Extensive Soft Tissue Injury Research Articles

Free Groin Flaps in Microsurgical Reconstruction of the Extremity

The authors performed free groin flap transplantation in 36 patients with extensive soft-tissue injury of the extremities. In each case, the vascular anatomy of the groin flap was analyzed during the operation. The anatomic classification of the superficial circumflex iliac artery according to its origin was as follows: a common origin with the superficial inferior epigastric artery in 15 cases (39.5 percent); an isolated origin and absent superficial inferior epigastric artery in 14 cases (36.8 percent), a separate origin in three cases (7.9 percent), and an origin from the profunda femoral artery in six cases (15.8 percent). These results are similar to those reported previously. The overall success rate was 72.2 percent. The success rate was better in the upper extremity (100.0 percent) than in the lower extremity (65.5 percent). Free vascularized groin flap transplantation is a suitable procedure for the one-stage reconstruction of severe soft-tissue injury, especially in the upper extremity.

Infections in open fractures of the hand

We reviewed one forty-six consecutive cases of patients with open fractures of the hand to identify factors that predict infection and poor outcome. The incidence of infection was 11%. The infection rate in type 1 open fractures was 0%; in type 2, 9%; and in type 3, 14%. Infection occurred in 20.5% of grossly contaminated wounds (p less than 0.02), and was most common in patients with extensive soft tissue and skeletal injury. Delay in treatment did not increase the incidence of infection or affect outcome. Functional outcome was highly correlated with the initial fracture type and with the presence of infection. Preoperative wound cultures were of no value in predicting the risk of infection or the nature of the likely pathogen. Patients with severe open fractures should be warned of the risk of infection, prolonged convalescence, and permanent impairment.

Arterial Trauma of the Upper Extremity in Children

Thirty children with upper extremity arterial trauma were retrospectively reviewed. Trauma was penetrating in 87% of cases and in 53% injury was caused by broken plate glass. The injured artery was repaired in all but four cases. Nerves were injured in 53% and tendons in 23%. All severed nerves and tendons were repaired primarily. Postoperatively three children with proximal injuries had no palpable pulse in the affected extremity. One patient died of underlying disease and another required amputation during initial surgery due to extensive soft-tissue injury. Followup revealed no dysfunction directly related to vascular insufficiency. Neurologic deficit was found in 33% of the children followed, but only in one was the limb totally nonfunctional. We conclude that the long-term outcome is largely dependent upon neurologic injury. Glass doors and large glass windows should be avoided in the vicinity of children's play areas.

External Fixation of Femoral Fractures

We report our experience with external fixation in 15 femoral fractures in 14 patients. Follow-up times ranged from 4 to 56 months. Thirteen patients had multiple injuries. All but two fractures healed. In one patient with a supracondylar fracture, a knee arthrodesis had to be performed. One septic osteomyelitis of the femur led to amputation. The range of active knee joint motion was greater than or equal to 90 degree in 13 knees. Only six knees, however, regained a flexion of greater than or equal to 120 degrees. Pin tract infection occurred in one case and resolved uneventfully after revision and systemic antibiotics. External fixation should not be routinely used for fixation of femoral fractures, but may be considered in multiply injured and critically ill patients or in case of extensive soft tissue injury.

Pseudoepitheliomatous Hyperplasia and Pyoderma Gangrenosum After a Brown Recluse Spider Bite

Brown recluse spider bites may result in extensive soft tissue injury, causing months of disability. We have described a patient who had a series of extensive surgical debridements after envenomation. Despite skin grafting, persistent cutaneous lesions and extensive satellitosis progressed to involve the entire lower extremity. A recent biopsy showed pseudoepitheliomatous hyperplasia and pyoderma gangrenosum complicating the original injury. Although the role of early surgical excision and newer forms of medical treatment including dapsone and antivenom are still in evolution, recent reports suggest that the majority of patients will respond to medical therapy and may not require any surgical intervention.

