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Functional Splinting of Upper Limb Injuries With Gauze-Based Topical Negative Pressure Wound Therapy
SURGICAL TECHNIQUE
Functional Splinting of Upper Limb Injuries With Gauze-Based Topical Negative Pressure Wound Therapy Christopher J. Taylor, Darren L. Chester, Steven L. Jeffery
Surgical Technique
Complex hand injuries can be difficult to dress effectively and achieve adequate splintage of the hand in a functional position. During the past 7 years, we have had a great deal of success with topical negative-pressure dressings in the management of complex blast-related extremity war injuries. We have more recently changed to using a gauze-based system and have found this particularly useful in dressing complex hand injuries. We have been able to use this vacuum dressing system to splint the hand in a position of function. This provides an easily applied dressing that, through topical negative pressure, promotes wound healing and ensures a resting functional position, thus minimizing postoperative stiffness. We have not been able to achieve this as efficiently with standard dressings and plaster-of-Paris casts. This article details the technique of functional splinting of complex hand injuries using a gauze-based, topical negativepressure dressing system. (J Hand Surg 2011;36A:1848–1851. © 2011 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Functional splinting, hand injury, topical negative pressure, war-related injury.
7 years, a great many military patients have been managed for war-related injuries at the Royal Centre for Defence Medicine, Selly Oak Hospital, and the Queen Elizabeth Hospital, Birmingham. The majority of wounds are extremity injuries, with many involving the upper limb. They are most commonly sustained through blast injury secondary to improvised explosive devices, rocket-propelled grenades, and land mines. They are, therefore, high-energy wounds, complex in nature, heavily contaminated, and involving composite tissue loss. As a result, these wounds require multiple staged, serial debridements before soft tissue and bony reconstruction.
D
URING THE LAST
From the Queen Elizabeth Hospital, Birmingham, United Kingdom. Received for publication June 13, 2010; accepted in revised form August 23, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Major Christopher J. Taylor, Department of Reconstructive Plastic Surgery, New Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom; e-mail: [email protected]. 0363-5023/11/36A11-0023$36.00/0 doi:10.1016/j.jhsa.2011.08.023
1848 䉬 © Published by Elsevier, Inc. on behalf of the ASSH.
Injury severity scores greater than 50 are not uncommon in our cohort of patients, with injury patterns and severity not previously witnessed in previous conflicts or in the civilian setting. This is due in part to improved medical care that is provided to current front-line troops from the point of wounding. Furthermore, levels of contamination are unprecedented due to the terrain and environment in which these high-energy blast injuries are sustained. Consequently, in our experience, softtissue reconstruction must not be rushed; it is our opinion that strict adherence to achieving closure within the first week after injury is not advisable unless a clean, non-contaminated wound is easily achieved. This is in line with recent reports of U.S. experience in dealing with military injuries.1 These difficult wounds, therefore, often require dressings for protracted periods. Wounds are commonly multiple and can be difficult to dress and manage. We have had excellent results from topical negative-pressure wound therapy (NPWT), initially using open reticulated-cell foam dressings (KCI, San Antonio, TX). The NPWT promotes wound healing by reducing excessive exudate and bacterial load while producing a moist environment and promoting formation of granulation tissue.2
1849
Surgical Technique
SPLINTING OF UPPER LIMB INJURIES WITH PRESSURE WOUND THERAPY
FIGURE 1: Typical upper limb injury seen in military casualties.
However, cutting standard foam dressings to a shape that is conformable with the multiple wounds encountered, in our experience, is time consuming. More recently we have switched to using gauze-based NPWT dressings, which we have found to be more easily applied and manageable.3 When there is a requirement to hold the hand in an immobilized position for any length of time following bony injury or tendon repair, for example, the hand should be splinted in a position of function, or “intrinsic plus.” This ensures that the collateral ligaments of the metacarpophalangeal (MCP) and interphalangeal joints are held in a stretched position, so that on commencing range of motion exercises, movement at these joints is not restricted by shortened collateral ligaments.4 In a hand with multiple composite soft tissue and bony injuries, when functional splinting is required, gauzebased NPWT allows for simple, easily applied dressings that provide optimum conditions for wound healing and functional splinting. This negates the need to dress the wounds and apply a plaster-of-Paris splint, both of which can be individually time consuming and are not always easily and effectively done together (Figs. 1, 2). Others have attempted similar combinations of vacuum-assisted closure and splinting methods,5 but gauze-based systems, in our opinion, are far simpler and more time efficient.
