Split-thickness skin excision in severe open fractures

Full-thickness skin avulsion of right leg following car accident trauma

The report presents a 24 year-old man who admitted at the orthopedic center with full-thickness skin avulsion of the right leg, due to his leg being caught under the wheel of a truck and subsequently traumatized. The day after injury, plastic and reconstructive surgery consult was done. After thoroughly irrigation, the 20 cm laceration was repaired above the knee. There was full-thickness skin necrosis below the knee down to the dorsal surface of the right leg (atypical form of skin avulsion). Debridment and graft was performed for the first stage. During the second stage, re-grafting was performed and the gasterocnemious flap was transposed to cover the Tibia bone. This study confirms early Plastic and reconstructive surgery consult from the trauma of lower extremities associated with skin lesion.

Verletzungen des Fußes beim polytraumatisierten Patienten

Foot injuries in polytraumatized patients are not critical for survival but for the later quality of life. Closed fractures or dislocations of the foot are frequently overlooked or misinterpreted in association with polytrauma, which leads to severe functional impairment in those patients who survive. Repeated clinical examinations and early radiographic examinations are essential in the unconscious patient after resuscitation. Emergent indications for surgery even in the presence of multiple injuries are open injuries, incarcerated soft tissues, manifest compartment syndrome of the foot, and neurovascular injury. The decision on limb salvage or amputation has to be individualized with respect to the patient's overall condition and the severity of local trauma to the foot. The "life before limb" principle has to be respected. Emergent reduction of fracture dislocations of the talus, calcaneus, Chopart's and Lisfranc's joints via direct approaches and temporary transfixation with K-wires should be attempted in a first step whenever possible. Additional external fixation facilitates wound care and prevents soft tissue contractions until definite internal fixation becomes feasible. Early soft tissue coverage is always sought in order to avoid infection.

The use of Integra® in an upper extremity avulsion injury

We present the case of a 22-year-old man who suffered an avulsion injury of the left upper extremity including the elbow region in an industrial accident. After debridement of the skin flap, the defect was primarily closed with Integra. On day 22 split thickness skin graft was performed. Functional and aesthetic outcome and skin quality are excellent.

Management of a traumatically avulsed skin-flap on the dorsum of the foot

BACKGROUND

It is common for traumatologists to see avulsion injuries with resulting composite skin flaps. Simply reattaching the avulsed flap by suturing it back into its bed may result in ischemic necrosis of the distal portion of the flap.

CASE REPORT

The authors present a case in which an extensive avulsion injury of the dorsum of the foot with amputation of the fourth and fifth toe was treated by defatting the avulsed flap and reattachment as a full-thickness graft. Healing was uneventful and no skin necrosis was encountered. At 1-year follow-up there was a stable skin situation at the dorsum of the foot. The patient has no difficulties with wearing shoes. However, there is diminished sensibility.

CONCLUSIONS

Indications for this type of surgical technique include all types of avulsion or degloving injuries that create composite skin flaps prone to undergo ischemic necrosis if simply reattached. This quick and easy method should be in the armamentarium of each surgeon possibly dealing with this type of injury.

Crush injuries of the foot in the industrial setting

Over the years patients with relatively minor compressive injuries seem to have a different morbidity, largely because of a constellation of neurologic findings, including dysesthesia and hyperesthesias. These are usually multifocal, and often extend far beyond the point of impact of the crushing force. Neuroischemia may play a role in the development of chronic pain after crush injuries to the foot, either through direct trauma to the peripheral nerves or by intraneural or extraneural fibrosis. This direct trauma to the nerve may cause chronic neuritis, which then triggers a sympathetically mediated pain syndrome. For the injured worker, these problems seem to be magnified. Early recognition of the extent of injury, the zone of injury, and the need for early soft tissue coverage is essential. With expeditious treatment, wound coverage, treatment of compartment syndromes, and early aggressive rehabilitation, many of the complications of these injuries, including chronic pain syndromes, can be minimized.