Quadriceps Contracture in Four Cats: a Complication of Internal Fixation of Femoral Fractures

In a series of twenty-two cats with femoral fractures repaired by internal fixation, four cases of quadriceps contracture (18.2%) were observed. Each case of contracture involved a midshaft fracture with extensive soft tissue injury. Repair with intramedullary pins and cerclage wires had been performed in each case. Exuberant callus production was noted in two cases, while in another quadriceps contracture followed injury to the ischiatic nerve. Contracture was evident two weeks postoperatively. Physiotherapy proved ineffective and surgical intervention was not undertaken as all cases were weightbearing on the affected limb.

Long-term results with autogenous tissue repair of traumatic extremity vascular injuries.

With extensive vascular injuries in which a vascular conduit is required, there is controversy as to whether an autogenous or prosthetic graft is preferable. The authors reviewed their experience with 91 extremity arterial injuries in which autogenous tissue was used to repair vascular injuries of the extremities. Twenty-two patients also had concomitant repair of associated venous injuries with autogenous vein grafts. Ten patients required amputations, despite patent grafts in five patients, because of severe muscle necrosis. Two patients had thrombosis of their vein grafts develop in the early postoperative period but did not require amputation. The authors identified only one late vein graft failure in a patient in whom an infected pseudoaneurysm developed. Three patients with extensive soft tissue injuries had infection develop in vein grafts, with subsequent massive bleeding that ultimately required arterial ligation. Among the 22 patients with repair of their venous injuries, occlusion of popliteal vein repairs was documented in two patients and suspected in three others. The remainder of patients had satisfactory results. The excellent results obtained in the vast majority of the authors' patients with extremity vascular injuries reinforces their preference for using autogenous tissue whenever a vascular conduit is required. Exceptions include patients with extensive soft tissue loss precluding adequate graft coverage, the repair of large vessels, and life-threatening emergencies when there is insufficient time to harvest and prepare a vein.

Problems in the Management of Type III (Severe) Open Fractures

Between 1976-1979, 87 Type III open fractures (in 75 patients) were treated at the Hennepin County Medical Center. Factors leading to increased morbidity in Type III fractures were: massive soft-tissue damage; compromised vascularity; severe wound contamination; and marked fracture instability. This study demonstrates, because of varied severity and prognosis, that the current designation of Type III open fracture is too inclusive. We recommend, therefore, that Type III open fractures be divided, in order of worsening prognosis, into three subtypes. Type IIIA--Adequate soft-tissue coverage of a fractured bone despite extensive soft-tissue laceration or flaps, or high-energy trauma irrespective of the size of the wound. Type IIIB--Extensive soft-tissue injury loss with periosteal stripping and bone exposure. This is usually associated with massive contamination. Type IIIC--Open fracture associated with arterial injury requiring repair. Wound sepsis in the three subtypes were: Type IIIA, 4%, IIIB, 52%; and IIIC, 42%; while amputation rates were, respectively, 0%, 16%, and 42%. Only two patients developed osteomyelitis, and 12 patients had delayed or nonunions. Five patients died, all as a result of multisystem trauma. The bacterial pathogens in infected open fractures have changed dramatically over the years. In the present series (1976-1979), 77% of infections were due to Gram-negative bacteria, compared with 24% previously (1961-1975). A change of antibiotic therapy from a first-generation cephalosporin alone to a combination of a cephalosporin and an aminoglycoside, or a third-generation cephalosporin, is currently indicated in Type III open fractures.

Multiple systems failure and circulatory support.

