1
|
Al Meklef R, Rein S, Kremer T. [Acute and post-acute soft tissue reconstruction]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2024:10.1007/s00113-024-01448-8. [PMID: 38886238 DOI: 10.1007/s00113-024-01448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 05/21/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND The precise analysis of the injured structures requiring reconstruction in complex wound defects is a prerequisite for successful restoration. OBJECTIVE The fundamental reconstructive strategies for soft tissue defects of the extremities including injuries to vessels, nerves and burn wounds in the context of the acute and post-acute trauma phases are presented. MATERIAL AND METHODS The different phases of soft tissue reconstruction are described. Recommendations for action with respect to the reconstruction of the functional structures are described. Two clinical case examples illustrate the approach. RESULTS The acute reconstruction phase is defined as the period 0-72 h after the traumatic event and includes surgical debridement, primary reconstruction of nerves and vessels using interpositional grafts if necessary and temporary soft tissue reconstruction. Combined thermomechanical trauma requires early debridement combined with internal fixation of open fractures. In the post-acute reconstruction phase, which is generally defined as a period of up to 6 weeks after the traumatic event, definitive soft tissue reconstruction is performed. In the case of long reinnervation distances, nerve transfer or motor replacement plastic surgery is performed in the post-acute phase. CONCLUSION The reconstruction of soft tissue after trauma necessitates a stage-dependent approach. In the acute phase procedures aim at the immediate preservation of the limb. In the post-acute phase, definitive soft tissue reconstruction is performed to enable maximum functional preservation. Combined thermomechanical injuries require early surgical treatment in order to prevent infections.
Collapse
Affiliation(s)
- Rami Al Meklef
- Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Deutschland
| | - Susanne Rein
- Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Deutschland
- Martin-Luther-Universität Halle-Wittenberg, Halle (Saale), Deutschland
| | - Thomas Kremer
- Klinik für Plastische und Handchirurgie mit Schwerbrandverletztenzentrum, Klinikum St. Georg gGmbH, Delitzscher Straße 141, 04129, Leipzig, Deutschland.
| |
Collapse
|
2
|
[Acute compartment syndrome of the extremities]. CHIRURGIE (HEIDELBERG, GERMANY) 2023; 94:93-102. [PMID: 35352147 PMCID: PMC9849316 DOI: 10.1007/s00104-022-01624-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 02/28/2022] [Indexed: 01/22/2023]
Abstract
Acute compartment syndrome of the extremities is a surgical emergency and a rapid diagnosis and immediate surgical treatment are essential for the outcome. The cause is an increase in the tissue pressure inside a muscle compartment enclosed by fasciae and the resulting disruption of microperfusion. This can have potentially disastrous consequences, such as loss of the extremity due to extensive tissue necrosis or a threat to life due to infectious complications. Although mostly triggered by trauma, a multitude of other causes can lead to the formation of a compartment syndrome, so that a basic knowledge of this condition is of great importance not only for trauma surgeons. This is particularly true because a timely treatment necessitates rapid diagnosis and evaluation of the indications. This article provides an overview of the underlying pathophysiology, the causes, the symptoms and the treatment of acute compartment syndrome.
Collapse
|
3
|
Moellhoff N, Throner V, Frank K, Benne A, Coenen M, Giunta RE, Haas-Lützenberger EM. Epidemiology of hand injuries that presented to a tertiary care facility in Germany: a study including 435 patients. Arch Orthop Trauma Surg 2023; 143:1715-1724. [PMID: 36138241 PMCID: PMC9958136 DOI: 10.1007/s00402-022-04617-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2022] [Accepted: 09/05/2022] [Indexed: 11/02/2022]
Abstract
BACKGROUND Hand injuries compose up to 30% of all injuries in emergency care. However, there is a lack of epidemiological data reflecting patient or accident-related variables, injury types, injured anatomical structures or trauma localization. OBJECTIVE The objective of this study is (1) to provide epidemiological information on hand injuries and their patterns and (2) to visualise the frequencies of affected areas of the hand in relation to the most common trauma mechanisms using color-coded heatmaps. METHODS This prospective single-center observational trial conducted at a surgical emergency department in Germany collected data of hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, diagnostic and therapeutic measures were analyzed. Color-coded heatmaps were generated marking anatomic danger zones. RESULTS 435 patients with a mean age of 39.5 were included. Most patients admitted on their own initiative (79%). Leisure and sport injuries were most frequent (75%). Digiti II-V were injured most commonly (43%), followed by metacarpals (19%) and the thumb (14%). Blunt trauma and cuts accounted for most injuries (74%). Hand-graphics depicted color-coded frequencies of the affected areas of the palmar and dorsal aspect of the hand for the most common types of injury, as well as the most frequent circumstances of accident. Elective surgery was recommended in 25% of cases, and hand surgical follow-up was proposed in over 50% of cases. CONCLUSIONS The dorsal aspect of the hand including the 5th metacarpal, the radial wrist and thenar region, as well as the fingertips of Digiti II/III represent anatomic danger zones to injury of the hand. Due to the large variety of potentially injured structures, diagnosis and treatment is not trivial. Specific training is required for all surgical specialties in emergency care, to increase quality of diagnostic work-up and management of hand injuries.
