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Hi, everyone. Um, I'll just wait to see if any more people join, and then we'll get started in a couple of minutes. Okay, so I think we'll get started. Um so welcome, everyone to the third webinar in the plastic surgery. Uh, series. My name is Jennifer, and I've worked in plastic surgery for the past year as an S h O. And I'm going to talk to you about the common things you'll see in lower limb injuries that might be referred to you as the plastic surgery s H o. Um, Sorry, I don't have a camera because I'm on a works computer, uh, without a webcam. So the topic that I'll discuss, uh, this webinar will be the open fracture of the lower limb. Uh, compartment syndrome, pretibial, laceration, hematoma, traumatic rights and lacerations. Um, but what I won't be talking about is burns in the lower limb and compromised three flaps because these are covered in other webinars and the plastic surgery series. Okay, uh, for each topic, I'm going to stick to the format of what? The red flags and key things to look out for key history, examination investigations, and then the management uh, one thing I will say is that there is a lot of crossover between orthopedics and plastic surgery. Uh, when it comes to managing lower limb injuries, uh, depending on your local hospital and their policies, it would depend on who manages what? Uh, but in most cases, these are the topics that I'll discuss our managed by both. Um, So if we start with open factors of the lower limb, uh, so your uncle plastic surgery s h O. And you're asked to see this leg by the emergency department along with the orthopedic registrar. This is a 25 year old male who has been a road traffic accident, and he's come off his motor by, um so you will usually be asked to see this. The orthopedic registrar will usually ring you, uh, and ask you to come and see it because you're going to need some sort of soft tissue coverage or a flat later on. Um, the patient will usually be have been stabilized by the emergency department or the trauma team plastic surgery. So it's not usually part of the arm called trauma Team, where orthopedic is. However, if you are there at the time they're going to be managed by the A TLS principles, which I'll talk about in the management a bit later on. So So ki history that you want to gap is, um, the mechanism of injury. Um, was it high or low energy? Um, was it a crush? Roll over in the car because it's going to impact how soft tissue is damaged and are there any other injuries elsewhere as this is going to affect where we can take a flap or a skin graft from you want to know how long ago the injury happened? Uh, this is especially important if this patient is showing any signs of ischemia because they're going to need to go to the theater more urgently. You want to know if there are any other injuries that need to be managed first, Um, and make sure that nothing is missed. The common one is in the hand where the patient has a broken little finger that no one has seen. Um, believe it or not, the patient will be more bothered about that than his leg. Uh, you also want to do what we call an ample history, which is check for allergies, medication, the past medical history. When did they last eat? Especially We're going to go to the theater. And any events surrounding the injury? Uh, so I've got a hole here and start that. So if you could all Which one of the following is a red flag or indication for taking the patient to surgical to surgery out there? So is it compartment syndrome? Devascularize limb gross contamination of the wound or polytrauma. Was it all of the above? Okay, so 76% of you have said all of the above, which is correct. So all of these are indications, um, for taking the patient to theater urgently. So you've got a gross contamination of the wound. Uh, this puts the patient at high risk of sepsis, and they're going to need a washout. Um, compartment syndrome, Uh, devascularize limb. Uh, they're going to need to go to surgery, uh, that night, and you may need to call the vascular registrar as well. Um, and any polytrauma patient that's got other injuries that requires immediate surgery. Um, so your examination in general, you just want to check what the hemodynamic stability of the patient is This might have already been done by E D. But you should check yourself, um, and then when we're focusing on the limb, you want to know where is the injury? Is the obvious deformity, the site, the size and the depth of the wounded? Any underlying exposed structures that you can see, uh, does the wind go right down to bone? Can you see tendons and muscles? Are they rupture? Little, Um, you're going to want to do a neurovascular examination, check peripheral process. And can you see any obvious pulsating blood vessels? Is it obvious? Bleeding still, Um, so when we do a neurovascular examination of the lower limb, I'll just start another pole. Um, when we test for