A CLINICAL REPORT OF TREATMENT OF A PATIENT WITH EXTENSIVE TRAUMATIC DETACHMENT OF SOFT TISSUES Petrov Yu.L., KorostelevM.Yu., Shikhaleva N.G.
City Clinical Hospital No.8, Chelyabinsk, Russia,
Russian Ilizarov Scientific Center for Traumatology and Orthopaedics, Kurgan, Russia
Extensive soft tissue detachment is a common serious surgical abnormality, which is characterized by detachment of the skin and subcutaneous fat from subjacent muscles and fascia as result of a sudden shift, which is applied to the skin surface [1, 2].
The main locations of extensive skin detachment are the lower extremities, the body, the scalp, and the face [3-6]. Detachments can be classified as closed/internal or opened/external lesions [7, 8, 9]. Such injury can lead to complete necrosis of detached tissues owing to disordered blood flow [10]. Moreover, the infectious process and necrotic fasciitis often develop under the detached skin due to incorrect management of wounds in patients with extensive crushing injuries. It often results in more severe condition and to the lethal outcome [7, 11].
However, the difference between vital and non-vital tissues is associated with some difficulties in early management of ESTD for both types of injuries [7]. It is difficult to develop the appropriate algorithm for decision making since each injury is unique according to variety of lesions. Therefore, the outcome of ESTD is often underestimated [1, 6]. The treatment outcomes are influenced by multiple factors: location, square and depth of tissue injuries, concurrent injuries and abnormalities, selection of treatment techniques, quality of primary surgical management of tissues, primary application of sutures, primary conservative management, subsequent staged removal of crushed tissues, VAC, Krasovitov’s primary plasty [12, 13, 14]. A technique of extremity fixation is also important for such injuries. Ilizarov’s transosseous fixation is the most optimal method for creation of favorable conditions for wound healing [15, 16].
One should note the presence of some organizational and medical problems, considering the difficulties relating to coding of this abnormality in ICD 10. The code T04.3 (crushing injury of several parts of lower extremity (ies)) is appropriate for lower extremity injuries. This type of the injury is not marked separately in the list of nosologies of compulsory medical insurance. Therefore, medical records of such patients are registered with use of other codes: the best variant – polytrauma, the worst one – degloving injury. There are not any confirmed range of examination of soft tissues, required management techniques, and criteria for realization of the standard for this pathology. There are not any clinical recommendations and standards of treatment (confirmed by Russian Health Ministry) for patients with this pathology.
CLINICAL CASE
The study was conducted in compliance with Helsinki Declare – Ethical Principles for Medical Research with Human Subjects, 2013, and the Rules for Clinical Practice in the Russian Federation confirmed by the Order by Health Ministry of Russia on 19 June, 2003, No.266. The patient gave the informed consent for surgical intervention and for publishing the data without personal identification.
The clinical case was presented by the patient K., female, age of 55. On April, 17, 2012, she was injured in a road traffic accident. While getting the bus, she fell to the ground. The bus crossed her left lower extremity. The emergency medical team transferred her to the admission unit of City Clinical Hospital No.8. Her condition was severe and was determined by traumatic shock of degree 2 and by ongoing bleeding. The diagnosis was: “Polytrauma, hemorrhagic shock of degree 2 (table), extensive opened detachment of soft tissues of left lower extremity (foot, leg, hip), ongoing bleeding from left inguinal region”.
Table
Time course of laboratory values of the patient K., age of 55
|
Values |
Date |
||||||||
|
17/04 |
23/04 |
27/04 |
03/05 |
06/05 |
08/05 |
12/05 |
18/05 |
20/05 |
|
|
Red blood cells, ×1012/L |
3.03 |
3.09 |
3.24 |
3.72 |
3.64 |
3.55 |
2.82 |
2.8 |
3.2 |
|
Leukocytes, ×109/L |
1.2 |
16.6 |
18.8 |
20.7 |
17.2 |
12.4 |
13 |
17.4 |
13.2 |
|
Lymphocytes |
35 |
32 |
24 |
18 |
18.2 |
14.2 |
9 |
13.2 |
11 |
|
Hemoglobin, g/L |
87 |
92 |
110 |
119 |
110 |
103 |
80 |
77 |
96 |
|
Hematocrit, % |
27.3 |
29.1 |
31.1 |
32.5 |
32.4 |
32.1 |
25.7 |
25.8 |
28.4 |
|
Platelets (109/l) |
434 |
462 |
453 |
194 |
204 |
225 |
415 |
516 |
562 |
|
Total protein, g/l |
67.2 |
65.5 |
61.4 |
50.2 |
51.6 |
63.2 |
60.2 |
61.0 |
65.2 |
|
Glucose, mmol/l |
6.9 |
6.7 |
7.8 |
8.2 |
7.1 |
6.6 |
6.9 |
6.8 |
6.5 |
|
Creatinine, mcmol/l |
45.4 |
48.0 |
52.0 |
74.4 |
71.3 |
70.7 |
70.0 |
66.0 |
47.0 |
|
Procalcitonin test, ng/ml |
- |
1.85 |
4.57 |
3.85 |
- |
- |
3.65 |
- |
0.18 |
|
Albumins, g/l |
- |
- |
- |
28 |
- |
- |
30.9 |
- |
32 |
|
Alanine aminotransferase, U/l |
105 |
289 |
144 |
134 |
38 |
- |
57 |
89 |
33 |
|
Aspartate aminotransferase, U/l |
114 |
203 |
121 |
158 |
42 |
- |
41 |
50 |
60 |
|
Total bilirubin, mcmol/l |
9.2 |
10.8 |
9.1 |
65.3 |
18 |
15.7 |
11.6 |
11.5 |
10.1 |
|
