Wound Management in Pediatric Lower Limb Injuries
An otherwise healthy 5-year-old male patient was admitted at the Pediatric Emergency Department at Padua University Hospital (Padua, Italy) in August 2011 for a severe trauma to the lower left leg due to a road accident. The injury involved the whole lower-third of the left leg, circumferentially, with a complete irregular loss of both the cutaneous and subcutaneous layers that resulted in a massive exposure of underlying fascial and muscular structures. Tibialis posterior muscle and flexor hallucis longus were partially disrupted together with their superficial fascia; no lesions of nerves, large vessels, or tendon structures were assessed and x-rays didn't report signs of bone fractures. Systemic signs included a mild head trauma and mild dyspnea. Since the patient showed sudden signs of hypovolemic shock, likely due to hemorrhagic losses, he was treated for hemodynamic support with blood transfusions and plasma expanders until stabilization of systemic parameters. Even so, his condition was not considered suitable for major surgical procedures, thus he underwent only an accurate surgical hemostasis with partial wound debridement, myorraphy, repair of the fascial structures, and conservative dressing by means of nonadherent petroleum jelly-based gauze before hospitalization. Other treatments included antibiotic prophylaxis and standard analgesic therapy.
On the second postoperative day, despite the lack of associated clinical signs or symptoms, a sudden decrease in hemoglobin values (5.9 g/dL) was observed, likely due to continuous petechial bleeding from the open wound. In addition, a concomitant increase of inflammatory markers (ie, C-reactive protein and erythrocyte sedimentation rate) with rising neutrophilic leucocytosis (16,000/mm) was assessed. Thus, both conditions required prompt surgical intervention to provide an adequate coverage of soft tissue exposures that could limit further blood loss and that could lessen the significant risk of local infection, which, in turn, could have further worsened systemic conditions and the chances for surgical repair of local defects.
Given the general condition of the patient, the authors considered it inadvisable to perform complex reconstructive surgeries as large pedicled or free flaps. In addition, easier surgical solutions offered by the reconstructive ladder, as full-thickness skin grafts or local flaps, were not suitable for a definitive repair due to the limited thickness and size of tissue available. Therefore, with the patient under general anesthesia, a secondary accurate debridement was performed to provide a viable wound bed, together with coverage of exposed soft tissue by means of a regenerative dermal substitute (Integra, Integra Life Sciences Corporation, Plainsboro, NJ). The graft was adequately shaped (10 x 25 cm) and fixed with absorbable sutures and a tie-over compressive dressing of gauze moistened with saline (NaCl 0.9%) over the protective silicone layer of the substitute (Figure 1). During the following days no relevant complications were observed. In an effort to decrease medication-related pain and stress, dressing changes were scheduled every 2 days and consisted only in the changing of nonadherent wet gauze overlying the silicone layer after proper disinfection. The chosen surgical procedure and dressings allowed the patient partical mobility, thereby improving his compliance to the treatment regimen and quality of life. After 5 days the patient was discharged and dressing changes were done at the outpatient clinic. On the 15th postoperative day, the patient was admitted for final reconstruction by means of a full-thickness skin graft. Early rehabilitation therapy was introduced. A clinical follow-up was scheduled with medical examination every 2 months up to 12 months, at which a complete functional recovery with appropriate repair of subcutaneous and cutaneous layers that appeared smooth and viable was observed (Figure 1). Subjective symptoms were not reported and the aesthetic outcome could be considered good thanks to the absence of a hypertrophic scar.
(Enlarge Image)
Figure 1.
(A,B) The wound after surgical removal of necrotic tissue. (C,D) Coverage of the soft tissue exposure by means of the regenerative dermal template; the outlying silicone layer is evident. (E,F) Results 12 months after final surgical reconstruction with skin grafts. The authors observed a complete functional recovery with appropriate repair of subcutaneous and cutaneous layers that appeared smooth and viable
Case Report
An otherwise healthy 5-year-old male patient was admitted at the Pediatric Emergency Department at Padua University Hospital (Padua, Italy) in August 2011 for a severe trauma to the lower left leg due to a road accident. The injury involved the whole lower-third of the left leg, circumferentially, with a complete irregular loss of both the cutaneous and subcutaneous layers that resulted in a massive exposure of underlying fascial and muscular structures. Tibialis posterior muscle and flexor hallucis longus were partially disrupted together with their superficial fascia; no lesions of nerves, large vessels, or tendon structures were assessed and x-rays didn't report signs of bone fractures. Systemic signs included a mild head trauma and mild dyspnea. Since the patient showed sudden signs of hypovolemic shock, likely due to hemorrhagic losses, he was treated for hemodynamic support with blood transfusions and plasma expanders until stabilization of systemic parameters. Even so, his condition was not considered suitable for major surgical procedures, thus he underwent only an accurate surgical hemostasis with partial wound debridement, myorraphy, repair of the fascial structures, and conservative dressing by means of nonadherent petroleum jelly-based gauze before hospitalization. Other treatments included antibiotic prophylaxis and standard analgesic therapy.
On the second postoperative day, despite the lack of associated clinical signs or symptoms, a sudden decrease in hemoglobin values (5.9 g/dL) was observed, likely due to continuous petechial bleeding from the open wound. In addition, a concomitant increase of inflammatory markers (ie, C-reactive protein and erythrocyte sedimentation rate) with rising neutrophilic leucocytosis (16,000/mm) was assessed. Thus, both conditions required prompt surgical intervention to provide an adequate coverage of soft tissue exposures that could limit further blood loss and that could lessen the significant risk of local infection, which, in turn, could have further worsened systemic conditions and the chances for surgical repair of local defects.
Given the general condition of the patient, the authors considered it inadvisable to perform complex reconstructive surgeries as large pedicled or free flaps. In addition, easier surgical solutions offered by the reconstructive ladder, as full-thickness skin grafts or local flaps, were not suitable for a definitive repair due to the limited thickness and size of tissue available. Therefore, with the patient under general anesthesia, a secondary accurate debridement was performed to provide a viable wound bed, together with coverage of exposed soft tissue by means of a regenerative dermal substitute (Integra, Integra Life Sciences Corporation, Plainsboro, NJ). The graft was adequately shaped (10 x 25 cm) and fixed with absorbable sutures and a tie-over compressive dressing of gauze moistened with saline (NaCl 0.9%) over the protective silicone layer of the substitute (Figure 1). During the following days no relevant complications were observed. In an effort to decrease medication-related pain and stress, dressing changes were scheduled every 2 days and consisted only in the changing of nonadherent wet gauze overlying the silicone layer after proper disinfection. The chosen surgical procedure and dressings allowed the patient partical mobility, thereby improving his compliance to the treatment regimen and quality of life. After 5 days the patient was discharged and dressing changes were done at the outpatient clinic. On the 15th postoperative day, the patient was admitted for final reconstruction by means of a full-thickness skin graft. Early rehabilitation therapy was introduced. A clinical follow-up was scheduled with medical examination every 2 months up to 12 months, at which a complete functional recovery with appropriate repair of subcutaneous and cutaneous layers that appeared smooth and viable was observed (Figure 1). Subjective symptoms were not reported and the aesthetic outcome could be considered good thanks to the absence of a hypertrophic scar.
(Enlarge Image)
Figure 1.
(A,B) The wound after surgical removal of necrotic tissue. (C,D) Coverage of the soft tissue exposure by means of the regenerative dermal template; the outlying silicone layer is evident. (E,F) Results 12 months after final surgical reconstruction with skin grafts. The authors observed a complete functional recovery with appropriate repair of subcutaneous and cutaneous layers that appeared smooth and viable
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