Catastrophic myonecrosis following circumferential pelvic binding after massive crush injury: A case report

Abstract

but this report describes catastrophiccomplications underlining the importance of early binderexchange.2. Case reportA 27-year-old man was transferred into the Regional PlasticSurgery Unit18 days followingmassive crush injuries sustained inan industrial accident. He was crushed in posterior to anteriordirection at the level of the pelvis and briefly trapped. Onadmission he was fully conscious but in profound hypovolaemicshock. A laceration was noted anterior to the left hip andneurological examination of his lower limbs showed sensationin tact with toe movement present bilaterally. Pelvic radiographydemonstrated dislocation of both sacro-iliac joints and confirmedan open fracture of the left acetabulum. An improvised pelvicbinder was applied and emergency laparotomy performed.At operation, the rectus abdominis was found to be transected,the small bowel crushed and lacerated and the rectum avulsed.There was a large retroperitoneal haematoma with psoastransected, and the aorta lacerated at its bifurcation, along withmultiple holes intheadjacentinferiorvena cava(IVC).The urethrawas also found to be divided but there was no renal or uretericinjury. The aorta was repaired with a long saphenous vein patch,and the IVC repaired with direct closure. The large bowel wasdefunctioned and a Hartmann’s procedure performed, a supra-pubic catheter inserted, and the abdomen left open. The pelvicbinder was left in place.Further investigation revealed that there was an unstable rightpedicle fracture of the fifth lumbar vertebra. Transfer to anothercentre for definitive fixation of the pelvis was delayed because ofdifficulty achieving stability during the following period ofextended resuscitation. Throughout this time the pelvic binderwascontinued.Onday3postinjurythepatientreturnedtotheatrefor change of dressings and placement of a feeding jejunostomytube. The abdomen was covered with a vac dressing. It wassubsequently noted that pressure areas were starting to developunder the binder at the level of the trochanters circumferentially.The patient was transferred to another centre and an externalfixator was applied to the pelvic ring anteriorly on day 7. By thistime the pressure areas around the buttocks had worsened andnecrotic areas were debrided along with full-thickness damage tothe skin from both trochanters to the anterior thighs, in line withthe previous binder (Fig. 1).Thepatientwastransferredtotheplasticsurgeryunitatday18,still sedated and ventilated. The patient underwent serial massivedebridementsofskinandmuscleoverhisbuttocksandlowerback.Each debridement was curtailed by bleeding which was con-tributed to by the rigid nature of the ischaemic muscle which