Direct bilirubin, mcmol/l |
7.1 |
8.9 |
6.5 |
28 |
- |
9.1 |
9.5 |
- |
7.8 |
After admission, the anamnesis data were collected, clinical and laboratory examinations were carried out, and X-ray examination of the left lower extremity and the pelvis was conducted. After admission, at the background of infusion, the arterial pressure was 90/60 mm Hg, pulse – 80 per minute, respiratory rate – 20 per minute. The total square of identified detached tissues was 19 % of body surface. An opened non-displaced fracture of the proximal phalanx of the left toe was identified. Injury Severity Score (ISS) (Baker S. P. et al., 1974) showed severe degree of the injury. Trauma Index (Kirkpatric J. R., Youmans R. L., 1971) was 12 (severe injury) [17, 18]. According to classification by Arnez Z.M. et al. (2009), the trauma was classified as the second group (non-circular wound; the injury site was limited by one layer (usually, between the deep fascia and subcutaneous fat)) [19].
At the background of anti-shock therapy, the traumatologist-orthopedists performed the surgery: primary surgical preparation of the left lower extremity, arrest of bleeding in the left inguinal region. The wounds of the left lower extremity were revised. A skin detachment (semi-circular pattern) with subcutaneous fat from superficial femoral and leg fascia was identified, a detachment in the knee joint – along posterior semi-circumference, circular pattern – on the foot.
The pulse was weak and rhythmical on the dorsal artery of the foot and on the posterior tibial artery. There were not any disorders of sensitivity in the toes. The sensitivity was low on the detached skin flaps. The left toe was pale and cool. Other toes were of body color, warm, but cooler than the toes of the healthy foot. Under general anesthesia, the tissues of the left lower extremity were washed with antiseptic solutions, the bleeding was arrested, the covering tissues were positioned correctly and were sutured. The active drains were installed. Considering the extension of soft tissue injuries, the limb was fixed with Ilizarov’s apparatus. Owing to severe condition, the patient was admitted to the intensive care unit.
On April, 19, 2012, tracheostomy was performed. Despite of the performed manipulations, the bleeding was persistent. Within the following day, about 400 ml of hemorrhagic discharge (from posterior region of the knee joint) was removed through the drains. As result, on the second day after the injury, the patient was transferred to the surgery room, where recurrent surgical preparation was performed. An attempt to find the injured magistral vessels was unsuccessful. The intervention was completed with installment of drains and with wound suturing.
The patient’s condition was severe in the postsurgical period. Within the following 10 days, the patient remained in ICU with purpose of dressings. The general condition was worsening gradually according to clinical signs of local and general status, with data of instrumental and laboratory examinations. Severe condition was determined by the events of previous traumatic and hemorrhagic shock, unfavorable course of extensive wound process, and toxicosis after products of tissue degradation entering the microcirculatory bed. The temperature was hectic.
On 11th day after the injury, cerebral, respiratory and cardiovascular insufficiency was identified, as well as acute hepatic and nutritive insufficiency. Glasgow Coma Scale was 10, RASS – 2. The local signs showed an increase in volume of the extremity, skin redness, extensive necrosis of the skin and subcutaneous fat. The sutures were removed. The wounds were opened, and turbid serous discharge was received. The blood analysis showed the intense change in the leukogram, hypovolemia, and positive procalcitonin test (the table). The results of the clinical and laboratory examination showed early posttraumatic sepsis. SOFA was 6, APACHE – 22. The wound inoculation included Pseudomonas aeruginosa (105), Acinetobacter baumannii (106), Aeromonas (106), Klebsiella pneumonia (106); the blood inoculation – Enterococcus faecium (104) and Acinetobacter baumannii (102).
During the cooperative concilium with participation of the plasty surgeon from the Chelyabinsk burn center (May, 3, 2012) it was decided to conduct the recurrent urgent surgical management of wounds with their revision, and removal of non-vital tissues. The patient had septic shock.
Another revision of the wounds showed a non-diagnosed extensive detachment of covering tissues in the left lower extremity, but also in left gluteal region, and in anterior abdominal wall in iliac, inguinal and left lateral regions (Fig. 1, 2). Under injured skin surfaces, tense hematomas were found (total volume – 300 ml). As result, the total square of injuries was 30 % of body surface. The revision of the wounds identified a laceration of gluteus maximus muscle. The laceration was covered by frayed wide fascia of the right hip (Fig. 3). Also some muscle of the leg and the hip were crushed. Such tissue injuries (necrobiosis) inevitably caused the endogenic intoxication and development of purulent septic complications.