Collapse
Affiliation(s)
- Nicholas Moellhoff
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Veronika Throner
- grid.5252.00000 0004 1936 973XDepartment of Medical Information Processing, Biometry, and Epidemiology (IBE), Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, LMU Munich, Munich, Germany ,Pettenkofer School of Public Health, Munich, Germany
| | - Konstantin Frank
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Ashley Benne
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Michaela Coenen
- grid.5252.00000 0004 1936 973XDepartment of Medical Information Processing, Biometry, and Epidemiology (IBE), Chair for Public Health and Health Services Research, Research Unit for Biopsychosocial Health, LMU Munich, Munich, Germany ,Pettenkofer School of Public Health, Munich, Germany
| | - Riccardo E. Giunta
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| | - Elisabeth M. Haas-Lützenberger
- grid.5252.00000 0004 1936 973XDivision of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336 Munich, Germany
| |
Collapse
|
4
|
Gutwerk A, Müller M, Karlas A, Pförringer D, Kanz KG, Biberthaler P, Braun KF. [Delayed occurrence of compartment syndrome of the upper arm after shovelling snow by a patient under oral anticoagulation]. Unfallchirurg 2020; 123:564-570. [PMID: 32239247 DOI: 10.1007/s00113-020-00795-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This article reports the case of an 81-year-old male patient under treatment with oral anticoagulation who suffered delayed compartment syndrome of the upper arm from arterial capillary hemorrhage after shovelling snow. The diagnosis was made 48 h after the initial symptoms in the emergency surgical department of the Klinikum rechts der Isar (München) with the presence of clear neurological deficits. Following computed tomography angiography (CTA) imaging an emergency dermatofasciotomy was carried out as well as a vascular ligature via a medial approach. Compartment syndromes are the result of pathologically elevated tissue pressure and as a rule with a rapid clinical course. A delayed diagnosis can therefore lead to irreversible tissue and nerve damage up to the loss of the extremity. Compartment syndromes are particularly frequent in the lower extremities whereas those of the upper extremities are rare. This case report is intended to raise awareness for an insidiously occurring compartment syndrome of the upper arm due to repetitive microtrauma (in this case shovelling snow) and arterial peripheral vascular hemorrhage with simultaneous anticoagulation. The necessary diagnostic and treatment steps are also elucidated.
Collapse
Affiliation(s)
- Alexander Gutwerk
- Klinik und Poliklinik für Unfallchirurgie am Klinikum rechts der Isar, Technische Universität München, München, Deutschland. .,Orthopädie, Sport- & Unfallklinik, Ev.-Luth. Diakonissenanstalt zu Flensburg, Knuthstraße 1, 24939, Flensburg, Deutschland.
| | - Michael Müller
- Klinik und Poliklinik für Unfallchirurgie am Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Angelos Karlas
- Klinik und Poliklinik für Gefäßchirurgie am Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Dominik Pförringer
- Klinik und Poliklinik für Unfallchirurgie am Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Karl-Georg Kanz
- Klinik und Poliklinik für Unfallchirurgie am Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Peter Biberthaler
- Klinik und Poliklinik für Unfallchirurgie am Klinikum rechts der Isar, Technische Universität München, München, Deutschland
| | - Karl Friedrich Braun
- Klinik und Poliklinik für Unfallchirurgie am Klinikum rechts der Isar, Technische Universität München, München, Deutschland.,Centrum für Muskuloskeletale Chirurgie, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
| |
Collapse
|
5
|
Schnapp L, Colakoglu S, Couceiro J, Oron A, Brock G, Banegas RN. Forearm Shortening Impact on Pronation and Supination. J Hand Surg Asian Pac Vol 2019; 24:289-296. [DOI: 10.1142/s242483551950036x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Background: Shortening has been described to treat severely mangled extremities, replantations and nonunions. Outcomes after this procedure in the forearm are vaguely described. This study addresses how the forearm rotation is affected by: (1) location of the shortening; (2) the amount of the shortening at different locations. Methods: Nine fresh cadaveric forearms were dissected preserving intact proximal and distal radio ulnar joints and interosseous membrane. The widest point of the interosseous space and its location over the ulna were measured, defining the peak interosseous distance (PID) and the peak interosseous distance level (PIDL). Stabilization and fixation of the specimens were performed by using a platform and external fixators. Consecutive ostectomies were performed within one centimeter intervals at the distal, middle and proximal forearm thirds. A repeated measures mixed-effects (RMME) specific model was designed for the statistical analysis. Results: Before intervention, the average full forearm rotation was 157° (101–185), supination 80° (56–90)/pronation 77° (45–95). The average PID was 15.6 mm in supination and 12.5 mm in pronation. The PIDP were 52.2% and 58.3% of the ulna length in supination and pronation, respectively. The rotation lost were: middle third 5.31°/cm in supination and 6.12°/cm in pronation, distal third 1.62°/cm in supination and 2.20°/cm in pronation, the proximal third was not affected by up to 5 cm of shortening. Conclusions: These data suggest that shortening of the middle and distal third of the forearm might have more significant adverse effect on forearm rotation compared with the proximal third.
