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).