FIGURE 2: Functional splinting and topical NPWT with gauze-based, vacuum-assisted closure.
No liner is usually required.6 The gauze can be applied directly to intact skin without fear of maceration, because the hydrophilic cotton fibers wick moisture away from the skin (unlike the hydrophobic sponge). Kerlix (Kerlix AMD, Tyco Healthcare, Gosport, UK), a gauze-like dressing, is applied to the wound from a roll. This is easily conformable and adaptive to the contours of the body part dressed. A suction drain is then placed over the Kerlix dressing, and an adhesive film dressing is applied to ensure an airtight seal. When fingers are dressed using this technique, the Kerlix gauze is easy to conform around the fingers and Ioban drapes (3M Healthcare, Bracknell, UK) can be used to sandwich the dressed digits effectively without the need for achieving individual seals between digits. The hand is then placed in the position deemed most appropriate for the particular injury pattern, and the drain is connected to the suction canister and typically set to ⫺80 mmHg intermittently. Although ⫺125 mmHg has been deemed standard pressure for NPWT, there is evidence that similar effects with regard to increased blood flow, wound contraction (if desirable), and
JHS 䉬 Vol A, November
1850
SPLINTING OF UPPER LIMB INJURIES WITH PRESSURE WOUND THERAPY
Surgical Technique
FIGURE 3: A Satisfactory joint positioning following splinting of the hand in a functional position using gauze-based topical NPWT. B Unsatisfactory joint positioning following conventional plaster-of-Paris splinting.
removal of exudate can be achieved with lower pressures.7–9 Higher pressures can be associated with skin edge ischemia and increased patient discomfort; for these reasons, we choose a pressure of ⫺80 mmHg. This maintains the hand in the splinted position. Our experience with conventional plaster-of-Paris splinting is that joint positioning is often not as satisfactory as one would assume (Figs. 3A, 3B). Gill et al evaluated effectiveness of plaster-of-Paris splints in maintaining a position of function. In a controlled setting in which volar and dorsal plaster-of-Paris splints were applied to uninjured hands using a standardized technique, the incidence of inadequate splints was 8% and 39% with volar and dorsal splints, respectively, for PIP joints and 19% and 3% with volar and dorsal splints, respectively, for MCP joints.10 Neither, therefore, was especially effective at maintaining adequate position of both PIP joint and MCP joint universally. With gauze-based NPWT splinting, we are able to mold the hand into the desired position before applying suction, and we are more readily able to visually assess accurate position. If it is not satisfactory, suction can be turned off, the hand re-set in a better position, and suction re-applied. In our cohort of patients, taking radiographs after dressing to check the position of the hand have not been deemed in the patient’s best interest. Furthermore, we have found that we cannot control excessive exudate levels with conventional dressings, and standard plaster-of-Paris splints have a tendency to soften and lose their shape. For this reason, we have not felt it appropriate to pro-
spectively randomize patients to receive gauze-based splints or standard dressings and plaster-of-Paris splints. A recent report detailing the paradoxical increase in pressure in inanimate objects to which circumferential NPWT is applied has indicated a 5 to 15 mmHg increase in local substance pressure when a suction pressure of 80 –100 mm Hg is applied through NPWT.11,12 This, the authors argue, can stimulate angiogenesis in the local tissues by reducing local microcirculatory flow, thus serving to increase wound bed vascularity. The authors in a related article went on to report that this increased pressure resulted in decreased perfusion of 17% beyond the area to which circumferential topical NPWT is applied with suction pressures of 125 mm Hg.13 We cannot corroborate whether local tissue pressure is, in fact, hypobaric or hyperbaric in areas adjacent to NPWT; however, we have not noticed any evidence of distal circulatory compromise or compromised tissue perfusion as a result of using circumferential gauze-based NPWT in limb injuries. In fact we have, when possible, monitored distal tissue oxygenation with a digital saturation probe and have not witnessed any case of decreased perfusion (Fig. 4). On the contrary, we have noticed a reduction in the edema present in the limb, which might improve tissue oxygenation. We have noticed that sponge shrinks when suction is applied, whereas gauze does not. Sponge essentially consists of many air bubbles surrounded by plastic strands. When suction is applied, all the air bubbles get smaller and the dressing shrinks. This would cause circulatory compromise if placed circum-
JHS 䉬 Vol A, November
2.