As our knowledge of and capabilities in surgery improve, the problems that we encounter change. We have learned to better support the circulation and the heart, the kidneys, the lungs and other organs in patients after trauma or after operation and failure of any one of these organs alone has been less of a problem. In the early 1970's, there was a simultaneous or sequential development of problems or failure of several organs. We called this syndrome multiple, progressive or sequential systems or organ failure (MOF). It is truly a syndrome related to surgical progress. By defining the problem and developing an understanding of it, we can better prevent its occurrence and increase the survival and well-being of those under our care. Common factors in patients who develop this syndrome include some or all of following: A) A multiple systems injury or extensive soft tissue injury and/or a major or extensive operation. These can lead to MOF, even in a previously normal patient. In patients with limited systems such as with prior vascular disease or emphysema, the problem is intensified. B) A period of shock accompanying the injury or operation and/or later circulatory instability with a marginal cardiac output. C) Requirement for multiple and perhaps continuous blood transfusions. D) Renal injury or an alteration in renal blood flow that may not be evident initially. E) Marginal ventilatory function with atelectasis, aspiration, fat embolism or other problems. F) Early problems such as continued or recurrent bleeding requiring reoperation, large hematomas, tissue necrosis, peritoneal contamination, pulmonary injury or head injury. G) Catabolism with all of its attendant problems. H) Failure of rapid return of gastrointestinal function and discontinuation of intravenous infusions to enable oral intake and spontaneous adequate ventilation for extubation. I) There are often clinical or technical errors or problems such as a leaking anastomosis or wound separation. J) Depressed host resistance leading to invasive sepsis or abscesses. As this occurs, ventilatory failure ensues or there is a worsening of previously abnormal ventilation, right heart failure secondary to increased pulmonary vascular resistance or myocardial depression with increased venous pressure, progressive evidence of hepatic failure with a rising bilirubin, renal failure and problems with an altered sensorium, coagulation and stress ulceration. The key factor in most reports on this problem has been infection. Attention to the problems of cell injury and a better definition of changes in host resistance, the relationship fsepsisto to pulmonary, renal and hepatic failure and other organ relationships should help to prevent this problem. The injured or surgically-treated patient who has experienced a severe metabolic insult may have multiple systems or organ failure. Careful evaluation, a well-planned operative procedure, and excellent supportive postoperative care with elimination of clinical or technical errors and prevention of sepsis should result in survival of most of these patients.

Prevention of peripheral nerve entrapment following extensive soft tissue injury, using silicone cuffing

Prevention of peripheral nerve entrapment following extensive soft tissue injury, using silicone cuffing

Prevention of Peripheral Nerve Entrapment Following Extensive Soft Tissue Injury, Using Silicone Cuffing

A semirigid silicone cuff was investigated in rats to prevent scar entrapment of the sciatic nerve. Scar was induced by crushing or burning the surrounding muscles. On one side, the nerve was covered by a longitudinally split semirigid silicone tube. On the other side, the same procedure was done without silicone coverage of the nerve. At different time periods the animals were sacrificed and the nerve with surrounding tissues examined. The protected nerve was found gliding freely during mobilization of the limb. The blood supply to the nerve was maintained through the split in the silastic cuff by formation of new mesoneurium. On the control side, the nerve was surrounded by a fibrous tissue in various stages of maturation depending upon the time postinjury. The nerve structure showed reduced vascularity and progressive degenerative changes of the axons. Clinical tests on the silicone cuff method are proposed fo selected patients with extensive soft tissue injury around nerves.

Fracture healing. A concept of competing healing factors.

In the discussion concerning the theory of the healing of shaft fractures the demand for absolute stability of the fracture has been a dominating factor. This cannot be an absolute prerequisite because fractures of the tibia or femur heal well even with continued weight-bearing and movement. The ingrowth of vessels is apparently not a crucial factor. It is evident, however, that fractures caused by direct violence with soft tissue damage heal more slowly than fractures caused by indirect violence, irrespective of the treatment. Soft tissue heals with fibrous scar; fractures heal by bone regeneration. The author postulates that the damaged tissue stimulates (possibly via molecular determinants) the structural genes of undifferentiated cells to produce mRNA and proteins for either fibrous tissue or bone formation. The rate or healing of the fracture is determined by the degree of bone damage in relation to soft tissue damage. In fractures with extensive soft tissue injury there occurs a competitive condition in the common haematoma, with a risk of delayed fracture healing due to the dominance of cells that are triggered off by fibrous tissue formation.