dorsiflexion, in what nerve are we testing? And then the next question is, when we test plantarflexion, what nerve are we testing? And then finally, whereabouts on the lower limb? Are you going to test for the sensory supply of the deep peroneal nerve? Sorry. That should say dorsum of the foot on the I'll just give you a minute to answer those questions. Okay, so it looks like the majority of you got those questions, right? So when we're testing from motor, uh, side of things. The DORSIFLEXION. Is testing the common paraneal nerve in the, um, lower limb. The and plantarflexion is tested the tibial nerve. Um, so if there's if the patient is not able to do that, then there is some possible nerve damage. You want to check Sensation, you're going to check um, in the first Web space at the dorsum of the foot for the deep peroneal nerve. And for the superficial. It's just anywhere else on the dorsum of the foot and the tibial nerve. It's checking the sensation on the sole of the foot and you want to do, and you're a vascular examination before you do any manipulation of the limb or any intervention, and you want to repeat that afterwards as well. Um, for the vascular side of things, um, I would not rely on capillary refill time because that is, uh, less reliable in lower limb trauma. Uh, you want to palpate for the pulses in the foot. Um, if you can't palpate them, then you can do Doppler's and see if you can hear them. Then, um and it's important to do repeated assessments because it might be okay to start with, but the patient consumed develop loss of their courses. Um, so, as with most things, there is a classification system, and the Costello and Anderson is the classification of open, lower limb fractures. Type one is a clean issues that is less than one centimeter. Type two is greater than one centimeter, but less than 10 centimeters without significant soft tissue pushing. And then Type three is split into a B and C A. Being there is adequate soft tissue. Coverage of the fracture, Um, and be is whether it's inadequate soft tissue coverage of the fracture with possible prognostic stripping. And C is any open fracture that is associated with vascular injury that requires repair. So I've got some pictures, Um, and I'll put them on a pole to see which class how you would classify these each picture. So this is one. Okay, so 72% of you have said that this is a type one, which is correct. I go back to the classification. This is a wound that is less than one centimeter. If I go to the next picture, so it looks like people are between type two and three a, uh, this is actually a type two, um, which I can see why you can get confused between the two. Um, so it's type two, because, um, there was no significant, uh, soft tissue crushing or loss. Um, it's the next picture. Okay, so it looks like it's 50% of you said this is three. Be 30% is three a. The correct answer is three a day. Even though that bone is sticking out there, there is a soft tissue loss. Um, which I'll explain a bit more when we've gone through all the pictures. Uh, another picture. Okay. So 68% of Europe said that this is type three B, which is correct because there is, As you can see, there's significant soft tissue loss right down to the bone there. Whereas in the previous picture, despite the extensive laceration, there's still adequate soft tissue coverage. Where is this? It's completely lost. Uh, and I've got one final picture, which hopefully should be an easy one for you, which looks like 100% of you got this right. Type three. It's a total mangled and devascularize limb. Okay, so you've obtained your history and examine the patient, Uh, some investigations that you might want to consider. Uh, you want to take a full set of bloods, check the coagulation, especially if they are you on any anti coagulator coagulation medication a group and save if you've lost a lot of blood. Um, definitely gonna want to get an X ray of this slim, especially before and after you do any manipulation. Uh, you want to include the joint above and below? Um, CT angiogram is important. We're concerned about any vascular injury, but also, uh, sometimes done before any, um, lower limb free flap operations to check the patency of the vessels before they transfer them from one area to another. So open fractures require timely and a multidisciplinary, uh, way of management. And initial evaluation is usually in accordance of a TLS principles and the boaz guidelines, which are the guidelines for open fracture management which can be found on the Internet. Um, following stabilization of the patient, you want to assess and identify document any established or evolving limb threatening conditions, Uh, prior to any, um manipulation. Um, and make sure that you document the neurovascular status. You want to make sure the patients had adequate analgesia because it's going to be very painful. Avoid handling the wound except to remove any gross contaminants