3. 4.
5. 6.
FIGURE 4: Measuring distal tissue oxygenation with a saturation probe.
ferentially around a limb. Gauze, on the other hand, is composed of many fibers of cotton, which simply become firm when the air is evacuated. In our experience of treating multiply injured military patients, for whom surgical debridements and dressing changes can be lengthy procedures, this type of dressing is quick, easily applied, and conducive to effective wound healing, and it provides immobilization in a position of safety. We would, therefore, recommend this dressing for complex upper limb injuries involving the hand when NPWT and immobilization are desirable.
7.
8.
9.
10. 11.
12.
13.
REFERENCES 1. Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from Operation Iraqi Freedom: successful subacute reconstruction of com-
1851
plex lower extremity battle injuries. Plast Reconstr Surg 2009; 123:218 –229. Webb LX, Pape HC. Current thought regarding the mechanism of action of negative pressure wound therapy with reticulated open cell foam. J Orthop Trauma 2008;22(Suppl):S135–S137. Hankin E, Jeffery S. Challenges of modern military trauma. Wounds UK 2010;6:47–54. Brody GS. Management of stiff metacarpophalangeal and interphalangeal joints. In: McCarthy JG, May JW & Littler JW, eds. Plastic Surgery. 1st ed. Vol. 7 (Part I). Philadelphia, PA: WB Saunders, 1990:4655– 4670. Kairinos N, Hudson DA. The ‘vacsplint’ for hands. J Plast Reconstr Aesthet Surg 2010;63:e425. Epub 2009 Dec 16. Evriviades D, Jeffery S, Cubison T, Lawton G, Gill M, Mortiboy D. Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine. Philos Trans R Soc Lond B Biol Sci 2011;366:219 –230. Ahearn C. Intermittent NPWT and lower negative pressures— exploring the disparity between science and current practice: a review. Ostomy Wound Manage 2009;55:22–28. Borgquist O, Ingemansson R, Malmsjö M. Wound edge microvascular blood flow during negative-pressure wound therapy: examining the effects of pressures from ⫺10 to ⫺175 mmHg. Plast Recontr Surg 2010;125:502–509. Borgquist O, Ingemansson R, Malmsjö M. The influence of low and high pressure levels during negative-pressure wound therapy on wound contraction and fluid evacuation. Plast Reconstr Surg 2011; 127:551–559. Gill DRJ, Smith KL, Harvey FJ. Plaster of Paris splintage for the hand: volar or dorsal? Aust N J Surg 1994;64:547–50. Kairinos N, Solomons M, Hudson D. Negative pressure wound therapy I: The paradox of negative pressure wound therapy. Plast Reconstr Surg 2009;123:589 – 600. Kairinos N, Solomons N, Hudson DA. The paradox of negative pressure wound therapy—in vitro studies. J Plast Reconstr Aesthet Surg 2010;63:174 –179. Kairinos N, Voogd AM, Botha PH, Kotze T, Khan D, Hudson D, et al. Negative pressure wound therapy II: Negative pressure wound therapy and increased perfusion. Just an illusion? Plast Reconstr Surg 2009;123:601.
JHS 䉬 Vol A, November
Surgical Technique
SPLINTING OF UPPER LIMB INJURIES WITH PRESSURE WOUND THERAPY
Functional Splinting of Upper Limb Injuries With Gauze-Based Topical Negative Pressure Wound Therapy Christopher J. Taylor, Darren L. Chester, Steven L. Jeffery
Surgical Technique
Complex hand injuries can be difficult to dress effectively and achieve adequate splintage of the hand in a functional position. During the past 7 years, we have had a great deal of success with topical negative-pressure dressings in the management of complex blast-related extremity war injuries. We have more recently changed to using a gauze-based system and have found this particularly useful in dressing complex hand injuries. We have been able to use this vacuum dressing system to splint the hand in a position of function. This provides an easily applied dressing that, through topical negative pressure, promotes wound healing and ensures a resting functional position, thus minimizing postoperative stiffness. We have not been able to achieve this as efficiently with standard dressings and plaster-of-Paris casts. This article details the technique of functional splinting of complex hand injuries using a gauze-based, topical negativepressure dressing system. (J Hand Surg 2011;36A:1848–1851. © 2011 Published by Elsevier Inc. on behalf of the American Society for Surgery of the Hand.) Key words Functional splinting, hand injury, topical negative pressure, war-related injury.
