The Libyan civil conflict: selected case series of orthopaedic trauma managed in Malta in 2014

Fourty year old gentleman involved in severe IED blast injury a few days prior to arriving in Malta affecting his head, chest and lower limbs. He was haemodynamically unstable, with a IGS2 score of 69. He presented in a state of sepsis and was directly transferred to the intensive care unit. His orthopaedic injuries included an unstable closed left subtrochanteric femoral fracture and an open comminuted fracture of the right tibia and foot with extensive soft tissue disruption graded as a Gustilo-Anderson type IIIC. His other injuries including posterior parietal soft tissue contusion, and right lower limb traumatic vascular injuries to the posterior tibial artery. DCO was performed in Libya where an external fixator was applied to his left femur (Fig. 1a). He then underwent conversion to a left intramedullary femoral nail (Fig. 1b) once stable a few days later. Marginal wound debridement and adjustments to the spanning external fixator was performed to the right leg concurrently. After a trial recovery period postoperatively along with intravenous antibiotics, his right lower leg with the partially missing calcaneum was unfortunately unsalvageable. He subsequently underwent a delayed right below knee amputation two weeks later. After being fitted with a prosthetic leg, his postoperative recovery was stable and he was transferred to a rehabilitation hospital for further care three weeks later.

Fifty year old gentleman involved in an IED blast and GSW. He underwent DCO in Libya and had a spanning external fixator with multiple K wires to stabilise a comminuted right elbow articular fracture (Gustilo-Anderson type IIIB, Fig. 2a). His presented haemodynamically stable with a IGS2 of 46. He also had a non-spanning external fixator applied to his left humerus for an open mid-shaft fracture (Gustilo-Anderson type IIIC, Fig. 2c). Other associated injuries were a complete loss of tissue coverage on the left mid humerus leaving bone exposed. The plastic surgical and vascular surgical teams were also involved in his initial assessment. He was taken to theatres within a few hours of arrival whereby his external fixation was revised, precise wound debridement performed (Fig. 2c), along with concurrent brachial artery bypass using his native greater saphenous vein graft for an brachial artery rupture due to septic erosion. His right elbow required serial debridements every few days and removal of metalwork due to on-going infection (Fig. 2d). After seven debridements and necrectomies over a period of one month along with prolonged intravenous antibiotics, he succumbed to an overwhelming systemic bacteraemia due to Klebsiella pneumonia Carpapenamase (KPC), a highly drug resistance Gram negative bacilli. Prior to the arrival of Libyan war trauma victims, our hospital and country had never had any documented cases of KPC. He died as an inpatient following multi-organ dysfunction and disseminated intravascular coagulopathy.

Thirty two year old man suffered a GSW to the left proximal femur and blast injury to the right leg secondary to an RPG. He underwent DCO initially with application of an external fixator for his left comminuted proximal femoral shaft (Gustilo-Anderson type IIIA). The extent of the comminution is well represented in the CT reconstructions seen in Fig. 3a. He also sustained a right distal tibial diaphyseal shaft fracture (Gustilo-Anderson type IIIB, Fig. 3b). He was haemodynamically stable on arrival, with an IGS2 score of 43. Other injuries included neurological compromise to the left leg with sciatic nerve palsy, bilateral lung contusion, stable superior and inferior pelvic fractures and a stable T12 fracture. Once stable from his lung injuries, the right tibial spanning external fixator was converted to a hybrid ring fixator as seen in Fig. 3c, and the proximal femoral fixator was converted to an interlocking intramedullary nail with bridging of the fracture site (Fig. 3d-f). He made a steady post-operative recovery and was able to mobilise initially non weight bearing then progressed to partial then weight bearing as tolerated with crutches. After eight weeks as an inpatient, he had good bone callous as evidenced in radiographs, along with full functional range of motions of the hip and knee joints. He was deemed fit to be transferred to a local rehabilitation hospital.

Twenty two year old who suffered a GSW to his right knee. He had a comminuted open fracture of his knee, with a shattered the distal femur, patella and tibial plateau as depicted in the reconstructed CT images and extensive soft tissue disruption (Gustilo-Anderson type IIIB, Fig. 4a–c). He had altered neurology in keeping with tibial nerve injury but intact vascular system distal to the knee. His parameters on admission were stable with a IGS2 score of 33. The patient was transferred with a spanning external fixator and multiple K-wires. These were removed in view of skin and joint infection, the wounds debrided thoroughly and the fracture treated definitively with another external fixator. He needed a total of five further debridements and necrectomies in theatres over a span of three weeks. However the patient discharged himself from hospital against medical advice before definitive soft tissue cover could be planned.

Twenty-six year old man who involved in a blast injury when an bomb exploded near him whilst he was driving his vehicle. He suffered from extensive shrapnel injuries. He was transferred to Malta within 4 days of the incident. He presented with a dense lower limb hemiplegia. A CT scan showed a 1.5 cm sized metallic foreign body at the level of T5 within the spinal canal (Fig. 5a). He also suffered from a left sided pneumothorax that required a chest drain, a fractured right scapula and fractured ribs along with multiple metallic foreign bodies in the chest wall (Fig. 5b). His parameters on admission were stable, with an IGS2 score of 33. Due to the dense paralysis distal to T5 that he presented with, it was deemed that there would be no benefit from removing the foreign body and thus no surgical interventions were performed on the spinal cord. He was also diagnosed with a left popliteal deep venous thrombosis one month into his inpatient hospital stay and was treated medically for this. Physiotherapy together with nursing care were the mainstays of his treatment. He was eventually transferred to a rehabilitation hospital.

Twenty seven year old man involved in an above ground explosive blast injury that severed the lateral half of his right foot (Fig. 6a). He also had a open tibial and fibular shaft fractures with extensive soft tissue loss (Fig. 6b–c). His parameters at admission were stable, with an IGS2 score of 43. In Libya he underwent DCO with an external fixator applied to the right foot and a metatarsal ray amputation to the lateral four toes. The extent of the soft tissue damage to the leg was significant (Gustilo-Anderson type IIIC) with obvious neurovascular disruption. The plastic surgeons were involved after the initial debridement on admission in an attempt to reconstruct and cover the foot using skin flaps and skin skin grafting, but it was deemed un-salvageable after two plastic surgical procedures. He required two further soft tissue debridements, however an eventual right below knee amputation was performed after four weeks. He made a good recovery and was then transferred to a rehabilitation hospital.