Queen Elizabeth II Hospital, Welwyn Garden City, Hertfordshire, UK.
The indications and methods of fasciotomy for acute compartment syndrome have been well documented. There has not been much attention paid to postoperative care, especially the management of the open wound produced. The common practice is to cover the wound with a split-skin graft if there is any difficulty with attempted closure. The resultant appearance may not be acceptable to the patient nor may the need to stay in hospital while the skin graft heals. A method relying on the elasticity of the skin which can also be used in out-patients is described.
Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia, USA.
Comparison of fasciotomy wound closures using traditional dressing changes and the vacuum-assisted closure device.
John Zannis, Jeff Angobaldo, Malcolm Marks, Anthony DeFranzo, Lisa David, Joseph Molnar, Louis Argenta
Department of Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, NC, USA.
Fasciotomy wounds can be a major contributor to length of stay for patients as well as a difficult reconstructive challenge. Once the compartment pressure has been relieved and stabilized, the wound should be closed as quickly and early as possible to avoid later complications. Skin grafting can lead to morbidity and scarring at both the donor and fasciotomy site. Primary closure results in a more functional and esthetic outcome with less morbidity for the patient, but can often be difficult to achieve secondary to edema, skin retraction, and skin edge necrosis. Our objective was to examine fasciotomy wound outcomes, including time to definitive closure, comparing traditional wet-to-dry dressings, and the vacuum-assisted closure (VAC) device. This retrospective chart review included a consecutive series of patients over a 10-year period. This series included 458 patients who underwent 804 fasciotomies. Of these fasciotomy wounds, 438 received exclusively VAC. dressings, 270 received only normal saline wet-to-dry dressings, and 96 were treated with a combination of both. Of the sample, 408 patients were treated with exclusively VAC therapy or wet-to-dry dressings and 50 patients were treated with a combination of both. In comparing all wounds, there was a statistically significant higher rate of primary closure using the VAC versus traditional wet-to-dry dressings (P < 0.05 for lower extremities and P < 0.03 for upper extremities). The time to primary closure of wounds was shorter in the VAC. group in comparison with the non-VAC group. This study has shown that the use of the VAC for fasciotomy wound closure results in a higher rate of primary closure versus traditional wet-to-dry dressings. In addition, the time to primary closure of wounds or time to skin grafting is shorter when the VAC was employed. The VAC used in the described settings decreases hospitalization time, allows for earlier rehabilitation, and ultimately leads to increased patient satisfaction.
Division of General Surgery, University of Ottawa, Ottawa, ON, Canada.
University Department of Surgery, Royal Free Hospital, Pond Street, London NW3 2QG, UK.
BACKGROUND Acute compartment syndrome is both a limb- and life-threatening emergency that requires prompt treatment. To avoid a delay in diagnosis requires vigilance and, if necessary, intracompartmental pressure measurement. This review encompasses both limb and abdominal compartment syndrome, including aetiology, diagnosis, treatment and outcome. METHODS A Pubmed and Cochrane database search was performed. Other articles were cross-referenced. RESULTS AND CONCLUSION Diagnosis of limb compartment syndrome is based on clinical vigilance and repeated examination. Many techniques exist for tissue pressure measurement but they are indicated only in doubtful cases, the unconscious or obtunded patient, and children. However, monitoring of pressure has no harmful effect and may allow early fasciotomy, although the intracompartmental pressure threshold for such an undertaking is still unclear. Abdominal compartment syndrome requires measurement of intra-abdominal pressure because clinical diagnosis is difficult. Treatment is by abdominal decompression and secondary closure. Both types of compartment syndrome require prompt treatment to avoid significant sequelae.