7 years, a great many military patients have been managed for war-related injuries at the Royal Centre for Defence Medicine, Selly Oak Hospital, and the Queen Elizabeth Hospital, Birmingham. The majority of wounds are extremity injuries, with many involving the upper limb. They are most commonly sustained through blast injury secondary to improvised explosive devices, rocket-propelled grenades, and land mines. They are, therefore, high-energy wounds, complex in nature, heavily contaminated, and involving composite tissue loss. As a result, these wounds require multiple staged, serial debridements before soft tissue and bony reconstruction.
D
URING THE LAST
From the Queen Elizabeth Hospital, Birmingham, United Kingdom. Received for publication June 13, 2010; accepted in revised form August 23, 2011. No benefits in any form have been received or will be received related directly or indirectly to the subject of this article. Corresponding author: Major Christopher J. Taylor, Department of Reconstructive Plastic Surgery, New Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom; e-mail: [email protected]. 0363-5023/11/36A11-0023$36.00/0 doi:10.1016/j.jhsa.2011.08.023
1848 䉬 © Published by Elsevier, Inc. on behalf of the ASSH.
Injury severity scores greater than 50 are not uncommon in our cohort of patients, with injury patterns and severity not previously witnessed in previous conflicts or in the civilian setting. This is due in part to improved medical care that is provided to current front-line troops from the point of wounding. Furthermore, levels of contamination are unprecedented due to the terrain and environment in which these high-energy blast injuries are sustained. Consequently, in our experience, softtissue reconstruction must not be rushed; it is our opinion that strict adherence to achieving closure within the first week after injury is not advisable unless a clean, non-contaminated wound is easily achieved. This is in line with recent reports of U.S. experience in dealing with military injuries.1 These difficult wounds, therefore, often require dressings for protracted periods. Wounds are commonly multiple and can be difficult to dress and manage. We have had excellent results from topical negative-pressure wound therapy (NPWT), initially using open reticulated-cell foam dressings (KCI, San Antonio, TX). The NPWT promotes wound healing by reducing excessive exudate and bacterial load while producing a moist environment and promoting formation of granulation tissue.2
1849
Surgical Technique
SPLINTING OF UPPER LIMB INJURIES WITH PRESSURE WOUND THERAPY
FIGURE 1: Typical upper limb injury seen in military casualties.
However, cutting standard foam dressings to a shape that is conformable with the multiple wounds encountered, in our experience, is time consuming. More recently we have switched to using gauze-based NPWT dressings, which we have found to be more easily applied and manageable.3 When there is a requirement to hold the hand in an immobilized position for any length of time following bony injury or tendon repair, for example, the hand should be splinted in a position of function, or “intrinsic plus.” This ensures that the collateral ligaments of the metacarpophalangeal (MCP) and interphalangeal joints are held in a stretched position, so that on commencing range of motion exercises, movement at these joints is not restricted by shortened collateral ligaments.4 In a hand with multiple composite soft tissue and bony injuries, when functional splinting is required, gauzebased NPWT allows for simple, easily applied dressings that provide optimum conditions for wound healing and functional splinting. This negates the need to dress the wounds and apply a plaster-of-Paris splint, both of which can be individually time consuming and are not always easily and effectively done together (Figs. 1, 2). Others have attempted similar combinations of vacuum-assisted closure and splinting methods,5 but gauze-based systems, in our opinion, are far simpler and more time efficient.
FIGURE 2: Functional splinting and topical NPWT with gauze-based, vacuum-assisted closure.
No liner is usually required.6 The gauze can be applied directly to intact skin without fear of maceration, because the hydrophilic cotton fibers wick moisture away from the skin (unlike the hydrophobic sponge). Kerlix (Kerlix AMD, Tyco Healthcare, Gosport, UK), a gauze-like dressing, is applied to the wound from a roll. This is easily conformable and adaptive to the contours of the body part dressed. A suction drain is then placed over the Kerlix dressing, and an adhesive film dressing is applied to ensure an airtight seal. When fingers are dressed using this technique, the Kerlix gauze is easy to conform around the fingers and Ioban drapes (3M Healthcare, Bracknell, UK) can be used to sandwich the dressed digits effectively without the need for achieving individual seals between digits. The hand is then placed in the position deemed most appropriate for the particular injury pattern, and the drain is connected to the suction canister and typically set to ⫺80 mmHg intermittently. Although ⫺125 mmHg has been deemed standard pressure for NPWT, there is evidence that similar effects with regard to increased blood flow, wound contraction (if desirable), and
JHS 䉬 Vol A, November
1850
SPLINTING OF UPPER LIMB INJURIES WITH PRESSURE WOUND THERAPY
Surgical Technique
FIGURE 3: A Satisfactory joint positioning following splinting of the hand in a functional position using gauze-based topical NPWT. B Unsatisfactory joint positioning following conventional plaster-of-Paris splinting.