and to steal from any further contamination. You want to cover the wound with a sterile, say saline so gauze and leave the wound undisturbed until the patient returns. The Operation Theater. Um, you want to make sure the patient gets antibiotics, which will be according to local guidelines or policy, and make sure that the patient is up to date with the tetanus. Uh, also, make sure you get a photo of the wound. Uh, because this allows you to show your seniors the defect without having to bandage the wound. If it's been bandaged up, um, an open fracture should usually be operated on within 12 to 24 hours of the injury on a joint or the plastic list. Okay, so we'll move on to Compartment Syndrome, which, uh, again, uh, in my hospital. If it's the upper limb, it will usually be managed by plastic surgery. If it's lower limb, it will be managed by orthopedics Less, for example, say it's a circumferential burn, Um, but ultimately the treatment is the same. Um, so compartment syndrome is a clinical diagnosis, Um, where there's increased pressure within a fixed osteo fascial compartment, which causes reduced capillary perfusion, going to local tissue hypoxia and Muslim necrosis and, ultimately, loss of limb function as it's a clinical diagnosis. This can be very challenging. Um, and I think it's important to escalate early if you're worried. So when does compartment Syndrome occur? Uh, anything that's going to increase the volume within that actual compartment or increase the pressure. So we've got high energy trauma, the fractures, crush injury, burns, especially circumferential burns. Any vascular injury or bleeding disorders, which, like blood, is going to build up within that compartment. Any type dressings or cast an extra visitation of IV infusion that usually happens in the pollen. Um, so I've got another pole here. What are the five signs of compartment syndrome? Okay, it looks like 82% of you've got that correct. So it's the five piece. So we've got pain out of proportion to the injury, which is worse on passive stretch parasthesia paralysis and palate and pulse business, which are both late signs. Um, it's important to remember that these signs might be affected by any previous administration of analgesia, for example, like peripheral nerve block or any nerve injury, which makes this diagnosis difficult in the polytrauma patient and any sedated patients. So Ki history is, Has the patient had any trauma to the limb? Was it high energy trauma there? Any underlying fractures you need to be aware of vascular injuries or crush or burn injury is the pain out of proportion is the patient's screaming in pain despite analgesia where, as usually a patient is, uh, for example, after they've just come out for an operation? Um, and they're not in pain. If this person is coming out of theater and seems to be in a lot of pain, which is unusual for that POSTOP, Um, that's you know you can you can compare it to other patients that have come out of the theater and you know that they're normally managed well with paracetamol or or um, off. And this guy is requiring more and more and more that you know, the pain is just out of proportion to the apparent injury or your usual, uh, picture. You want to check their operation notes? Have they had a nerve block as well. Check the time in the onset of when the symptoms started. Have they got a tight dressing on or any cast that you can remove? Um, and then check. Their most importantly, fasting state is if you're worried they were going to have to go back to the theater. So when did they last eat? Uh, so on your examination, you want to just generally check how the patient is, um, hemodynamically and then look at their limb, uh, with the look feel. Move. Um, So when you look as the limbs swollen, look at the skin color. Have they got any obvious wounds? If you feel is it tender there jumping off the bed? Is the skin warm? Does the legs feel tense? And you might want to do a neurovascular examination. Um, And again, if you can't feel any peripheral pulses, then do a bedside doctor. Um, and then you want to move? Ask the patient to Dorsey flags plantarflex the, uh, foot, and then you can passively do it. And passive stretching of the effective compartment is going to cause severe pain. Um, so a little case scenario How this might present is a 32 year old male motor bike rider who's brought into E D following a collision with the tree. His injuries include extensive soft tissue Diab Asians and approximately to be a fracture on the same side. Significant leg pain, his undergone fixation and debridement, and theater and epidural was placed the following day. US to junior S H O is asked to review the patient's severe pain, uh, in his leg, which is below the knee. Initially, it's thought that the pain is due to a patchy epidural block and further doses. Given a good effect, however, the pain returned, and in the evening you're asked to see him again and the patient