets reversed blood flow through the, through the vein um along the path of the nerve. So you can see that it's been marked out. This paddle of skin has been flipped over to cover the bone here. This defect and this defect don't have exposed bones. So they can just be skin grafted. So the light creamy color you can see on there is a skin graft and then you can see that that's healed up nicely there. A pedicled A LT. So alt is antri lateral thigh flap. So this is based off of the uh the descending branch from the lateral femoral circumflex and the perforators that come off that. So there's a way that you mark them out. So you mark where the knee is, um mark where the ass is and then they'll, you find the perforators along that line. Um It's really important, you measure the pivot point. So there's a pivot point here and then that would have been tunneled underneath the skin and flipped over to cover there more often than not. And the units I've worked in, we use a free at. So you would take the at off. So you detach it from his blood supply and then replumb it in um further south on the leg, uh gastrocnemius. So really, really robust flap. So you can see there if you go into the thigh, you can take a medial gastroc, a medial head of gastro, there's a gastro that's got two heads. You take a medial head and you can flip that around and you can use that to cover knee defect. Um, so you can see here there's exposed metalwork that wasn't intended clearly, this person's had an infection or some sort of breakdown. Um So what they've done is taken the gastro and they've also taken a skin paddle with it as well and flipped that up around into cover hemus. Um So the hea you can take it around the back here and use that to flip up and round. If you've got exposed muscle at the end, if it's not being tunneled, then you can skin graft over the top. So skin grafting on top of muscle. Normally it takes because uh muscle is a very good vasculature. However, it doesn't look as nice as doing um a free flap with um with skin overlying it. Um As you can see there, there's exposed metalwork. Um They've got a big old plate in there. It's been dissected down, half the PSA has been um raised and then it's been flipped over into place um and then covered with a skin graft. But you can see the patients got a very nice result and they've got clearly good movement of their ankle following that uh tibial artery perforator flap. So, based on the perforator from the anterior tibial artery, um you raise a little island of skin, flip it around and cover it up. So you can see in this one that's been done. Um Again, the donor site has been grafted and part of the foot here has been grafted. But the important part if you've got exposed um bone or, or tendons that don't have any patien on the covering of the tendons and you may need s substantial soft tissue coverage. So that's what this is now in. Um a lot of those other flaps require mag um magnifications either with loops which are the magnifying glasses or with a microscope. Um But traditionally, and this is described, I think a couple of 100 years ago with cross leg flap. Um So basically you lift up like a book, a page of a book, fast cutaneous, a fasciocutaneous flap and then you literally stitch the person's leg to their other leg in kids. And sometimes you put some metalwork between the two as a frame so drilled into the bone to hold them in place, you leave that for three weeks and then you come back and separate it. So you can see there's a big nasty defect here, taking a flap from there three weeks later, come and detached it. And then you can see that's been nicely covered. This is what you can see here quite nicely. This is still quite bulky so that may need to be debulked. But um in the future, um I still know not me personally, but I know some surgeons that work in war zones and things and this cross leg flap flap is is pretty good in terms of being robust and working. Um So it still is used in more austere environments, the gracilis or the gracilis, muscle up in the groin. You can take that as a muscle flap. We use the gracilis for facial reanimation. You can take it as an innervated muscle flap. If someone's had a facial nerve palsy, you can go in and do that. But obviously that this talking it can be used just as a, a small quite muscle flap if you've got a small area of bone to cover. So you can see here, you've got a nice section of the grass which is based on the of the pedicle underneath and a nice patch of skin. You can see the the main area of trauma would have been here, which is now covered with the, the pa the paddle of skin and the rest of it's been skin grafted and you can see that's a nice result there. A LTI spoke about 40 an anterolateral thigh flap. Um This is a really big flap and it can be used to cover up quite extensive areas. But again, it needs to be debulked in the future lap do size. A complete workhorse lap dorsi has been used all over the body for many, many years and you can take a varying amount of, of tissue. So you can either take a small skin paddle, a big skin paddle. Um You can take a small amount of muscle or a large amount of muscle um and you can use that to wrap around. So you can see this person's almost the whole tibia is exposed with metalwork and the the like dorsal muscle has been used to wrap that up. Um And then skin grafted over the top to save this person's leg, which otherwise would have been amputated because you can see there's just no soft tissue coverage there. You can also then do what's called chimeric flaps, which are a combination um of different flaps at once. So, so part of it might be fasciocutaneous, part of it might be muscular. Um So you can see here they've taken part of the muscle part of fasciculus and it's been plumbed in to cover different areas of what's AAA nasty wound. As a general rule, we divide it into thirds, but in reality, it depends on the center. Centers are comfortable doing a LT S, for instance, they'll do, they'll try and do a LT S for a lot of other things because of COVID and the lack of theater availability. Um we actually