Elevated compartmental pressures after closure of a forearm burn wound with a skin-stretching device

Copyright

0 1997 Elsevier

ELSEVIER

Burns Vol. 23, No. 2, pp. 154-156,1997 Science Ltd for ISBI. All rights reserved Printed in Great Britain 0305-4179/97 $17.00 + 0.00

ii: SO305-4179(96)00090-3

Elevated compartmental forearm burn wound evic .

Hu.ssmannl,

J.

*Institute for Plastic Illinois and “Division

pressures after closure of with a skin-stretchin

Kucanl and W. A. Zamboni” and Reconstructive Surgery, Southern IKnois University School of Medicine, Springfield, 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 device’ was used for permanent wound closure following 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. 0 2397 Elsevier Science Ltd for ISBI. All rights reserved. --

Burns, Vol. 23, No. 2, 754-156,1997

ase report 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 bum 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 cm x 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 X-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

Figure 1. Entrance wound left forearm high voltage electrical injury.

Figure 2. Forearm debridement.

wound

on postinjury

resulting

from

a

day 4 after second

Hussxnann

et al.: Skin-stretching

device

155

Figure 3. Two skin-stretching devices were used to approximate the skin edges over the central portion of the wound to cov’er the exposed radial artery

Table I. Compartment skin-stretching device Time before1 after application device Before 0 10 min 30 min 50 min 80 min 120 min 160 min 6h IOh 24 h 36 h 2 days 3 days 4 days

pressures

Intervention

after application

Pressure in flexor compartment of forearm (cmH,OI

of the

Pressure h7 extensor compartment of forearm (cm Wl

14

17

55 49 55 46 39 16 13 18 21 20 13 15 16

54 53 54 44 37 18 19 15 23 18 19 21 18

.Application

Wound closure End of operation

Figure 4. Final result 6 months following

injury.

System, Life Medical Sciences Inc., Scottsdale, AZ) were positioned to achieve delayed primary wound closure (F’igure 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 exlensor 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 cmH,O 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 cmH,O 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 subseq.uent 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).

Discussion 0ne 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 GillieP in 31920(Figure 5). This technique was not revisited until 1993 when Hishowitz et al.’ 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 a1.3used 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

156

Figure 5. 1920 illustration

Burns:

of a skin-stretching

device used to cover a war wound

of the face. (Reproduced

Vol. 23, No. 2,1997

from Gillies HD,

19iO)?

artery vs. a skin graft and for simplicity vs. flap closure. 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.

2 Gillies HD. Plastic Surgery of fhe 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.

References

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1 Hirshowitz R, Lindenbaum E, Har-Shai Y. A skin-stretching device for the harnessing of the viscoelastic properties of skin. Plasf Reconstr Surg 1993; 92: 260.

Paper accepted 18 July 1996.

Correspondence should be addressed to: William A. Zamboni, M.D., Division of Plastic Surgery, Unaversity of Nevada School of Medicine, 2040 W Charleston Blvd., Suite 601, Las Vegas, NV 89102, USA.