continues to experience, uh, this uncharacteristic severe knee pain. And on your examination, you know that there's distal sensory loss. So at this point, you should be thinking, uh, of compartment syndrome. If you've got a cast on from his, um uh, surgery, you want to remove that, but you should alert your senior immediately and prepare the patient to go back to the theater. And while you're waiting, uh, for your senior to come and review the patient for the patient to go to theater or in cases where you're not sure if it's compartment syndrome, where it's not obvious. Uh, do some bloods, uh, the usual fbc and using using and include lactate and CK. They will usually be raised. Um, you can do an X ray to exclude an underlying factor. Sometimes, uh, urine can be tested, which would be, uh, high in my globe in. And if you're unsure, compartment pressures can be tested, but usually it's pretty obvious, Um, but if you do test compartment syndrome, uh, but if you do test the compartment pressures, it's usually 30 mg of mercury above the diastolic pressure is an indication for the patient to go to the theater for treatment. Um, so compartment syndrome is a surgical emergency that needs to be diagnosed and treated promptly. Um, depending on the hospital, uh, discussed with the orthopedics and plastics, Um, as soon as possible. Um, make sure the patients had some adequate analgesia. They got tight dressing or cast on. You split that make the patient near by mouth. It gives him some fluids of the risk of rhabdomyolysis. Um, discuss with the on call team. You need to 30 coordinator, um, and ultimately, uh, fasciotomy is the definitive treatment, which is surgical decompression to reduce the pressure in the compartment. Um, some long term effects of compartment syndrome, uh, include permanent loss of sense of your motor function, scarring and contractors, chronic wounds and infection, and even amputation and severe disfigurement. That's why it's important to recognized the science early and involve your seniors. Here is a cross section picture of the limb lower limb, uh, where you can see the four compartments you got your anterior lateral and then superficial and deep posterior compartment. Uh, which shows the two incision technique for to decompress all four compartments. So you have one incision is an anterior lateral incision, and then you've got a posterior medial incision, which hopefully you can see from the arrows there. So if we move onto necrotizing fasciitis, um, again, this is in the lower limb in the hospital I work in is managed by orthopedics. The upper limit is managed by plastics. I know. In other hospitals, it's managed completely by plastics. Whichever limit is, um, plastics are usually asked to help later stages to help with the soft tissue defects. Um, so what is necrotizing fasciitis? It's a rapid, progressively progressive soft tissue infection, which can be life and limb threatening. And the toxins released by the cause of organisms lead to spread infection along fascial planes and then thrombosis of perforating blood vessels that supply the skin and subcutaneous tissues from deeper layers causes poor circulation, tissue, ischemia and skin necrosis. Um, so some red flags to look out for, uh is the unwell patient who's got evidence of septic shock, patient with risk factors, which I'll talk about on the next side in their key history, um, and rapid progression of clinical signs and symptoms because I have to remember that neck rash is a clinical diagnosis. So Ki history points, uh, timing, onset duration and the progression of the skin changes. Has there been any recent trauma by wound to the affected area? The patient had any recent surgery, and then some of these risk factors that was talking about is the patient diabetic, obese? Uh, you got any underlying malignancy? Kidney, liver disease Are the immune suppressed on steroids? I want to check that on anticoagulants. If they're going to theater, they're gonna have a lot of skin debrided. Um, so you need to check this. Any anti coagulation needs to be reversed. Uh, and you want to check the fasting status because these patients are going to go to the theater on your examination again. You do your general examination to check the stability of the patient, but when you're focusing on the limb, it might look initially a bit like cellulitis. Um, early signs will be erythema, swelling and some tenderness, but later on it'll start to get skin bully blisters and some fluctuation and then late signs or hemorrhagic bully crepitus in necrosis investigations to do your full bloods lactate a CK include glucose and group and safe send blood cultures and green swabs. Um, imaging should not delay the patient going to theater. But if you do do imaging sometimes on a CT scan, it will show like gas under the skin. And this is a scoring system that stands for laboratory risk indicator for, uh, necrotizing fasciitis. This you can find this on