CASE PRESENTATION
A 37-year-old woman was struck by a container truck and subsequently run
over twice by wheels. She presented at our emergency trauma center
approximately 5 hours after the incident. Physical examination revealed
a significant degloving injury on her right hand (Figure 1). In
addition, her hips exhibited swelling with impaired mobility, and there
was ecchymosis and swelling of the skin from the left groin to the upper
left thigh. Both ankle joints were swollen and immobilized. CT (Figure
1) confirmed a comminuted fracture of the sacrum and obturator, left
femoral neck combined with an intertrochanteric fracture, right fifth
metacarpal fracture, dislocation of the right carpometacarpal joint,
right lateral malleolar fracture, left distal tibiofibular fracture, and
multiple fractures of the metatarsal tarsal in both feet. There was also
injury to the left superior and inferior gluteal arteries,
retroperitoneal hematoma, right kidney contusion, and a horseshoe
kidney. Emergency interventions included pelvic external fixation and
left internal iliac artery embolization, along with bilateral ankle
external fixation. Subsequently, the patient was transferred to ICU.
Pelvic CT revealed a sharp bone fragment from the lower sciatic branch
piercing towards the vagina (Figure 1). Notably, the left hip joint, and
the area underneath the abdominal wall exhibited an extensive ’free
black air bubble sign’ (Figure 2), indicating the entry of air into the
body through an open wound. Sharp fracture fragments were identified in
the pelvic floor near the urethra and vagina. Unfortunately,
professionals in radiology, emergency departments, orthopedic trauma,
general surgery, obstetrics, and gynecology overlooked this critical CT
sign.
On the fifth day of admission, percutaneous drainage was performed on
the Morel-Lavallée injury of the left thigh , resulting in the drainage
of 1700 ml of bloody mixed fatty fluid. On the ninth day, extensive skin
necrosis had become apparent on the left hip, anterolateral left thigh,
right thigh, and lateral right calf (Figure 3). Physical examination
indicated swollen labia and a blood clot at the external vagina,
initially interpreted by the gynecologist as a menstrual blood clot. the
general surgeon determined that there was no colonic, rectal, or vaginal
rupture and concluded that there was no indication for colostomy. The
second gynecological discovered contusion on the vaginal wall at the 5
o’clock position through colposcopy. Additionally, a 2.0 mm puncture
wound was identified in the left nympholabial furrow (Figure 3). On the
tenth day, debridement exploration and Vacuum-assisted Closure Drainage
(VSD) were performed to remove necrotic skin from the left buttock and
left thigh. The exploration revealed pus accumulation in the perineal
area and the adductor femoral canal, along with necrosis of the
iliotibial fascia, lateral femoral muscle. Black necrosis was observed
in sacrococcygeal area (Figure 4). The wound infection and necrosis
persisted and worsened due to continuous contamination from defecation,
along with pus accumulation in the sacral, vaginal, and rectal fossa,
despite debridement on the fourteenth day. Despite undergoing multiple
debridements, the wound remained uncontrollably infected, primarily due
to fecal contamination. Although nutritional support therapy was
administered, the patient continued to experience anemia and low-protein
levels. On the twentieth day, an exploratory laparotomy and colostomy
were performed, the perineal area was clean without fecal contamination.
Intravenous administration of 1.0g Vancomycin twice daily, coupled with
adding Vancomycin to a 3-liter bag for wound irrigation and drainage,
effectively brought the wound infection and necrosis under control. All
laboratory indexes showed a tendency to normalize. Subsequently, the
patient underwent right hand dorsal, left hip, and buttock flap
transplantation, along with internal fixation of the right fifth
metacarpal fracture. Throughout the hospitalization, the patient
received a total of 54 units of RBCs, 1,200 ml of fresh frozen plasma,
2,870 ml of frozen plasma, and 865 g of human albumin. Three months
post-trauma, pelvic CT and MR scans revealed necrosis of the left
femoral head (Figure 5), with no ’free black air bubble sign’. The joint
surgeon recommended Total Hip Arthroplasty (THA) after 3-6 months of
wound healing.
After a 122-day hospitalization, the right abdominal colostomy showed no
signs of infection. All wounds had successfully healed (Figure 6).