A CLINICAL CASE OF SUCCESSFUL TREATMENT OF A PATIENT WITH POLYTRAUMA AND EXTENSIVE TRAUMATIC SKIN DETACHMENT IN THE LEFT LEG Blazhenko A.N., Kurinny S.N., Mukhanov M.L., Blazhenko A.A., Afaunov A.A.
Kuban State Medical University, Krasnodar, Russia
Traumatic detachment of the skin is the consequence of impaction of high energy trauma. Its incidence in multiple and associated injuries is 1.5-3.8 % [1, 2]. The treatment of such patients is associated with some difficulties since the appropriate treatment protocols (algorithms) have not been developed [3, 4]. The presence of an extensive injury to tissues with their infection, and the problem of persistent wound surfaces have some prerequisites to development of multiple complications [5-8] leading to decrease in working capability and to disability [9]. The Russian medical literature does not give enough attention to traumatic detachment of covering tissues. So, foreign and Russian publications do not describe any issues of transportation of patients, and recommendations for cases with extension crushing injuries to covering tissues, fascias and muscles. There are only limited findings on treatment of the associated injury and bone fractures [1].
Objective – to discuss the features of two-stage skin grafting by Krasovitov using vacuum compression to the area of the replanted skin autograft.
The study was conducted in compliance with World Medical Association Declaration of Helsinki – Ethical Principles for Medical Research Involving Human Subjects, 2013, and the Rules for Clinical Practice in the Russian Federation (the Order by Russian Health Ministry, 19 June 2003, No.266), with the written consent for participation and for data using, with approval from the local ethical committee of Kuban State Medical University (the protocol No.69, 26 October 2018).
MATERIALS AND METHODS
A clinical case with surgical treatment of a patient K., (age of 33, the case history No.2017015566) with the injury after the road traffic accident (collision of two cars) is presented.
The patient was transferred by the medical ambulance car to a level 2 trauma center (the primary admission hospital), where he was examined. The clinical diagnosis was made: “A severe associated injury (polytrauma) to the head, the chest and extremities”.
Closed traumatic injury (AIS = 1).
A closed chest injury: multiple rib fractures to the right, the right lung contusion, right-sided tension pneumothorax, subcutaneous emphysema of the chest and the neck (AIS = 4).
Gustilo-Andersen type IIIB fracture of the left fibular bone, traumatic detachment of the skin (extensive degloving injury to the left leg) – approximately 5 % of body square, with partial rupture and a crushing injury to posterior muscles of the leg. Posttraumatic neuropathy of the left fibular nerve (AIS = 2).
A dominating injury – chest injury, a life-threatening consequence of the chest injury – acute respiratory failure, a life-threatening consequence of polytrauma – traumatic shock of degree 2.
The prognosis for life was positive.
The first stage of surgical treatment was realized in the level 2 trauma center:
- draining of the right pleural cavity with correction of acute respiratory failure;
- primary surgical management of the degloving injury of the left leg with traumatic detachment of the skin (wound toilet with antiseptic solutions, skin suturing, active draining) (Fig. 1).
Figure 1
Patient K.: view of the left leg when entering the trauma center 1 level
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After achievement of condition stabilization in eight hours after trauma, the sanitary aviation reanimobile (accompanied by the intensivist, with continuous artificial lung ventilation and intensive infusion therapy) transported the patient to the level 1 trauma center for arrangement of specific medical care.
One hour after admission to Krasnodar City Clinical Hospital No.1, at the background of stabilization of the patient’s condition, the recurrent surgical preparation of the left leg wound was conducted. The sutures were removed. The surgical revision of the wound was carried out. It found some fields of the crushing injury to muscular and fat tissues with their doubtful vitality. As result, a decision was made to perform two stages of Krasovitov layer-by-layer skin plasty.
The first (preparative) stage included the dissection, preparation and conservation of the detached skin flap, necrectomy of crushed soft tissues, application of the external fixing device (EFD) and aseptic dressings (Fig. 2-4).
Figure 2
Repeated debridement of the left leg
Figure 3
View of the cut and treated skin flap
Figure 4
Left lower limb after repeated surgical treatment and fixation with the external fixing device.
48 hours after recurrent surgical preparation, the patient was delivered to the surgery room. The revision of the wounds did not show any signs of necrosis of muscular and fat tissue. It allowed realizing the replantation of the preserved skin autograft (layer-by-layer autoplasty of the defect of covering tissues of anterior, medial and lateral surface of the left leg according to Krasovitov) (Fig. 5).
Figure 5
Completion of the Krasovitov skin plastics stage
The surgery was completed with application of VAC-dressing with negative pressure (50 mmHg) for provision of smooth pressure to the skin autograft (Fig. 6).
Figure 6
VAC-bandage with a negative pressure of 50 mmHg for equal compression of the skin autograft
Five days after replantation (according to Krasovitov) of the full-thickness skin autograft, the satisfactory survival of the autograft was noted, as well as maturation of granulations along the posterior surface of the left leg, which could not be covered with the skin autograft. As result, the skin autoplasty for the skin defect on the posterior surface was conducted with the split-thickness skin graft (Fig. 8). The VAC-dressing was applied for 48 hours (50 mmHg negative pressure).
Figure 7
Adapted skin autograft 5 days after performing skin autoplasty according to Krasovitov
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Figure 8
Skin autoplasty of a soft tissue defect in the left leg with split skin autograft
RESULTS
14 days after the injury, after the multi-stage surgical management, the full survival of Krasovitov skin graft and the split-skin graft was achieved.
The infectious complications and osteonecrosis were prevented. The figure 9 shows the treatment outcome and condition of the covering tissues of the left leg in 7 weeks after the surgical management.
Figure 9
The result of the surgical treatment of traumatic detachment of the skin of the left tibia 7 weeks after injury
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CONCLUSION
1. The treatment of patients with polytrauma and traumatic detachment of the skin should be conducted in level 1 trauma centers. For realization of staged specialized treatment, the transfer from the primary hospital is initiated within the first 24 hours after trauma.
2. Patients with polytrauma and traumatic detachment of the skin, with unstable condition or/and signs of muscular tissue necrosis in the region of skin detachment, should receive the two-staged Krasovitov skin plasty for decreasing the traumatic potential of a surgical intervention and for creation of more favorable conditions for survival of the skin autograft.
3. Application of VAC-dressing onto the Krasovitov skin autograft (50 mmHg negative pressure promotes its smooth compression and better adaptation to subjacent tissues.
Information on financing and conflict of interest
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interest relating to this article.