start doing more local flaps. So starting to use these perforators. So doing local perforator flaps. So basically raising up the side here like a paddle and flipping that over in. So instead of doing these bigger free flaps, um we would tend to do attempt more local flaps first. So someone's had their free flap done. Um It's important that, you know, I mean, when you qualify, you may work in a plastics unit. Um, you may get called to a ward where you have to look at someone's flap. It's very unlikely unless you're actually going for plastics. But obviously, by being on this talk, I suspect a lot of you do. Um, so flaps can often start to get congested or um, with venous blood or lose their blood supply. So my approach is look at the environment is the room cold. You want the patient to be nice and warm, you don't want their extremities to be constricting the patient themselves. Do they look distressed dry? How is that positioning? Do they have any pressure on the flap? So, quite often the patient will be in at least a splint. So they might have plaster on the back of the leg or the side of the leg. What I like to do is put a piece of tape over the dressing and put no pressure here free flap. And that lets all the nursing staff know, you know, they have lots of multiple changeovers of shifts, but everyone that comes and looks at that knows right. I'm not gonna put any pressure on that part. Um Then how does the flap look? So the color is it, does it look tense? Is it bulging? Is it bleeding? Um then you feel it. So temperature put a refill and then look at the, the Doppler as well. So when, when it's been plumbed in with a pedicle, which is the blood supply. We, we tend to put a stitch where you can use a Doppler to hear, hear the blood supply and to check it, nursing staff from plastics units know how to monitor. And after someone's had a free flap done on the first night, they'll probably get 15 minute observations. So someone will come in, be coming in and looking at all of this every 15 minutes and if anything changes, they might ring the doctor. So at the bedside, you need to make sure the patient's warm, wet and well position them, make sure there's no compression check. The dressings aren't too tight. Look at the operation note, look at their bloods. Are they anemic? If someone's anemic, they won't have as good blood supply to that flap. Are they starved if they do need to go to theater? Have they had um, correct VT prophylaxis. Do they need to go back to theater? But ultimately, you're gonna call the boss for the next 10 years of your careers. You'll probably be calling the boss if a flap goes off in the middle of the night. So there's always that to fall back on. I still call the boss. If a flaps going off, I would be ringing the boss after gathering all this information. So you've gotta think about, is it an inflow problem? Is the arterial supply compromised? Is it an outflow problem? Which is more common? Is the venous drainage compromised. Is there a problem within the flap? Um So think about it. Is there a pedicle or the blood supply going to the flap within the flap or coming out of the flap? Has something plotted off within the flap could be twisting could be compression. They could have a hematoma underneath the skin near where the pedicle is, which could be causing compression on the pedicle at the bedside. You could take the dressings down, reposition the patient release sutures, give her pain relief, prick the flap. That's not recommended unless you know exactly what happened during the operation because you could put a needle into the pedicle and damage it. You can score the flap. So if it becomes congested, you can score the surface of it, score the skin, allow it to bleed, allow it to decongest itself. Um and even use um leeches. So we're talking for an hour, we'll just race through the last few bits and then I can answer any questions. So an amputation is, is always a consideration. So an amputation is a treatment. If someone is dying and they're bleeding out and they've got an unsalvageable limb, the amputation could save their life. So don't just think that an amputation is a cop out. Sometimes amputation is the correct treatment for that patient in someone that's fit and well and wants to get back to activity that may be able to walk on a prosthetic. And amputation might be the best option for them. Um, so like I said, damage control surgery, they've got multilevel vascular injury. If they've got, um, if they're, they're delayed in their presentation, um, if they've got unsalvageable bone, they're not gonna have a solid post or foundation to walk on, then it may be, the amputation is best for them. Um, and you can see that just emphasizing the things I've just said. If someone has a stiff, useless or painful limb, then we may consider amputation sometimes when I worked in Salford in orthopedics in the limb. Um recon unit, sometimes people went a year or two years in frames um and developed chronic pain and they just, they, they were begging to have their leg cut off. Um Amputation should be a too consultant, decision should get psychological input, especially when it's delayed. Um But just remember, keep that in the back of your mind that amputation is, is always an option. Um This is quite an interesting project. Um It's from 2010. So it's quite old now, but it looked at um how well people did, depending whether they had reconstruction or amputation. Um And what the factors were, was it in America? Not in the UK. But I think some of it's still um can be transferred, the data can be transferred to us. So basically, they found that it didn't really matter about the mechanism of injury um or the type of injury they had um that, that didn't affect their outcome. What affected their outcome is their socioeconomic status and also their race. So it showed um an element of underlying um preferential treatment or better treatment potentially for higher socioeconomic classes and, and Caucasian people, they are more likely to have um health insurance. Obviously, it's different in the UK because we have the NHS. Um