like Medco. Okay, um, which can be used to suggest whether there's a high risk of neck fascia or not. So a score of six, uh, is a high risk and less than six. It's not but it does not completely rule it out. So that includes CRP, hemoglobin, white cell count, sodium creatinine and blood glucose level. But that should not be, uh, used as above sick. Yes, they definitely do. But those six know they don't. It should be a clinical diagnosis as well. Uh, so the management is, uh, using crisps crisp and sepsis guidelines. You're going to want to give them IV fluids, put into a urinary catheter fluid balance. We're going to need IV antibiotics, which should be according to your trust policy, which usually says to discuss with the microbiologist uh, it's most commonly a polymicrobial, and most common is group A strep. Um, you want to involve the plastics your plastic senior contact theaters? Uh, anesthetist I t U. Because the most likely to go there, post up and contact the microbiologist to go on antibiotics. You also want to inform the microbiology lab prior to taking the patient of theater because usually deep tissue samples are sent from theater at the beginning of the procedure, which can be used for culture and to help guide treatment. But the early aggressive surgical deployment is what is required. Um, it's of all nonviable tissue and usually a planned return to the theater for a second look usually takes place 24 to 48 hours after initial debridement. So next we've got the pre tibial laceration, or hemotomas, so the skin overlying the shin is often fragile. Um, poor integrity, especially an elderly, Um, and this poor quality of skin is, uh, just exacerbates injury, even from trivial trauma and hematoma, can be very large and even compromised the surrounding healthy tissue via pressure effect. You can see that picture on the left, but hematoma has expanded so much that it's split the skin. So usually this presents as, uh, an old lady. So 82 year old female, she's fallen over on the garden steps, and she's got a pre tibial laceration. She's on apixaban for her A f, and she lives alone. That's usually a typical case that you'd be asked to see. Um, so your history you want to know how they did it with high energy, low energy? Is it clean, or is it contaminated and past medical history? Um, check the fitness of the patient. Uh, they're smoker. That's going to affect healing, um, or they don't want any any anti platelets or anti coagulation. Um, and for all non mechanical force, a full medical investigation worker, but usually required to rule out any underlying medical cause for contributing to that event. So when you examine, um, you know to look at the laceration, the size of it, the shape, the depth location. Is there a skin flap? Is there a hematoma? Is it still bleeding is expanding? Um, the skin condition is usually thin. Skin is the surrounding bruising. Has the skin actually become necrotic? Is it still viable? Um, is there any skin loss? Uh, are they going to need a skin graft to replace that? Is it infected? Any signs of cellulitis? Um so investigations, uh, is the usual your full blood count using these CLP regulation and agreements a, uh, x ray, uh, to exclude any underlying factors or foreign bodies. Um, And take a photo so you can show your senior once it's bandaged up. So to manage a laceration, just want to clean and dress it. Um, usually, it's something like gel in our goals and then boiling crepe. Um, it's usually difficult to close the skin because it's so thin, Um or and I've seen people use steri strips. However, not all surgeons like this, and you should check with your senior what they prefer, Um, or they may just literally want it to be managed in dressings clinic. Just continuous dressings. Management of a hematoma. Uh, evacuation can sometimes be done in the emergency department. Um, however, if it's large, then it's usually dressed, um, and take it to the theater, especially if it's still bleeding. Because surgical intervention may be required for debridement of any necrotic skin. Patient may need a skin graft to cover any skin defects When we do addressing that should include the foot as well, because you want the whole, um, up to the knee to the foot. So just to prevent any edema or swelling, um, until the advise the patient to elevate their leg at home and they're usually manage, uh, followed up in the plastic dressing clinic. Um, you can hold the anti coagulation unless it's contraindicated. Um, and then we want to manage any underlying medical problems. Um, so we should usually get a medical review. Um, and they can be managed to the medics, and we will the plastic surgeons can visit the patient if there's still an impatient on the ward and manage their pretibial injury or hematoma. And if there are any signs of infection or cellulitis, this will need to be treated as well. So move on to any bites or lacerations, which most commonly appealed the handle the arm