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1、Wound Coverage Techniques for the Injured Extremity,Gil Ortega, MD, MPH Original Author: David Sanders, MD; Created January 2006 New Author: Gil Ortega, MD, MPH; Revised September 2009,Objectives,Review multi-disciplinary approach to evaluation and treatment of Soft Tissue injuries Review up to date
2、 methods of coverage Open Primary vs. Secondary Skin grafting Flap Review Non-surgical and Surgical Options for Soft-Tissue injuries Review current literature concerning Soft-Tissue injuries and Wound Coverage Techniques,Initial Assessment,History Time and mechanism of injury Functional demands of t
3、he patient Patient variables Age Diabetes Malnutrition Obesity Infection Smoker Medications Underlying physiology Occupation,Initial Assessment,Physical exam Severity of Injury Energy of Injury Morphology of associated fracture Bone loss Blood supply Location,Initial Treatment,Management of soft tis
4、sue injury requires: Early aggressive debridement in OR Early intravenous antibiotics Skeletal stabilization Timely soft tissue coverage Tetanus prophylaxis Prophylactic antibiotics: 1st generation cephalosporin Clindamycin if penicillin allergy Penicillin for clostridia-prone wounds,Wide Variety of
5、 Soft Tissue Injuries; Similar Initial Treatment Options,Injury: Realignment/splint Neurovascular exam Cover wound with sterile dressing Radiographs,Wound Colonization,Initial colonization of traumatic wound Increases with time Need to debride necrotic muscle, dead space, and poorly vascularized tis
6、sue including bony injuries,Wound Excision- Debridement,Conversion of traumatic wound to a “surgical” wound with debridement of all devitalized tissue skin, fascia, and bone Unless gross contamination, evidence unclear as to best time for operative debridement as to whether 0-6 hours, 6-12 hours or
7、12 hours to decrease risk of infection, however, patient must receive IV antibiotics promptly Tripuraneni K et al. The Effect of Time Delay to Surgical Debridement of Open Tibia Shaft Fractures on Infection Rate. ORTHOPEDICS 2008; 31:1195.,Initial Management After Debridement,Restore vascularity Sta
8、bilize skeletal injury Splinting External Fixation Early Total Orthopaedic Care vs. Damage Control Orthopaedics Repair nerves Repair musculotendinous units PLAN reconstruction When patient is best physiologically stable When best team is available for reconstruction(s),Reconstructive Ladder,Methods,
9、Types,Direct closure Skin Grafts Local and Regional Flaps Distant Pedicle Flaps Free Flaps,Primary Secondary STSG FTSG Random Axial Random Axial (See next slide),Reconstructive Ladder,Free flaps Cutaneous Fascial/ Fasciocutaneous Muscle/ Musculocutaneous Osteocutananeous,Direct Closure,Direct closur
10、e is simplest and often most effective means of achieving viable coverage May need to “recruit” more skin to achieve a tension free closure,Direct closure,Decreasing wound tension can be accomplished by: Relaxing skin incisions “Pie crusting” of the skin under tension (perpendicular to the direction
11、 of tension) Application of negative pressure wound therapy,Negative pressure therapy,Advantages: Increased neovascularization Increased granulation tissue formation, Decreased bacterial count Decreased seroma formation Wound contracture Disadvantages: Device Cost Cant see wound when sponge is in pl
12、ace,Negative pressure therapy,Components: Apply a polyvinyl sponge to wound Impermeable membrane sealing wound from the external environment Low or intermittent negative pressure vacuum suction i.e. KCI Vacuum Assisted Closure, or V.A.C. Therapy System,Negative pressure therapy,Routine use of VAC wi
13、th open tibia fractures is safe According to Bhattacharyya et al, in Gustilo Type IIIB tibia fractures, vacuum-assisted closure therapy does not allow delay of soft-tissue coverage past 7 days without a concomitant elevation in infection rates Bhattacharyya et al. Routine use of wound vacuum-assiste
14、d closure does not allow coverage delay for open tibia fractures. Plast Reconstr Surg. 2008 Apr;121(4):1263-6.,Skin Grafting,Split thickness (STSG) Full thickness (FTSG),STSG,Advantages May be meshed Large area Require less revascularization Temporary coverage,Disadvantages Poor cosmesis Limited dur
15、ability Contracts over time Donor site problems Pain Infection,FTSG,Advantages No wound contracture Increased sensibility Increased durability Better cosmesis Primary closure of donor site,Disadvantages Longer to revascularize Cannot mesh Recipient site must have rich vasculature,Wound Preparation f
16、or Grafts,Vascularity Hemostasis Debride all necrotic tissue Optimize co-morbid conditions,Donor Site Selection,STSG 0.015 inches thick (thickness #15 scalpel) Lateral buttock Ant. and Lat. Thigh Lower abdomen Avoid medial thigh and forearm,FTSG Depends on area to be covered Large grafts-lower abdomen and groin Small- medial brachium and volar wrist crease Plantar skin from instep,Skin Harvest for STSG,Sterile preparation Lubricate Set depth (0.012 inch most common) Traction with