Department of Surgery, Marshall University School of Medicine, Huntington, WV 25701, USA. firstname.lastname@example.org
A variety of techniques have recently been advanced for delayed primary closure of wounds following emergent fasciotomy for compartment syndrome. We introduce a very simple, effective method for gradual reapproximation of margins using daily reapplication of Steri-strips (3M Surgical Products, St. Paul, Minnesota). This method allows final closure of fasciotomy wounds with simple suture in 5-8 days without scar contractures, marginal necrosis, infection, or significant pain. Moreover, because it requires no specialized equipment and can be applied in skilled nursing centers or at home by trained nurses, this technique could reduce the cost of caring for fasciotomy patients.
Department of Orthopaedics, Northern General Hospital, Sheffield, UK.
Fasciotomy for compartment syndrome in the lower limb is a surgical emergency to preserve future limb function. The advised standard procedure involves both medial and lateral dermotomy in addition to the fasciotomy. There is often concern before and after performing fasciotomy about the cosmetic appearance and prolonged hospital stay if split skin grafting is required to cover the resultant skin defect. This is the case in over 50% of lower limb fasciotomies. We have used a technique of subcuticular prolene suture, first described for the delayed primary closure of contaminated abdominal wounds, in six patients who had undergone lower limb fasciotomies. In all of these cases delayed primary closure was easily achieved without the need for skin grafting. Experiments using a synthetic skin model have shown a 60% reduction in suture tension when compared with interrupted vertical mattress suturing. The subcutaneous prolene suture has the advantage of being both the method of approximation and final closure whilst spreading tension evenly across the wound edges without causing skin edge necrosis. It appears to be simpler and more economical than any technique so far described for the successful delayed primary closure of fasciotomy wounds.
Other papers by authors:
Cardiff Royal Infirmary, U.K.
Simultaneous rupture of the quadriceps tendon with contralateral rupture of the patellar tendon in an otherwise healthy athlete.
Orthopaedic Directorate, Queen Elizabeth II Hospital, Welwyn Garden City, Hertfordshire, United Kingdom.
A case of a healthy athlete with simultaneous rupture of quadriceps tendon and rupture of the contralateral patella tendon is reported. Both tendons rupturing in the same patient is rare and this is the first reported case in a previously healthy person. Different mechanisms are implicated in the different ruptures. The rarity is because the simultaneous presence of contributory factors for either injury in the same person is uncommon.
Queen Mary's NHS Trust, Sidcup, UK.
Bungee running, a new sport related to bungee jumping, is fast becoming more common. This report of two cases of injury associated with it shows the need for safety precautions during the game.
Queen Mary's Hospital, Sidcup, Kent, UK.
A report of a case of osteochondral fracture of the lateral femoral condyle in a patient doing a karate kick. The problems related to fixation of osteochondral fragments with protruding screws are highlighted and the suitability of Herbert screw fixation noted.
There has been an increase in complaints of backache amongst oarsmen recently. It is suggested that backache is related to the training programme and the modern style of rowing and that the rotational forces of rowing are responsible for the symptoms. An approach to the management of the problem is suggested.
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Andrew D Duckworth, Sarah E Mitchell, Samuel G Molyneux, Timothy O White, Charles M Court-Brown, Margaret M McQueen
Edinburgh Orthopaedic Trauma Unit, Royal Infirmary of Edinburgh, 51 Little France Crescent, Edinburgh EH16 4SU, United Kingdom. email@example.com
BACKGROUND The aims of this study were to document our experience with acute forearm compartment syndrome and to determine the risk factors for the need for split-thickness skin-grafting and the development of complications after fasciotomy. METHODS We identified from our trauma database all patients who underwent fasciotomy for an acute forearm compartment syndrome over a twenty-two-year period. Diagnosis was made with use of clinical signs in all patients, with compartment pressure monitoring used as a diagnostic adjunct in some patients. Outcome measures were the use of split-thickness skin grafts and the identification of complications following forearm fasciotomy. RESULTS There were ninety patients in the study cohort, with a mean age of thirty-three years (range, thirteen to eighty-one years) and a significant male predominance (eighty-two patients; p < 0.001). A fracture of the radius or ulna, or both, was seen in sixty-two patients (69%), with soft-tissue injuries as the causative factor in twenty-eight (31%). The median time to fasciotomy was twelve hours (range, two to seventy-two hours). Risk factors for requiring split-thickness skin-grafting were younger age and a crush injury (p < 0.05 for both). Risk factors for the development of complications were a delay in fasciotomy of more than six hours (p = 0.018) and preoperative motor symptoms, which approached significance (p = 0.068). CONCLUSIONS Forearm compartment syndrome requiring fasciotomy predominantly affects males and can occur following either a fracture or soft-tissue injury. Age is an important predictor of undergoing split-thickness skin-grafting for wound closure. Complications occur in a third of patients and are associated with an increasing time from injury to fasciotomy.
