Shark Attack
A 39 year old healthy woman was attacked by a shark while on vacation, and sustained severe injuries to her left lateral thigh as well as her left arm. Operative procedures performed included the repair of multiple muscles, tendons, and nerve lacerations to the left forearm with closure under tension. In addition, closure of the left thigh wound defect was attempted using the recovered amputated part as a composite graft. No clear record of antibiotic use was available.
Upon arrival six days post injury (PID #6), the left upper extremity was dressed but not splinted. The digits were dusky with areas of skin necrosis, no peripheral pulses were palpable however a weak radial pulse was audible with the use of a hand-held Doppler. The left lower extremity wound was covered with a bolster dressing under which the necrotic composite graft was present.
Left thigh upon arrival to Canada. Left thigh upon arrival to Canada prior to undergoing first Canadian operative management illustrating a necrotic composite graft.
The patient was admitted, was started empirically on broad spectrum antibiotics (including ancef, flagyl, and clindamycin) and infectious diseases was immediately consulted to help guide therapy while awaiting operative management.
An urgent irrigation and debridement of the upper and lower extremity wounds was performed the day of arrival.
Left upper extremity during the initial debridement
Left thigh during the initial debridement
A second irrigation and debridement of each site, followed by an anterolateral thigh (ALT) free flap closure of the left thigh defect was performed 48 hours later. The postoperative course remained unremarkable up until postoperative day 6 when the flap appeared dusky and cold and had a weakening of Doppler signals.
The patient’s left arm had sustained significant soft tissue defects, Volkmann’s contracture and severe neurovascular injury. On PID#33, the patient was clinically stable and psychologically ready to undergo an elective mid-humeral amputation of the left arm after the left hand remained insensate and perfused only by collateral flow.
Anterolateral thigh flap’s (ALT) congested appearance
The left thigh was reconstructed using a contralateral ALT flap. The status of the flap was stable until postoperative day 6 (PID#15) when, as illustrated, the flap started to appear dusky, cold and had weakened Doppler signals.
Despite adequate functional recovery, the aesthetic result remained unacceptable and as a result, on PID#393, a final reconstructive procedure was performed to replace the split-thickness skin graft with a free transverse rectus abdominus myocutaneous flap (TRAM).
The patient was discharged home on postoperative day 14 after an uneventful hospital course. An acceptable aesthetic and functional outcome was achieved. Rehabilitation received during her time in hospital and beyond allowed her to resume daily activities.
The patient was able to use this experience as a stepping-stone into becoming a motivational speaker, writer and member of a shark attack survivors group.
Left thigh aesthetic appearance at discharge
Left thigh second reconstructive attempt
n total, the patient underwent four washouts (irrigation and debridement) of wounds, two split-thickness skin grafts, one free ALT flap, and one free TRAM flap for the reconstruction and salvage of the left lower extremity
Left thigh postoperative final appearance
PATIENT CONSENT
The patient provided written informed consent for the publication and the use of their images.
Credits: Laura Snell Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, pubmed.