Erhöhte Kompartmentdrücke bei Wundverschluß mit dem Haut-Dehnungsapparat
Elevated compartmental pressures after closure of a forearm burn wound with a skin-stretching device
J. Hussmann1, J. O. Kucan1 and W. A. Zamboni2 1Institute for Plastic and Reconstructive Surgery, Southern Illinois University School of Medicine, Springfield, Illinois and 2Division of Plastic Surgery, University of Nevada School of Medicine, Las Vegas, Nevada, USA
A case of successful delayed primary closure of an upper extremity electrical blow-out injury is described using an alternative technique. The Sure-Closure skin-stretching device1 was used for permanent wound closure fallowing serial debridement to protect the radial artery which was exposed over a distance of 21 cm. This method increases the options possible to achieve wound closure. However, the potential risks of this method include potentially high compartment pressures over a prolonged time in the postoperative period which requires close monitoring of limb perfusion. © 1997 Elsevier Science Ltd for ISBI. All rights reserved.
Burns, Vol. 23, No.2, 154-156, 1997
A 37-year-old white male was admitted to a regional burn centre following an electrical injury of 7200 V. Physical examination revealed 8 per cent total body surface area (TBSA) full-thickness burn with a blow-out injury (8 cm x 15 cm) on the radiovolar aspect of the patient’s left
forearm involving underlying muscle (Figure 1). Evaluation of distal sensory and motor function was normal except that wrist extension and supination were weak due to loss of the majority of extensor carpi radialis and brachioradialis muscles. A fourth-degree burn (10 cmx 14 cm) was present on the anterior left abdomen. The lateral aspects of the feet showed full-thickness burns of the right 4th and 5th toes and left 5th toe.
The patient was taken to the operating room on days 2 and 4 postinjury for serial debridement of devitalized tissue which extended into the distal portion of the upper arm (Figure 2). The second debridement resulted in exposure of a 21-cm segment of the radial artery in the central portion of the wound. Porcine xenograft provided temporary wound coverage following both debridements. Delayed primary closure of the wound was performed 6 days after the injury to cover the exposed radial artery. Two skin-stretching devices (Sure-Closure Skin Stretching
PD Dr. med. habil. Jürgen Hussmann
Godwin et al.: Shack fires: a consequence of urban migration
The injuries produced by shack fires and the predisposing factors are different to domestic fires reported in developed countries‘>. Factors such as senility, psychiatric disorders6 and drug abuse7 are not causal factors as in First World burns. Even alcohol was an uncommon predisposing factor and accounted for only 14 per cent of the shack fires. Sadly, arson, which is a not uncommon method of inflicting assault, accounted for more than 10 per cent of the fires. Most of the shack fires appear to arise from accidents related to the use of open fires for lighting, heating and cooking by unsophisticated, poorly educated, impoverished people. Due to the materials in the shack, fires spread quickly and the victims have little time to escape, thus sustaining major burns and associated inhalational injuries.
The type of injury sustained is quite specific: large burns occur commonly and in this study over two-thirds of patients sustained full-thickness burns as part of their injury. The victim usually attempts to douse the fire and retrieve his possessions and thus the upper limbs are the most common areas burnt. For the same reasons and due to the rapid spread of the fire, the head and neck are also commonly burnt. The confirmed space and toxic fumes released from synthetic materials within the shack led to over 60 per cent of patients sustaining inhalational injuries.
In almost a third of patients, the lower respiratory tract was involved, and in over 10 per cent (11 patients) the injuries were so severe that conservative treatment was undertaken. Twenty per cent (18 of 88 patients) of the actively treated patients required intubation and assisted ventilation. This group also had a high mortality.
The impact on the patients life is also considerable. As noted by others8, these patients carry the conspicuous marks of the ordeal for a lifetime. The upper limbs and face are commonly burnt areas, which not only leave physical scars but also have a profound psychological impact. Although the burn wounds will be healed at discharge, psychological problems will be aggravated by the gradual deformity or disfigurement
due to scars and contractures following healing of the burn“, Wallace and Lees1º reported that 30-40 per cent of burn victims were found to be
suffering from severe psychological problems up to 2 years after injury. Such injuries jeopardize the chances of returning to work, or even of finding future employment especially as most of the victims are manual workers or unskilled labourers. In addition all of the patients‘ possessions are usually destroyed in the fire.
These injuries place an enormous economic burden on an already overstretched health service.
The fact that most injuries occur in young, previously healthy males underscores this fact. Furthermore, on average each patient spends a month in hospital and more than 20 per cent require admission to an ICU.
Almost all the patients required skin grafting in theatre. Thereafter, the patients require multiple out-patient visits _to prevent contractures and treat hypertrophie scars. Out-patient attendance is often irregular owing to both financial constraints and poor patient motivation as a result of depression. While it is difficult to quantify due to the economic climate, it is our impression that few patients ever return to
work. Xiao and Cai9 noted that as the size of the burn increases so does the incidence of unemployment.
Shack burns are a national tragedy brought about by urbanization and aggravated by a buoyant economic climate. Prevention is the most effective form of treatment. The major component of this is social upliftment. Thus, improved housing with electrification must be a national priority. In addition, active educational programmes should be directed at burn prevention. Regrettably, it appears at least in the short-term that shack fires with their significant morbidity and high mortality will continue to be common cause for admission to the bums unit.