J Vasc Surg. 2012 Jun ;55 (6):1826-8 22277688
Department of Thoracic, Cardiac, and Vascular Surgery, University of Tuebingen, Tuebingen, Germany.
We present a silicon sheet for temporary wound covering and gradual wound closure after open fasciotomy. Fasciotomy was performed in a total of 70 limbs with compartment syndrome (CS). The main etiology of CS was predominantly vascular. All patients were treated with a silicon sheet to cover the soft tissue defect and gradually reapproximate the skin margins. In 53% of the patients, a delayed final wound closure was achieved after a mean of 11.9 days. This method allows final closure of fasciotomy wounds without scar contractures, marginal necrosis, infection, or significant pain.
J Anesth. 2012 Feb ;26 (1):97-9 21986719
Severe post-burn neck contracture release and skin graft harvest using tumescent local anaesthesia as the sole anesthetic technique.
Department of Anaesthesiology, Government Medical College, Rampur Road, Haldwani, Nainital, 263139, Uttrakhand, India. firstname.lastname@example.org
Severe post-burn contractures in the neck often cause anatomical distortion and restriction of neck movements, resulting in varying degrees of difficulty in airway management. Any mode of anesthesia that may obviate the need for imperative airway control may be desirable in such situations in which a difficult airway may be anticipated. Here we present one such situation where tumescent local anesthesia was employed to manage a case of severe post-burn neck contractures posted for contracture release and split-skin grafting. The other benefits of this method were minimal blood loss and excellent postoperative analgesia. In conclusion, it can be emphasized that the application of tumescent anesthesia is an important anesthetic tool in patients with predicted difficult airway management.
Int Orthop. 2011 Apr ;35 (4):569-75 20401657
Department of Trauma Surgery, Medical University Vienna, Vienna, Austria.
Trauma-associated acute compartment syndrome (ACS) of the extremities is a well-known complication in adults. There are only a handful of articles that describe the symptoms, the diagnostic procedure and treatment of ACS in children. The aim of this study was to analyse the diagnostic procedures in children compared to adolescents with ACS to obtain evidence for the diagnosis, treatment and outcome of children with ACS. Twenty-four children and adolescents with ACS have been treated at the Department of Trauma Surgery of the Medical University of Vienna, Austria. Two age-related groups were investigated to compare the diagnostic and therapeutic algorithm: group A comprising children aged 2-14 years (n = 12) and group B comprising adolescents aged 15-18 years (n = 12). Patient characteristics, diagnosis and therapy-associated data, complications and clinical outcome were analysed. In both groups we found fractures in most of our patients (n = 19) followed by contusion of the soft tissues (n = 3). In group A most of our patients were injured as pedestrians in car accidents (n = 5) followed by low-energy blunt trauma (n = 3). The most common region of injury and traumatic ACS was the lower leg (n = 7) followed by the feet (n = 3). For fracture stabilisation most of the patients (n = 6) received an external fixator. The mean time from admission to the fasciotomy was 27.9 hours. In four patients a compartment pressure measurement was performed with pressure levels from 30 to 75 mmHg. A histological examination of soft tissue was performed in five patients. From fasciotomy to definitive wound closure 2.4 operations were necessary. The mean hospital stay was 18.9 days. In group B most of our patients had a motorcycle accident (n = 5). The most common region for traumatic ACS in this group was also the lower leg (n = 9). In most of the patients (n = 6) intramedullary nails could be implanted. The mean time from admission to the fasciotomy was 27.1 hours. In six patients a compartment pressure measurement was performed with pressures from 25 to 90 mmHg. In five patients a histological examination was performed. From fasciotomy to definitive wound closure 2.3 operations were necessary. The mean hospital stay was 18.4 days. Secondary fasciotomy closure was performed in all cases. A split-skin graft was only necessary in three patients (13%). We avoided primary closure in the same setting when the fasciotomy was performed. Thus, we found no difference between the two groups in the diagnostic procedures, the indication for fasciotomy, the number of operations needed from fasciotomy to definitive wound closure, time of hospitalisation and clinical outcome. The rate of permanent complications was 4.2%(one patient from group A), which means that nearly all patients experienced full recovery after fasciotomy. ACS represents a surgical emergency and the indication should be determined early even in doubtful cases to avoid complications.