but can occur in the legs as well. Uh, and the management is the same. So you've got most common ones that you see our dog bites, cat bites and human bites. Um, dog and cat whites are usually associated with secondary infections due to the large number of bacteria in the animals mouth. Uh, usually cat bites present, uh, usually a delayed presentation because the wound initially looks okay until the infection sets in. Your dog bites cause significant, uh, abortion, injuries and damage. There is cat bite. So just small wounds but penetrating. And then your human rights are most commonly a result of a fight. Right? So I've got two pictures here. Um, what do you think has caused? Um, picture, one cat, a dog or a human? And then there's another pole for what he thinks because picture, too. Okay, so I think the majority of got you, right. So for picture 1 68% said dog bite, which is correct of a picture. 2 89% of said cat bite. So the picture to you can see those two little ones where the cats teeth marks just small and penetrating. Um, and picture one is more. Their skin has been taken out the for human by usually, you can see the teeth marks left, Um, which makes it a bit more off here. So I'm taking the history. You want to know the mechanism injury? Is it a clean bite or have the tissue has been divorced and damaged. Is it sharp crush or sharing force that's happened? You want to know if it's clean or contaminated? Usually it is contaminated. Um, because the bacteria in that animals mouth, you want to know When did it happen? Because usually, like I said, the people who get cat bites, uh, often delay that presentation. I want to know if there's any other associated injuries. Um, you want to check their vaccination status in terms of what tetanus for, uh, the dog and cat bite in human bites. You want to assess the risk of hepatitis B, C and HIV. Um, and any relevant medical history or drug history of the immune suppressed, um, the diabetic. Any vascular disease that may affect healing, Um, Or, for example, when the fight bites, have they been, um, bitten by an IV D, you would increase the risk as well. So when you examine, you want to, uh, they'll be usually a lot of swelling and the patient be in pain. Um, it's usually a delayed presentation, and they're usually be pretty much tracking up the arm or the leg. Um, you want to assess the size, shape and where the wound is? Um, if there's any loss of skin or tissue, then, uh, depending on the location. Uh, you worry about different structures. Um, is there any discharge? Is it bleeding any obvious cellulitis? Um, And if the wound is deep, can you see any structure such as vessels, nerves and tendons? Any muscle bone exposed? Assess the surrounding skin, Um, for cellulitis? Uh, it's become narcotic. Um, is there any skin loss and can you see any visible foreign bodies? You want to do a focus muscular, skeletal and your vascular examination, especially if it's obvious that there's a lot of skin loss or there might be some nerve damage investigations. Um, you want to do your usual bloods? Um, you want to do microbiology swabs as well That can help guide antibiotics. Take a photo, um, and do an X ray because you want to rule out any fractures or foreign bodies left in the wind. The management will be to soak the area in antiseptic solution, such as better deal for 10 to 20 minutes or continuously worship. Um, for a cat bite, you can use a Kanye attached to an IV wash. Um, so you take the needle out and you can put that in the hall and it will wash through, uh, to wash the winds out. And you can, uh, make sure you give antibiotics again according to your local guidelines, and gives the patient tetanus prophylaxis. You're going to want to address the well. Um, however, if they need any structures repaired, then no need to stay in as an inpatient. And now I need consenting and booking for department and repair of structures on the next plastics trauma list and and you want to admit any patients that require IV antibiotics or strict elevation of a limb or any regular routine checks and dressings. Um, if you're in doubt, then I would discuss with the alcohol plastic surgery this trial consultant. Sometimes the wounds can be directly closed, but not every consultant likes that. So you should discuss that with your senior as well. That's it. Thank you. So if anyone's got any questions, if you just post them in the chat, Uh, and here is the link or Q Icar QR code for some feedback, which will also give you your certificate for attending today's session. I'll also post that in the chat at the end. But if you want to sign up to the next session in plastic surgeries Webinar series, it'll be on burns management, uh, with a Burns consultant next Tuesday. Okay, it doesn't look like there are any questions, so thank you, everybody for listening. Um, just make sure you fill out the feedback and you get your certificate. I hope you enjoy the rest of your evening.