History. Ms. A was admitted to the authors’ facility in January 2014 at age 14 years. When she was 11 years old, she was sold to a family and became the victim of human trafficking. At the age of 12 years, she experienced a spontaneous abortion, after which she managed to escape her captors and was placed into a government-run home where the case first was reported to authorities. Ms. A was hospitalized on 2 different occasions at the local county hospital due to psychological problems. She was diagnosed with anxiety disorder, reaction to severe stress, and adjustment disorder for which she was treated with counseling, oral antidepressives, and anxiolitics.
After 1 year at the childcare facility, she allegedly heard she would be returned to her captors. This information and fear were the trigger for attempting suicide; she jumped off a 3-story building. Ms. A experienced severe polytrauma, including a closed fracture of the right tibia and fibula and an open tibial fracture on the left leg with an extremely contaminated large skin and soft tissue defect of about 50% of the total lower leg volume, severe fracture comminution (bone “crumbling”), and periosteal stripping. She suffered other injuries that further complicated her recovery, including fractures of her pelvic bones (acetabulum and right ischiopubic bone); basilar skull; left frontal, orbital, and zygomatic bones; and right sphenoid bone and nasal bones. Ms. A also had a diffuse cerebral contusion and bleeding into the maxillary, ethmoidal, frontal, and sphenoid sinuses. Due to thoracic contusion and bilateral contusion of the lungs, her condition was further complicated by respiratory failure.
Treatment. Soon after Ms. A was admitted to the county hospital, surgery for the leg trauma was postponed due to head and thoracic injuries, and cast immobilization was placed. Three (3) days later, Ms. A developed compartment syndrome (a relatively uncommon complication in open fracture injuries in children1) of the left lower leg and underwent a fasciectomy and placement of an external fixator. The primary fasciectomy (that resulted in a large tissue necrosis and local infection) was delayed because the cast immobilization covered the leg and during the next 3 days, the neurocirculatory status of the leg was not properly checked.
Two (2) weeks after the initial injury, Ms. A was transferred to the authors’ Department of Plastic and Reconstructive Surgery where her lower leg was examined. Local findings included an open tibial fracture with external fixation, necrotic muscles of the anterior and lateral muscle compartments, purulent secretions, and a skin defect measuring 33 cm x 20 cm with necrotic edges, exposing the entire length of the lateral, posterior, and anterior aspects of the lower leg (see Figure 1). Additionally, Ms. A had a closed fracture of the right lower leg, also with external fixation.
Upon her arrival, a surgeon performed a necrectomy and wound debridement of the necrotic skin and muscle tissue of the left lower leg and applied constant negative pressure wound therapy (NPWT) at -120 mm Hg that was changed every 4 to 5 days for the next 3 weeks (see Figure 2).
After optimization of the wound bed, the external fixator was removed and osteosynthesis was performed using cortical screws. The residual soft tissue defect was filled using a free microvascular latissimus dorsi flap, anastomosing the thoracodorsal artery and vein to the popliteal artery and vein, respectively. To cover the skin defect, a split-thickness skin graft harvested from her left thigh region was placed (see Figure 3). Within 72 hours, the donor tissue developed dark discoloration and a loss of Doppler signal. It was surgically removed due to flap failure and tissue necrosis. To close the skin and soft-tissue defect, NPWT again was applied at the same setting (-120 mm Hg) and changed every 4 to 5 days for the next 5 months. During this period, several split-thickness skin grafts from the left thigh were harvested and placed to cover the residual skin defect, after which NPWT was reapplied as previously described (see Figures 4, 5). In the last month of her treatment, Ms. A also underwent a total of 22, 1-hour hyperbaric chamber treatments.
Two (2) months after the initial injury, the external fixator on the right lower leg was removed, the right tibia was manually repositioned, and osteosynthesis was achieved using an intramedullary nail. During the same surgical procedure, the screws previously placed in left lower leg were removed, necrectomy of necrotic bone of the proximal part of the left tibia was performed, and an external fixator again was positioned. Ms. A was hospitalized for a total of 6 consecutive months.
Immediately upon arrival and throughout hospitalization, a pediatric psychiatrist monitored Ms. A on a daily basis. Ms. A was treated with anxiolitic and antidepressive medications — diazepam, 10 mg per day, and sertraline, 25 mg per day. She also underwent weekly psychotherapy consultations. During her stay, multiple wound, urine, blood, and central venous catheter cultures were taken, and appropriate antibiotics were prescribed according to the antibiogram results. Bacterial isolates from wound cultures included Enterococcus faecalis, Pseudomonas aeruginosa, Staphylococcus species, and Acinetobacter baumannii.
Prognosis. Six (6) months after admission, Ms. A was discharged from the Department of Plastic and Reconstructive Surgery and transferred to the Department of Orthopedics, afebrile with all wounds closed. She underwent 5 separate additional surgical procedures at the Department of Orthopaedic Surgery.
The first surgical procedure involved elongation of the left Achilles tendon, tenotomy of the left posterior tibial muscle, and capsulotomy of the left posterior talocrural and subtalar joints. The second and third surgical procedures were tenotomies of the left digital flexor muscles and the abductor muscle of the left thumb. The fourth procedure was to correct the patient’s pes cavus using the Steindler technique (ie, muscle and fascia stripping from the plantar surface of the calcaneus). The last procedure was performed to correct pseudoarthrosis of the left lower leg using an Ilizarov apparatus that was removed 3 months later.
Ms. A’s early postoperative status at the Department of Orthopedic Surgery was satisfactory. She was independently mobile with the aid of crutches and orthotics.
Follow-up. Ms. A’s follow-up was performed based on common clinical practice in the authors’ department. At her 18-month follow-up, Ms. A was afebrile, all wounds were closed, and she experienced no discomfort. No edema was noted on her lower limbs, her left knee was flexed to about 75˚ with the aid of orthotics, and she was mobile (see Figures 6, 7). She continued to receive regular psychiatric counselling and remains on her psychiatric medications.