Hyun-Joo Lee, Joon-Woo Kim, Chang-Wug Oh, Woo-Kie Min, Oog-Jin Shon, Jong-Keon Oh, Byung-Chul Park, Joo-Chul Ihn
Department of Orthopedic Surgery, Kyungpook National University Hospital, Daegu, Korea. email@example.com.
BACKGROUND This study was performed to evaluate the results of negative pressure wound therapy (NPWT) in patients with open wounds in the foot and ankle region. MATERIALS AND METHODS Using a NPWT device, 16 patients were prospectively treated for soft tissue injuries around the foot and ankle. Mean patient age was 32.8 years (range, 3-67 years). All patients had suffered an acute trauma, due to a traffic accident, a fall, or a crush injury, and all had wounds with underlying tendon or bone exposure. Necrotic tissues were debrided before applying NPWT. Dressings were changed every 3 or 4 days and treatment was continued for 18.4 days on average (range, 11-29 days). RESULTS Exposed tendons and bone were successfully covered with healthy granulation tissue in all cases except one. The sizes of soft tissue defects reduced from 56.4 cm2 to 42.9 cm2 after NPWT (mean decrease of 24%). In 15 of the 16 cases, coverage with granulation tissue was achieved and followed by a skin graft. A free flap was needed to cover exposed bone and tendon in one case. No major complication occurred that was directly attributable to treatment. In terms of minor complications, two patients suffered scar contracture of grafted skin. CONCLUSION NPWT was found to facilitate the rapid formation of healthy granulation tissue on open wounds in the foot and ankle region, and thus, to shorten healing time and minimize secondary soft tissue defect coverage procedures.
Department of Surgery, Rijnland Hospital Leiderdorp, the Netherlands. firstname.lastname@example.org
Surgeons at a Dutch wound clinic close open wounds with split-skin grafts. Concerns about the risk of postoperative complications in some patients led them to find an alternative option. Use of an extracellular matrix dressing was effective.
Division of Plastic and Reconstructive Surgery, Zuoying Armed Forces Hospital, Kaohsiung, Taiwan.
BACKGROUND The Meek technique of skin expansion is useful for covering a large open wound with a small piece of skin graft, but requires a carefully followed protocol. METHODS Over the past 5 years, a skin graft expansion technique following the Meek principle was used to treat 37 individuals who had sustained third degree burns involving more than 40% of the body surface. A scheme was devised whereby the body was divided into six areas, in order to clarify the optimal order of wound debridements and skin grafting procedures as well as the regimen of aftercare. RESULTS The mean body surface involvement was 72.9% and the mean area of third degree burns was 41%. The average number of operations required was 1.84. There were four deaths among in this group of patients. CONCLUSIONS The Meek technique of skin expansion and the suggested protocol are together efficient and effective in covering an open wound, particularly where there is a paucity of skin graft donor sites.
