MANAGEMENT OF COMPLEX TREATMENT OF CHILDREN WITH EXTENSIVE WOUND DEFECTS OF

SOFT TISSUES OF VARIOUS AETIOLOGY Budkevich L.I., Shurova L.V., Starostin O. I.,

Rybchyonok V. V., Burkin I.A.

Pirogov Russian National Research Medical University

(RNRMU)Ostrovityanov st.,1, Moscow, 117997

phone/fax: (495) 434-0329, 434-6129; e-mail: rsmu@rsmu.ru

Relevance

Growth of number of children with heavy

mechanical (fig.1) and thermal injuries (fig.2),

accompanied with extensive wound defects and

increase of number of survived children with

heavy craniocereberal and spinal trauma with

development of generalized neurotrophic damages

(fig.3) , determines increase in patients with

extensive wound defects of soft tissues. It

demands revision of principles of traditional

treatment of this group of patients which will

allow to reduce duration of recovery and exclude

disability of the patients.

fig.1

fig.2

Fig.4

Purpose: Development of management of treatment of patients with extensive wounds of various etiology at stages of conservative and surgical treatment by using modern wound

coverings and early reconstructive plastic surgery.

Materials and methods:According to this technique 17 patients aged 4 to 17 y.o. were treated. Among them: deep electric trauma of joints (3 children), degloving wounds of lower extremities resulting from car accidents (8 children), bed sores (6 children after brain and spinal injuries).

The first stage of treatment was early removal of necrotized tissues by surgical methods (scalpel, electric knife, radiowave dissector, water jet knife “Versajet”). In the postoperative period modern wound coverings based on gels, film coverings, atraumaticgauze dressings were used until the beginning of granulation. After that, surgical treatment was carried out, characterized by closing wound defect with skin of normal texture. For this purpose full thickness autologous skin transplants were used as well as skin-and-fat grafts and muscular transplants on microvascular anastomoses. Long-term immobilization of operation area with use of devices of external fixing, systemic antibacterial therapy, infusion-transfusion therapy with rheological preparations were obligatory.

Clinical example No. 1Patient P.,7 of y.o. was traumatized 21.03.11 in T-nd as a result of car running over the left foot.

First aid was given at the spot (primary surgical wound management with following autologous split skin grafting). Due to the fracture of the bones of the left shin, the extremity was braced with external fixing apparatus. Antibacterial therapy and

bandagings with ointments was carried out. In 7 days after the surgery the necrosis of the skin graft developed. 13.04.11 (16th day after the trauma) the child was referred to the Burns Department of the Children’s Hospital No. 9, Moscow

Wound in an hour after the traumaWound after primary surgical

management, autografting and applying external fixator

Transplant necrosis 7 days after primary surgical management

and autografting

Beginning of lysis of the transplant 7 days after primary surgical management and autografting

Lysis of the transplant 16 days after primary surgical management and autografting with exposure of

the hucklebone13.04.11. (The 16th day after trauma) hospitalization in Burns Department of Speransky Children’s Hospital No. 9, Moscow with the diagnosis: "A granulating wound of the left foot, S=1% of the body surface. Undisplaced closed fracture of the lower

third of the left shin bones. Complete ruprure of extensor tendons and loss of tendons on the level of the ankle joint“. 20.04.11. Operation "Additional correction of the lower left extremity with external fixing device was executed. Full

thickness autografting .

Hucklebone

Results 2 months after the full thickness

autografting operationResults 6 months after

the full thickness autografting operation

Results of operation in 2 months – rehabilitation of function of the left knee joint

Type of a wound before operation«30.05.13: full-thickness autografting in the area of knee joint and the split transplants on the wounds in shin and hip»

Autologous skin graft (full thickness ) Donor wound after suturing

Wound after operation

Clinical example No. 2. Patient Z. 11 y.o. 8.05.13. was hit by a car.Diagnosis: severe multiple trauma, closed craniocerebral injury, brain concussion, closed injury of an abdomen, subcapsular

rupture of spleen, crush injury of lower right extremety on the level of lower hip, mechanical compression of lower leftextremity, fracture of right hand bones. First professional medical aid was given in Central Regional Hospital of town B-tsy, Moscow Region (artificial ventilation, right hip amputation, abdominal paracentesis). At admission to Speransky Children’s Hospital №9 the extensive necrosis was revealed of soft tissues of the left hip, knee joint area and shin

Necrosis of soft tissues of left hip, knee joint and shin in 5 days

Operation 15.08.13. Extensive fascial necrectomy.

Wound before operation Wound after removal of eschar

Treatment of the wound of stump of right hip with vacuum system

Clinical example No. 3. Patient T., 13 y.o. was traumatized 9.08.13. as a result of hitting his foot against a sharp edge of a metal pipe. He was admitted to Speransky Children’s Hospital #9 with extensive scalped wound of the dorsal part of the foot. Primary surgical wound management was carried out

Wound at reception

Wound after Primary surgical wound management

Wound after formation of granulation after necrosis of fat

graft

2.10.13. Plastic operation: muscle grafting on vascular anastomoses and autografting with full thickness transplant

Operation planningFull thickness

autodermotransplant Donor wound after suturing

Surgical release of rectusabdominis muscle

Diagram of position of rectus abdominis muscle

Vascular pedicle of muscular transplant

Excision of granulationand releasing vascular pedicle

Diagram of position of recipient blood vessels

Wound closing in the field of the right foot with muscular graft on vascular

anastоmosis and full thickness skin transplant

Creation of vascular anastоmosis

Restoration of blood circulation in the muscle

Closing muscle with full thickness autodermotransplant

Clinical example No. 4. 7.11.11 patient G., 16 y.o. at sport training received complex cerebro-spinal trauma (closed dislocation of C4 of vertebra with full anatomic break-up of spinal cord). At the place of residence (Nizhnekamsk Regional Hospital) surgical treatment was carried out: open reposition of dislocation of C4, metal osteosynthesis of C4-C5, autologous bone transplantation Referred to Speransky Hospital No. 9 for surgical closing of pressure ulcers. 8.11.12. Surgical operation "Excision of hypertrophic granulations, elimination of multiple pressure ulcers in lumbar, sacral and buttocks areas with plastic operations – rotating skin-fat grafting.

Wounds before operation Formation of skin-fat graft

Defect is closed by skin-fat graft

Pressure ulcerGraft

Results of operation in 15 days

Results:According to this technique 17 patients aged 4 to 17 y.o. were treated. Among them: deep electric trauma of joints (3 children), degloving wounds of lower extremities resulting from car accidents (8 children), bed sores (6 children after brain and spinal injuries).

There were no complications and there was full taking of the autologous skin transplants, skin-and-fat grafts, complete rehabilitation of function of extremities and normal skin.

Summary:Execution of early reconstructive plastic surgeries on the basis of use of full

thickness skin transplants, skin and fat grafts and muscular transplants on vascular anastomosis, is an effective way of closing extensive wound defects in active and functional zones.

Early reconstructive plastic surgeries need to be carried out within the first weeks after trauma (or diagnosis of wound defect accompanied with neurotrophiccomplications) before formation of scars or deformations.