BODYCAST - THE OFFICIAL JOURNAL OF THE CSOT

By J.T. Griffiths*, J.L. Hobby, J.M. Britton Department of Trauma and Orthopaedic Surgery, Basingstoke and North Hampshire NHS Foundation Trust, Aldermaston Road, Basingstoke, Hampshire RG24 9NA. Reprinted with permission from Injury Extra, 41 (2010) 120- 121.

Introduction

Functional bracing and early mobilization werefirstdemonstrated to be an effective means of treating tibial fractures by Sarmiento in 1970 (Sarmiento, 1970). Studies have since demonstrated the effective treatment of stable tibial and ankle fractures by functional bracing or pneumatic aircast bracing (Allen et al., 2004; Brink, Staunstrup, & Sommer, 1996; Stuart, Brumby,& Smith, 1989; Whitelaw, Wetzler, Levy, Segal, & Bissonnette, 1991; Wykes, Eccles, Thennavan, & Barrie, 2004). We present a case whereby a patient developed extensive foot and ankle tissue necrosis, resulting in below knee amputation, following prolonged application of a pneumatic aircast walker (PACW).

Case report

An 83-year-old nursing home resident was admitted to hospital with extensive tissue necrosis to her right foot and ankle seven weeks following treatment for a distal tibial metaphyseal fracture. The patient had a complex medical history including dementia, multiple sclerosis, non-insulin-dependent diabetes mellitus and a cerebrovascular event affecting the right side. Seven weeks prior to admission, the patient fell at her home whilst transferring from bed to commode. She attended the Accident and Emergency (A + E) department and x-rays revealed a minimally displaced right distal tibial metaphyseal fracture (Figure lA and B). She was placed in a below knee back slab. She re-attended the fracture clinic two days later and was placed in a non-weight-bearing scotch cast for four weeks. On review at one month mild tenderness was elicited on palpation over the fracture site and x-rays demonstrated early callus formation. A superficial skin abrasion was noted to the dorsum of her right foot, but the skin was intact. She was placed in a PACW for another month to allow the nursing home to monitor the soft tissues whilst aiding her mobility. However, the PACW was not removed for some time and the soft tissues were not monitored. The patient was re-admitted via A + E three weeks following application of the PACW with extensive tissue necrosis of the right foot and ankle (Figure 2A-C). Admission blood tests revealed a white cell count of 19.4 x 109 with a c-reactive protein of 87 mg/L and an erythrocyte sedimentation rate of 75 mm/H. Although her foot
was vascularly intact, the patient was reviewed by the vascular consultant who agreed with the diagnosis of pressure necrosis secondary to prolonged application of the PACW the extent of the necrosis and her co-morbidities, a decision was
made to perform a below knee amputation. Following the amputation, the patient underwent two further operations to
debride the stump prior to the final stump closure. The stump healed satisfactorily. She also had a percutaneous endoscopic gastrostomy (PEG) tube inserted to enhance her nutritional status and aid wound healing. Her total hospital stay was just over 10 weeks.

This abstract is a portion of the article which appears in the Summer 2011 issue of BodyCast.  
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