1 Haq A. Pattern of burn injuries at a Kenyan provincial hospital. Burns 1990; 16: 185-188.
2 Adamo C, Esposito G, Lissia M, Vonella M, Zagaria N, Scuderi N. Epidermiological data on burn injuries in Angola: a retrospective study of 7230 patients. Burns 1995; 21: 536-538.
3 Sowemimo GOA. Burn injuries in Lagos. Burns 1982; 9: 280-283.
4 Barillo DJ, Goode R. Fire fatality study: demographics of fire victims. Burns 1996; 22: 85-88.
5 Mierly MC, Baker SP. Fatal house fires in an urban population. JAMA 1983; 249: 1466-1468.
6 McArthur JD, Moore FD. Epidermiology of burns: the burn prone patient. JAMA 1975; 231: 259-263.
7 Haum A, Perbix W, Hack HJ, Stark GB, Spilker G, Doehn M. Alcohol and drug abuse in burn injuries. Burns 1995; 21: 194-199.
8 Partridge J, Robinson E. Psychological and social aspects of burns. Burns 1995; 21: 453-457.
9 Xiao J, Cai BR. Functional and occupational outcome in patients surviving massive burns. Burns 1995; 21: 415-421.
10 Wallace I, Lees J. A psychological follow-up study of adult patients discharged from a British Burns Unit. Burns 1988; 14: 39-45.
Paper accepted 28 August 1996.
Correspondence should be addressed to: Dr D. A. Hudson, Ward F17, Department of Plastic and Reconstructive
Surgery, New Somerset Hospital and University of Cape Town, Observatory 7925, Cape Town, Republic of South Africa.
PD Dr. med. habil. Jürgen Hussmann
System, Life Medical Sciences Inc., Scottsdale, AZ) were positioned to achieve delayed primary wound closure (Figure 3). Fifty minutes of intraoperative stretching was required to achieve approximation of the wound edges. The middle portion of the wound was closed using interrupted vertical mattress sutures. Meshed split-thickness skin grafts were used to close the small open areas proximally and distally. The flexor and extensor compartment pressures were regularly measured over a 80-min period in the operating room and during a 4-day period postoperatively (Table I) using the Stryker device. Compartment pressures in both flexor and extensor compartments were elevated between 37 and 55 cmH20 during the first 120 min following application of the skin-stretching device. The first reading within normal range was 160 min after application of the skin stretcher. Between 24 and 36 h following application of the device, pressures from 18 to 23 cmH20 were noted. Subsequent readings were also within normal range. During the entire postoperative period there were no signs of compromised circulation; radial and ulnar pulses, fingertip capillary refill, and skin temperature were monitored closely and all remained normal. The subsequent
wound healing was uneventful. Postoperative neurological examination performed at regular intervals did not reveal any sensory or motor dysfunction during the patient’s 3-week hospital course. The patient attained good function of his injured forearm and hand at 6 months
following the injury (Figure 4).
One of the earliest reports of the use of a skinstretching device for wound closure was published in a book about war injuries by Sir Harold Gillies‘:“ in 1920 (Figure 5). This technique was not revisited until 1993 when Hishowitz et al.1 reported the use of the Sure-Closure skin-stretching device to achieve primary wound closure of surprisingly large defects with good aesthetic results. More recently, Narayanan et al.“ used this device in 24 patients to accomplish closure of a variety of complicated wounds with comparison to 16 control patients with wounds closed by traditional methods. In this study, skin stretching resulted in a significant decrease in operating time and hospital costs compared to the control group of wounds closed by other methods. Our report corroborated the positive results by Hishowitz and Narayanan in that successful closure of a complex would was achieved by intraoperative skin stretching. Advantages over skin grafting include more stable coverage of vital structures, simplicity, superior aesthetic outcome, absence of donor morbidity and less change of myodesis of forearm flexor muscles.
Nevertheless, careful consideration of the benefits vs. potential risks is mandatory for. each individual application of the device, which should be critically compared to the standard armementarium of wound closure from skin grafts to local and distant flap procedures. However, although a skin graft or flap could have been used for this wound, delayed primary closure after skin stretching was chosen, to provide better long-term stable coveage of the radial
PD Dr. med. habil. Jürgen Hussmann
artery vs. a skin graft and for simplicity vs. flap clos-ure. Our case report demonstrates that this method, when applied to extremity wounds, may
result in increased compartment pressures over prolonged periods of time. Deleterious sequelae of iatrogenic compartment syndrome, including skin and muscle necrosis, could potentially occur. Therefore, close monitoring of postoperative perfusion is recommended when this device is used to close extremity wounds.
1 Hirshowitz B, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin. Plast Recensir Surg 1993; 92: 260.
2 Gillies HD. Plastic Surgery of the Face Based on Selected Cases of War Injuries of the Face Including Burns. London: Oxford University Press, 1920; p 50.
3 Narayanan K, Futnell JW, Bentz M, Herwitz D. Comparative clinical study of the Sure-Closure device with conventional wound closure techniques. Ann Plast Surg 1991; 35: 485.
Paper accepted 18 July 1996.
Correspondence should be addressed to: William A. Zamboni, M.D., Division of Plastic Surgery, University of Nevada School of Medicine, 2040 W Charleston Blvd., Suite 601, Las Vegas, NV 89102, USA.