Technical refinement in the management of circumferentially avulsed skin of the leg

Between 1989 and 1994, 42 patients with circumferential skin avulsion of lower extremities were treated with full-thickness skin graft from defatted avulsed flap. Among them, 39 patients were run over by rubber tires during car accidents; the remaining 3 patients were victims of industrial accidents by roller machines. The full-thickness skin grafts were prepared from the avulsed skin flap in attachment to avoid junctional hypertrophic scarring. They were then secured with multiple skin staples to their anatomical position to improve skin graft take. Initial take of graft averaged 91 percent (ranged from 75 percent to 100 percent). Twelve patients underwent secondary overgrafting after tangential excision of non-viable skin graft. Follow-up averaging 2.6 years revealed stable wounds in most of the patients. Ten patients experienced occasional breakdown of skin graft in the patella and popliteal fossa, which was treated conservatively. Except for five who had deformed contours of the leg due to muscle transfers, the patients were satisfied with the cosmetic appearance of their legs. Compared with conventional methods, this approach provided better appearance and less contracture.

Treatment of open fractures of the foot and ankle: a preliminary report

A retrospective study was performed on 33 patients who sustained isolated open-fracture injuries to the foot and ankle. A wide variety of open-fracture injuries of the foot and ankle are documented. Of the 33 cases, only 2 became clinically infected, translating into an infection rate of 6.06%. A literature review of open-fracture injuries is presented along with the preliminary results of the retrospective study.

Interfragmentary lag screws and external fixation for severe open tibial fractures: a biomechanical and clinical study

The stability offered by the interfragmentary lag screw with a unilateral external fixator frame was studied in both experimental and prospective clinical studies. The in-vitro stability of the fixation with and without the interfragmentary lag screw was tested by a universal testing machine in compression, four-point bending, and torsion in 18 human tibiae. The in-vivo study was conducted prospectively in 18 patients with 19 severe open tibial fractures. All patients were treated with one definite surgical procedure on admission. The interfragmentary lag screw increased the sytem stiffness 47.4 times in compression, 9.9 times in bending, and 3.2 times in torsion. The immediate one-stage care of severe open fractures with a simple external fixation system in combination with the interfragmentary lag screw shortens hospitalization and may enhance healing.

Split-thickness skin excision: its use for immediate wound care in crush injuries of the foot

Split-thickness skin excision (STSE) was used as an adjunctive modality in the treatment of eight crush injuries of the foot. Compartment syndromes were present in four feet and were treated with fasciotomy. Wound debridement, internal fixation of fractures, and STSE followed. This technique accurately determined the viability of the skin flap, simultaneously providing skin for local wound coverage. All flaps treated in this manner survived and all (100%) of the degloved STSE grafts healed. Additional procedures were performed in four patients (two free flaps and two split-thickness skin grafts) adjacent to the debrided flap for complete coverage. STSE proved to be an effective modality for skin coverage in crush injuries of the foot associated with degloving of skin.

Crush injuries of the foot with compartment syndrome: immediate one-stage management

Severe crush injuries with compartment syndrome were treated in five patients by an immediate one-stage procedure. This procedure included the assessment of skin flap viability with accurate debridement of devascularized tissues. It was performed according to the split-thickness skin excision technique. Compartment pressures were measured and the fasciotomies were performed through open wounds or separate medial and lateral incisions. The medial incision was extended to release the tarsal tunnel. Fractures were reduced and internally fixed and exposed bones were covered with locally transposed muscles. Skin grafts, taken earlier for the skin viability assessment, were meshed and applied to replace skin loss. All wounds and fractures healed uneventfully with no major functional loss. In multiple trauma, the physician should maintain a high index of suspicion for early diagnosis and treatment of severe foot injuries. Early treatment leads to more desirable results, shorter hospitalization, and faster rehabilitation.