But it's just interesting. So people that had good support, it didn't matter whether they had an amputation or reconstruction, they did better um than the people that didn't have that good support. So that's why it's important. Once you got through all the drama of the, the initial trauma, find out what their social um set up is. Who do they live with? Do they have good support? Are they employed? Are they unemployed? Will they be able to finance themselves whilst they're in hospital? These are devastating injuries, life changing injuries. Um So it's important to take the whole picture, the whole patient into consideration and also have long discussions with the family as well. Um They're the standards of um open fractures of the lower limbs. So that's the, the extended version of the boast four guidelines that you can have a look at. Uh anyone that's interested in plastics have a look at. Um Keynotes is quite a good whistle stop tour of plastics. Um But there's also loads of free resources online. So the plastics, the plastics fella. Um It's quite a good website. There's loads and loads on youtube on different plastic procedures. A lot of them are sort of cowboy American private plastic surgeons. So we take it all with a pinch of salt. Um But if you're interested in plastics, I'd advise you get um taste of weeks and plastics. Um As a foundation doctor cos most centers won't have plastics. Um try to do your elective and plastics or ask about any projects, projects in your local units um that you can get involved in and then go in through courses for training and then apply for a training number. Um So that's the end of the slides. Um We've still got people here, which is good. Um Has anyone got any questions? Hm Can people in the audience see the, the chat? You should be able to, I've got one from Isabella. Um She said from getting into plastics point of view, would you say that plastics them CST is a must? So that's a very good question and a very, there's a long answer and a short answer. So the the short answer is no, it's not a must. Um because most people will take more than one attempt to get um into plastics. ST three, I personally took three attempts. So I got my number on my third round. I took two attempts to get into core surgical training. Um So plastics often, although it's not the most competitive surgical specialty, it's not like cardiothoracic. It is still quite competitive. The ST three application for plastics, if anyone's had a look at it, um, there, there's lots of quite advanced operating in there. So if you've done a CST, plastic steam CST, you're more likely to have done more operating, that being said, the best way to get the operating experience is working is a trust grade registrar, for instance, in plastics. So a lot of my friends and a lot of my colleagues will have done any, any, any surgical, any CST and then have done a year as a plastics at Joe, either before or after or a year or two of being a plastics um trust grade registrar. Um So if you want to fly through, then um I'd say I'd say a themed one is a must. But if you accept the reality of the training pathway in plastics, it's not completely necessary. I work with a couple of people at the minute that have done a non plastics, them CST. Um So they're planning next year to do probably another six months or a year as an sho in plastics as a trust grade local employed fellow. Um And then they will look to do ST three applications plus or minus um a year as a plastics. We trust grade level. So it's not, it's not a must. But um I think it helps, it helps with your mental health as well because if you don't wanna be doing bone abscesses for six months on general surgery cos you're interested in plastics then going in and doing a general surgery or the vascular or the urolo or? Yeah, urology. II would have hated it if I'd ended up with six months of urology, to be honest. But it's all good learning, like, especially when it comes to trauma. Having an understanding of different specialities in trauma is really useful. So, no, it's not a must, but it does help. I think it also depends on geography as well, whether you're willing to move, whether you have any ties. Um Personally, I wanted to stay in the North West. Um So I probably wouldn't have moved for a course, search for a plastic C CST posted elsewhere. Um But other people have less ties and they're willing to move anywhere in the country. But um again, that's, that's a personal thing and it's important to talk to people you work with about the options when you come to that stage. Um Cool. Hope that answers your question, Isabella. Um Has anyone got any other questions? Some? Thank you. Thanks, Chris. Chris is attending from the Democratic Republic of Congo. Um ok, if there's no more questions, um then you can always, I think you can post them on the event afterwards. I don't know whether you can move the Q and A after the event. I think there is a way of doing that. Um But if you've, if anyone does have any burning questions and get in touch with um the the society and they can always get in touch with me and hopefully I'll do more sessions in the future if it was well received, please fill, fill out your feedback forms. Um cos that's really important for, for my portfolio to prove that I do stuff. Yeah, definitely. I mean, first of all, thank you Dan for doing the talk. It's really interesting and useful for a lot of us, especially for years doing MS and plastics. Um And thank you to everyone who attended and stayed all the way for you to the end as well. Um As you said, we'll be doing more lectures and talks in the future and we'll be doing some more in person workshops and conferences that we're hoping to get everyone involved in. So, yeah. Yeah, I mean, it, it's obviously very accessible for people to do it online, but in person, especially with plastics is a lot better get people drawing things and um getting hands on. Um So that would be great. Hopefully something to look forward to. Thank you so much. All right. Have a good Christmas everyone. Thanks a lot. See you later. See you. Bye. Yeah.