Transcutaneous electrical neurostimulation in musculoskeletal pain of acute spinal cord injuries.

Cervical, thoracic, thoracolumbar, and lumbar fractures associated with physiologic complete or incomplete spinal cord injuries frequently have severe soft-tissue injury as well as severe pain associated with the site or area of injury. Transcutaneous electrical neurostimulation has proved effective in the treatment of various causes of severe acute and chronic intractable pains. We applied this modality to a group of 20 patients who had acute spinal cord injuries and pain associated with severe, extensive soft-tissue injury. Its advantages include ease of application, lack of major complications, increased intestinal peristalsis, and avoidance of narcotic analgesic medications. It also produced significant (greater than 50%) pain relief in 75% of patients treated by transcutaneous electrical neurostimulation.

Prolonged retention of glutaraldehyde-treated skin homografts in humans

Treatment of cadaver skin homografts in vitro with glutaraldehyde significantly prolonged their average retention time from 10·9 to 21·8 days in 21 patients with burns and/or extensive soft tissue injuries. The glutaraldehyde-treated homografts serve as a useful non-viable wound cover. They remain adherent to the wound bed for prolonged periods and support the formation of granulation tissue favourable for the subsequent acceptance of autografts. Toxic symptoms or allergic reactions were not noticed in any of the recipients. Treatment of the skin with glutaraldehyde is simple to perform, requires minimal laboratory equipment, and is not time consuming.

Angiography and Hemodynamic Measurements in Extensive Soft Tissue Trauma to the Extremity

The early circulatory changes following extensive soft tissue injury to the hind leg of the dog was examined by angiography and by measurement of blood flow by an electromagnetic flowmeter. The trauma caused a marked increase of blood flow and vasodilatation in the injured extremity with or without combination of a fracture. The later gradual increase of calculated vascular peripheral resistance was angiographically reflected by successively impaired flow in peripheral arteries. In spite of the decrease of flow, the dilatation of the larger arteries persisted for several hours.

Massive thigh injuries with vascular disruption. Role of porcine skin grafting of exposed arterial vein grafts.

Twenty-five patients with extensive soft tissue injury and femoral-popliteal arterial disruption were treated over a four-year period. Injury was most often due to closerange shotgun blasts, and often involved adjacent structures. Of the patients, 72% were admitted in severe shock; all but one were successfully resuscitated. Three patients did well following primary above-knee amputation. The remaining 21 had primary vascular repair, and 14 survived with a viable limb. There were four secondary amputations and four postoperative deaths. Adverse factors affecting survival and limb salvage included inadequate debridement, primary wound closure, failure of the vascular repair, and omission or incomplete fasciotomy. Split-thickness porcine skin grafts were used as a biological dressing to cover an exposed vascular repair in four patients. Limb salvage was achieved in three of these.

Coccygectomy for drainage of pelvic abscesses after pelvic wounds

Ten patients who had extensive soft tissue, bony, and visceral injuries from high velocity missile wounds of the pelvis were seen with pelvic infections. Adequate drainage of the pelvis is difficult to obtain. Coccygectomy with presacral drainage of the pelvis has been found to give excellent wide open, dependent pelvic drainage in these patients.

Major and Extensive Soft-Tissue Injuries Complicating Skeletal Fractures

Management of major and extensive soft-tissue injuries associated with skeletal fractures requires a planned approach and action based on broad training and knowledge, and not one or two past experiences.

Splints and casts in the treatment of war injuries

The use of splints and casts in the treatment of war injuries varied according to the particular echelon of command in which they were required. In general, emergency splinting was effected with the regulation army halfring splint. For transportation following primary surgery plaster was almost universally employed. Definitive splinting in the Zone of Communication was accomplished by use of the halfring splint or plaster, frequently by a combination of the two. Internal splinting was, for the most part, reserved for the Zone of the Interior. Two points deserve especial attention; the use of splints in the protection of extensive soft tissue injuries during transportation and the abuse of splints in the treatment of fractures of the hand.