Figure 1
A picture of the left lower extremity of the patient K., age of 55, on 15th day after the injury before revision of detached tissues. There are some developing regions of necrosis of covering tissues of the left hip, gray subcutaneous fat of the wound, of the knee and of the foot, with bleedings into covering tissues proximal of the wound
Figure 2
A picture of the left foot of the patient K., age of 55, on 15th day after the injury. There are some injured covering tissues. It is difficult to estimate characteristics and severity of the injury due to a common surgical error. The covering tissues around the wound are widely and densely colored with the brilliant green, and it is difficult to estimate the features of skin surface (cyanosis, necrosis, hyperemia)
Figure 3
A picture of the patient K., age of 55. Hip wound revision showed a detachment of covering tissues between superficial femoral fascia and subcutaneous fat, reaching the pubic symphysis and omphalus line
During surgery, the wide opening of “the pockets” was done, and necrotic and ischemic tissues were incised. The total square of incised covering tissues was 15 % of body surface. However, a half of removed skin was prepared with Krasovitov’s technique and was arranged for subsequent replantation (Fig. 4). The active drains were installed, and the apposition sutures for fixation of flaps were applied. In the end of surgery, the wounds were partially closed with layer-by-layer skin autografts. The vacuum dressing VivanoMed with variable uncharging (Paul Hartmann AG; Paul-Hartmann-Str.12, 89522, Heidenheim, Germany; FSZ 2012/12770; the date of state registration of medical item: 20.08.2012; validity of marketing authorization: permanently) was applied to the deep wound of anterior surface of the right hip.
Figure 4
A picture of the left lower extremity of the patient K., age of 55, during surgery on 55th day after trauma
|
Figure 4-1
A picture of the left lower extremity of the patient K., age of 55, during surgery on 55th day after trauma |
Figure 4-2
A picture of the left lower extremity of the patient K., age of 55, during surgery on 55th day after trauma |
|
|
After surgery, the patient was treated in ICU. The patient’s condition stabilized within three days. Dressings and surgical preparation with general anesthesia, and general infusion and antibacterial therapy were regular in the postsurgical period. The time course of procalcitonin test shows the correction of systemic inflammatory response of the body (the table).
On May, 11, 21, 25, the staged necrectomy and plasty for wounds of the left lower extremity with use of split skin grafts (Fig. 5) were conducted. On May, 22, 2015, the patient was extubated. On May, 25, 2012, she was transferred to the general room to continue drug therapy and dressings. Beginning from May, 28, 2012, the patient could stand up, with gradual increase in physical load. On May, 30, 2012, the patient was transferred from the surgical center to the rehabilitation unit. The period of treatment of acute trauma was 33 days.
Figure 5
The stage of reconstructive treatment of the patient K., age of 55, 1 month after trauma.
|
Figure 5-2 The stage of reconstructive treatment of the patient K., age of 55, 1 month after trauma. |
Figure 5-2 The stage of reconstructive treatment of the patient K., age of 55, 1 month after trauma. |
 |
 |
At the moment of discharge, the favorable healing of all wounds was noted. Mosaic hypesthesia of the skin was in regions of detachment. During rehabilitation period, the patient achieved the ability of vertical position and walking.
After hospital discharge, the patient received the rehabilitation course in outpatient conditions. She could walk independently after two months from the injury. Two years later, she returned to her professional activity as lecturer at physical culture department. Six years after the injury, the control examination did not find any complains. There were not any wounds and trophic ulcers. She engaged in sports activities. The footwear was usual (Fig. 6).
Figure 6
The long term result of treatment of the patient K., age of 55, after 6 years
|
Figure 6-1
The long term result of treatment of the patient K., age of 55, after 6 years |
Figure 6-2
The long term result of treatment of the patient K., age of 55, after 6 years |
 |
 |
CONCLUSION
The reviewed clinical case showed the following moments:
1. In absence of serious injuries to internal organs, and in case of minimal skeletal injury at the background of extensive detachment of soft tissues, a life-threatening state develops, which requires for long term intensive care and urgent surgical interventions.
2. The early use of modern diagnostic techniques (ultrasonic examination, contrast CT, MRI for the left lower extremity, anterior abdominal wall and gluteal region) would allow earlier and more precise diagnosing, determining the severity of tissue injuries and selecting more correct surgical management).
3. Timely participation of the plasty surgeon is required for confirmation of diagnosis, for arrangement of specialized medical care for extensive detachment of covering tissues.
4. Preparation of skin with the brilliant green (or with other coloring antiseptics) hinders the visual estimation of covering tissues, and it should be excluded from the range of medical procedures.
5. The initial organizational and tactical errors are common for medical care for patients with such injuries. As result, it is necessary to conduct the great informational and organizational activity for development and implementation of the algorithm for management of patients with soft tissue detachment.
Information on financing and conflict of interests
The study was conducted without sponsorship. The authors declare the absence of any clear or potential conflicts of interest relating to publication of this article.