Limb salvage following snakebite using acute limb shortening and secondary lengthening

A case of 16-year-old boy from the remote tribal population of Uttarakhand is described, who sustained a viper snakebite. The patient after various interventions and referrals developed locoregional and systemic complications. He not only had an open tibiofibular fracture but a large bimalleolar defect over his lower limb. The wound infection with underlying osteomyelitis progressed to septic shock and failure of the conventional cross-leg flap. Computed tomography scan of the limb revealed a single patent vessel, eliminating the option of microvascular flap. Limb amputation was considered for source control; however, in an attempt to salvage the limb, the novel approach of acute limb shortening with secondary limb lengthening was performed with parental consent, an approach not previously reported in the management of snakebite injuries. Adequate infection control was achieved following removal of the osteomyelitic bone, and the defect was covered with overlapping tissue from the docked limb and a cross-thigh flap. Secondary lengthening was performed after 3 months, and following extensive surgical and rehabilitative interventions, the boy's limb was salvaged and he retains a near-normal gait. This case report entails a detailed account of how mutilating a snakebite injury could be and how unconventional techniques like acute limb shortening with secondary lengthening can be used in such injuries.