Department of Anesthesia, Himalayan Institute of Medical Sciences, Dehradun 248140, India. email@example.com
The prone position impairs the ability for endotracheal intubation by direct laryngoscopy. We describe the airway management of a 25-year-old woman with an extensive open wound over her back and fractured pelvis. She was treated in the prone position and was scheduled for debridement of her wound with skin grafting during general anesthesia. Her trachea was successfully intubated on the first attempt using an intubating Laryngeal Mask Airway while she was in the prone position.
Wound Repair Regen. ;3 (4):467-72 17147658
Wound Healing Center, Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical College of Virginia, Virginia Commonwealth University, Richmond, VA 23298, USA.
In many species, open cutaneous fetal wounds do not heal in utero. Such open wounds have been shown to close only after their exclusion from amniotic fluid, thus leading to the hypothesis that amniotic fluid inhibits open wound healing. Therefore the effect of amniotic fluid exposure on the healing of open fetal skin wounds was studied. Fetuses of New Zealand White rabbits received a full-thickness circular 4 mm diameter skin punch biopsy wound. Wounds were left uncovered, covered with a latex patch, or covered with a latex patch with a central hole (doughnut). This third group provided for wound exposure to amniotic fluid while controlling for any wound splinting effect of the patch. Wounds were harvested after 5 days, the wound area was determined planimetrically, and wound edges were examined by means of light microscopy. Analysis of glycosaminoglycans in the wound extra-cellular matrix was performed on a separate group of wounds treated similarly. Uncovered wounds enlarged by an average of 60%, whereas wounds covered with the doughnut patch enlarged by an average of 24%. In contrast, the wounds in the patch-covered group decreased in size by an average of 84%. Histologically all groups contained proliferating fibroblasts and epithelial migration at the wound edge but also an absence of granulation tissue. The patch-covered wounds, which had decreased wound area, were significantly enriched in hyaluronic acid. These results suggest that the healing of the patch-covered wounds occurs without the formation of granulation tissue, presumably through a process of cellular migration and proliferation and that healing was inhibited by exposure to amniotic fluid. Hyaluronic acid has been shown to be permissive of cellular migration and to play a key role in tissue regeneration. Therefore, we speculate that direct exposure of open wounds to amniotic fluid during the late stages of fetal development in the rabbit prevents hyaluronic acid deposition, which in turn may alter wound closure.
A randomized, double-blind, placebo-controlled multicenter trial evaluating topical zinc oxide for acute open wounds following pilonidal disease excision.
Magnus S Agren, Ulla Ostenfeld, Finn Kallehave, Yan Gong, Kjeld Raffn, Michael E Crawford, Katalin Kiss, Alice Friis-Møller, Christian Gluud, Lars N Jorgensen
Department of Surgery K, Bispebjerg Hospital, Copenhagen University Hospital, Copenhagen, Denmark. firstname.lastname@example.org
The purpose of this randomized, double-blind, placebo-controlled multicenter trial was to compare topical zinc oxide with placebo mesh on secondary healing pilonidal wounds. Sixty-four (53 men) consecutive patients, aged 17-60 years, were centrally randomized to either treatment with 3% zinc oxide (n = 33) or placebo (n = 31) by concealed allocation. Patients were followed with strict recording of beneficial and harmful effects including masked assessment of time to complete wound closure. Analysis was carried out on an intention-to-treat basis. Median healing times were 54 days (interquartile range 42-71 days) for the zinc and 62 days (55-82 days) for the placebo group (p = 0.32). Topical zinc oxide increased (p < 0.001) wound fluid zinc levels to 1,540 (1,035-2,265) microM and decreased (p < 0.05) the occurrence of Staphylococcus aureus in wounds. Fewer zinc oxide (n = 3) than placebo-treated patients (n = 12) were prescribed postoperative antibiotics (p = 0.005). Serum-zinc levels increased (p < 0.001) postoperatively in both groups but did not differ significantly between the two groups on day 7. Zinc oxide was not associated with increased pain by the visual analog scale, cellular abnormalities by histopathological examination of wound biopsies, or other harmful effects. Larger clinical trials will be required to show definitive effects of topical zinc oxide on wound healing and infection.