PURPOSE :                 Despite city-wide advances in pedestrian safety, continues to have a high pedestrian-versus-automotive vehicle (PVA) rate compared to similar metropolitan areas.  San Francisco General Hospital (SFGH) is the Level I trauma center serving this area, where our physicians utilize a multi-disciplinary approach to care for patients with lower extremity trauma.  Utilizing our Trauma Registry database, we assessed the types of PVA-related lower extremity injuries encountered and the role of plastic surgery in the management of these injuries.

METHODS:                We searched our database, which meets Level I Trauma Registry criteria, for PVAs that required admission.  Our database links traumas with ICD-9 codes accumulated during hospitalization (admission and operative diagnoses).  We searched the most recent 5-year period (2003-2007) with records submitted to the National Trauma Registry.  We were able to select the subset of PVAs (including automobiles, motorcycles, and buses) that correlated with lower extremity injury diagnosis codes (upper leg, lower leg, foot).  We also searched for PVAs that led to plastic surgery involvement (by service admission or transfer, or by operative attending), and from this group only included operations involving the lower extremities.

RESULTS :                 In a 5 year period (2003-2007) there were 3558 PVAs taken to our emergency department for treatment.  Of these, 983 were admitted and the rest were released.  670 (68%) of these admitted patients had associated lower extremity trauma.  Of these 670 patients, their injuries included 387 (57.7%) tibia-fibula fractures (72 open, 315 closed), 97 (14.4%) femur fractures (11 open, 86 closed), 81 (12%) ankle-foot fractures (20 open, 61 closed), 72 (10.7%) foot injuries (22 open, 50 closed), 16 (2.4%) degloving injuries (involving any portion of the lower extremity), and 7 (1%) patella fractures (all closed).  10 (1.4%) patients had lower extremity amputations (3 below-knee, 1 above-knee, 3 below-ankle, 3 bilateral lower extremity amputations).            Of the PVA’s with lower extremity trauma, 19 (2.8%) required consultation from plastic surgery.  Specifically, these injuries include 9 open tibia-fibula fractures, 7 degloving injuries, 2 open foot fractures and 1 open femur fracture.  Coverage methods used included: skin grafts only (4), local fasciocutaneous flaps (3), rotational muscle flaps (4), or some type of free flap (8).  Our surgeons were involved in the soft tissue management of 2 patients who ultimately underwent bilateral lower extremity amputations. 

CONCLUSION :         From our 5-year review of PVA trauma in we found that of those requiring admission, a large number (68%) had associated lower extremity trauma.  Tibia-fibula injuries comprised the majority (57.5%) of lower extremity injuries, followed by femur fractures (14.4%).  Plastic surgery was involved in 2.8% of these PVA-related lower extremity trauma cases, and was limited mostly to open tibia-fibula fractures, degloving injuries, and amputations.  Soft tissue coverage and limb preservation were the indications for consultation in these cases.  With plastic surgery involvement in only 2.8% of cases we feel that our services may be underutilized and we encourage consultation by our colleagues to assist in the management of these patients.