[Timing of soft tissue reconstruction in severe crush injury of the upper extremity]

[Acute and post-acute soft tissue reconstruction]

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.

LATERAL ARM FREE FLAPS IN THE DEFECTS OF THE UPPER EXTREMITY — A REVIEW OF 72 CASES

Lateral arm flaps are versatile in the use of upper extremity moderate-sized defects with little morbidity and with acceptable cosmesis. The conditions are outlined in a series of 74 lateral arm flaps performed on 72 patients and the results are given. Five patients were operated on as emergencies, 12 were operated within the first 72 hours of injury and 57 patients were treated electively. Skin defects were between 6 × 4 cm and 20 × 9 cm . Five (7%) flaps were lost due to venous thrombosis, three that sustained a high-voltage electric burn. Two other patients that were treated for a high-voltage electric burn had a successful revision of the anastomosis site in the early post-operative duration. One flap was abandoned due to very thin pedicle and obesity of the patient. A higher failure rate is encountered most frequently with the cases of high-voltage electric burn. To deal with this problem, a modified approach such as an extended approach and/or including the forearm skin to the flap is recommended during the flap harvest. For a longer pedicle to be anatomized more proximally, perforator flaps with longer pedicles may be used as an alternative.

[Fractures of the extremities with severe open soft tissue damage. Initial management and reconstructive treatment strategies]

The successful management of open extremity injuries continues to represent a surgical challenge requiring a structured and multidisciplinary treatment concept. The treatment strategy depends on specific parameters, including the overall injury severity, life threatening trauma components, the degree oft soft tissue injury, the ischemia time, the contamination of the wound as well as the age and accompanying diseases of the patient. The treatment of fractures with a high-grade open soft tissue injury is guided by the severity of soft tissue damage including neurovascular damages, type of the fracture, overall state of the patient and is based on a clearly defined reconstructive algorithm sequentially employing initial wound treatment (debridement), stabilisation of the fracture and soft tissue coverage. The initial wound management includes radical and serial debridements and vessel reconstruction, followed by the gradual reconstruction of bone, tendons and nerves and a subsequent plastic soft tissue coverage.The sequential and priority-orientated implementation of these treatment steps is decisive for the long term outcome, which ideally results in an regular healing of bone and soft tissue without the presence of infection and good regain of extremity function.

[Management of severe soft-tissue trauma in the upper extremity - shoulder, upper and lower arm]

OBJECTIVE

Salvage of the respective extremity. Standardized approach to adequate soft-tissue coverage (isolated severe soft-tissue trauma) and preconditioning for fracture healing (in complex trauma) as a basis for functional restoration. Limitation of secondary soft-tissue loss. Prevention of infection.

INDICATIONS

Isolated extended severe soft-tissue trauma (crush trauma, degloving injury) in the region of the shoulder and the upper extremity. Complex trauma with soft-tissue involvement Gustilo IIIB/C or Tscherne GIII/IV. Segmental soft-tissue/bone loss. Subtotal or partial amputations.

CONTRAINDICATIONS

Unstable polytraumatized patient with vital hazards and the priority for lifesaving measures. Irretrievable devascularization or unreconstructable neural destruction, extended severe loss of multiple muscular units.

SURGICAL TECHNIQUE

Systematic, eventually serial debridement, temporary joint transfixation, reconstruction of macrocirculation, dermatofasciotomy in compartment syndrome, preferably primary shortening in segmental soft-tissue/bone loss, temporary soft-tissue coverage, systematic conditioning of soft tissues, postprimary or secondary soft-tissue reconstruction, secondary change to preferably internal fixation techniques.

POSTOPERATIVE MANAGEMENT

Individualized earliest possible passive or assisted mobilization of nontransfixed joints, early removal of transfixation and change to internal fixation modes, eventually secondary reconstructive measures (e.g., augmentation of bone defects, flap correction, secondary nerve reconstruction, functional muscle transposition procedures, arthrolyses).

RESULTS

Patency rate after vascular reconstruction > 90%, flap survival > 95%, need for amputation is a rare entity; main determinants of prognosis: severity of soft-tissue trauma, neural damage, and potential for reconstruction.