Collapse
Affiliation(s)
- Luis Schnapp
- Christine M. Kleinert Institute, University of Louisville, Hand and Microsurgery, Louisville, KY, USA
| | - Salih Colakoglu
- University of Colorado Hospital, Plastic and Reconstructive Surgery, Aurora, CO, USA
| | - Jose Couceiro
- Christine M. Kleinert Institute, University of Louisville, Hand and Microsurgery, Louisville, KY, USA
| | - Amir Oron
- Christine M. Kleinert Institute, University of Louisville, Hand and Microsurgery, Louisville, KY, USA
| | - Guy Brock
- The Ohio State University, Biomedical informatics, Columbus, OH, USA
| | | |
Collapse
|
6
|
Märdian S, Krapohl BD, Roffeis J, Disch AC, Schaser KD, Schwabe P. Complete major amputation of the upper extremity: Early results and initial treatment algorithm. J Trauma Acute Care Surg 2015; 78:586-93. [PMID: 25710431 DOI: 10.1097/ta.0000000000000548] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Traumatic major amputations of the upper extremity are devastating injuries. These injuries have a profound impact on patient's quality of life and pose a burden on social economy. The aims of the current study were to report about the initial management of isolated traumatic major upper limb amputation from the time of admission to definitive soft tissue closure and to establish a distinct initial management algorithm. METHODS We recorded data concerning the initial management of the patient and the amputated body part in the emergency department (ED) (time from admission to the operation, Injury Severity Score [ISS], cold ischemia time from injury to ED, and total cold ischemia time). The duration, amount of surgical procedures, the time to definitive soft tissue coverage, and the choice of flap were part of the documentation. All intraoperative and postoperative complications were recorded. RESULTS All patients were successfully replanted (time from injury to ED, 59 ± 4 minutes; ISS16; time from admission to operating room 57 ± 10 minutes; total cold ischemia time 203 ± 20 minutes; total number of procedures 7.3 ± 2.5); definitive soft tissue coverage could be achieved 23 ± 14 days after injury. Two thromboembolic complications occurred, which could be treated by embolectomy during revision surgery, and we saw one early infection, which could be successfully managed by serial debridements in our series. CONCLUSION The management of complete major amputations of the upper extremity should be reserved for large trauma centers with enough resources concerning technical, structural, and personnel infrastructure to meet the demands of surgical reconstruction as well as the postoperative care. Following a distinct treatment algorithm is mandatory to increase the rate of successful major replantations, thus laying the foundation for promising secondary functional reconstructive efforts. LEVEL OF EVIDENCE Therapeutic study, level V.
Collapse
Affiliation(s)
- Sven Märdian
- From the Center for Musculoskeletal Surgery, Charite Universitatsmedizin Berlin, Berlin, Germany
| | | | | | | | | | | |
Collapse
|
7
|
Latifi R, El-Hennawy H, El-Menyar A, Peralta R, Asim M, Consunji R, Al-Thani H. The therapeutic challenges of degloving soft-tissue injuries. J Emerg Trauma Shock 2014; 7:228-32. [PMID: 25114435 PMCID: PMC4126125 DOI: 10.4103/0974-2700.136870] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2013] [Accepted: 04/09/2014] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Degloving soft-tissue injuries are serious and debilitating conditions. Deciding on the most appropriate treatment is often difficult. However, their impact on patients' outcomes is frequently underestimated. OBJECTIVES We aimed to study the incidence, clinical presentation, management and outcome of degloving soft-tissue injuries. MATERIALS AND METHODS We conducted a narrative traditional review using the key words; degloving injury and soft-tissue injuries through search engines PubMed, Science Direct, and Scopus. RESULTS There are several therapeutic options for treating degloving soft-tissue injuries; however, no evidence-based guidelines have been published on how to manage degloving soft-tissue injuries, although numerous articles outline the management of such injuries. CONCLUSION Degloving soft-tissue injuries are underreported and potentially devastating. They require early recognition, and early management. A multidisciplinary approach is usually needed to ensure the effective rehabilitation of these patients.
Collapse
Affiliation(s)
- Rifat Latifi
- Department of Surgery, University of Arizona, Tucson, Arizona, USA ; Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | | | - Ayman El-Menyar
- Clinical Medicine, Weill Cornell Medical College ; Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Ruben Peralta
- Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | - Mohammad Asim
- Clinical Research, Trauma Surgery Section, Hamad General Hospital, Doha, Qatar
| | | | | |
Collapse
|