removal of exudate can be achieved with lower pressures.7–9 Higher pressures can be associated with skin edge ischemia and increased patient discomfort; for these reasons, we choose a pressure of ⫺80 mmHg. This maintains the hand in the splinted position. Our experience with conventional plaster-of-Paris splinting is that joint positioning is often not as satisfactory as one would assume (Figs. 3A, 3B). Gill et al evaluated effectiveness of plaster-of-Paris splints in maintaining a position of function. In a controlled setting in which volar and dorsal plaster-of-Paris splints were applied to uninjured hands using a standardized technique, the incidence of inadequate splints was 8% and 39% with volar and dorsal splints, respectively, for PIP joints and 19% and 3% with volar and dorsal splints, respectively, for MCP joints.10 Neither, therefore, was especially effective at maintaining adequate position of both PIP joint and MCP joint universally. With gauze-based NPWT splinting, we are able to mold the hand into the desired position before applying suction, and we are more readily able to visually assess accurate position. If it is not satisfactory, suction can be turned off, the hand re-set in a better position, and suction re-applied. In our cohort of patients, taking radiographs after dressing to check the position of the hand have not been deemed in the patient’s best interest. Furthermore, we have found that we cannot control excessive exudate levels with conventional dressings, and standard plaster-of-Paris splints have a tendency to soften and lose their shape. For this reason, we have not felt it appropriate to pro-
spectively randomize patients to receive gauze-based splints or standard dressings and plaster-of-Paris splints. A recent report detailing the paradoxical increase in pressure in inanimate objects to which circumferential NPWT is applied has indicated a 5 to 15 mmHg increase in local substance pressure when a suction pressure of 80 –100 mm Hg is applied through NPWT.11,12 This, the authors argue, can stimulate angiogenesis in the local tissues by reducing local microcirculatory flow, thus serving to increase wound bed vascularity. The authors in a related article went on to report that this increased pressure resulted in decreased perfusion of 17% beyond the area to which circumferential topical NPWT is applied with suction pressures of 125 mm Hg.13 We cannot corroborate whether local tissue pressure is, in fact, hypobaric or hyperbaric in areas adjacent to NPWT; however, we have not noticed any evidence of distal circulatory compromise or compromised tissue perfusion as a result of using circumferential gauze-based NPWT in limb injuries. In fact we have, when possible, monitored distal tissue oxygenation with a digital saturation probe and have not witnessed any case of decreased perfusion (Fig. 4). On the contrary, we have noticed a reduction in the edema present in the limb, which might improve tissue oxygenation. We have noticed that sponge shrinks when suction is applied, whereas gauze does not. Sponge essentially consists of many air bubbles surrounded by plastic strands. When suction is applied, all the air bubbles get smaller and the dressing shrinks. This would cause circulatory compromise if placed circum-
JHS 䉬 Vol A, November
2.
3. 4.
5. 6.
FIGURE 4: Measuring distal tissue oxygenation with a saturation probe.
ferentially around a limb. Gauze, on the other hand, is composed of many fibers of cotton, which simply become firm when the air is evacuated. In our experience of treating multiply injured military patients, for whom surgical debridements and dressing changes can be lengthy procedures, this type of dressing is quick, easily applied, and conducive to effective wound healing, and it provides immobilization in a position of safety. We would, therefore, recommend this dressing for complex upper limb injuries involving the hand when NPWT and immobilization are desirable.
7.
8.
9.
10. 11.
12.
13.
REFERENCES 1. Kumar AR, Grewal NS, Chung TL, Bradley JP. Lessons from Operation Iraqi Freedom: successful subacute reconstruction of com-
1851
plex lower extremity battle injuries. Plast Reconstr Surg 2009; 123:218 –229. Webb LX, Pape HC. Current thought regarding the mechanism of action of negative pressure wound therapy with reticulated open cell foam. J Orthop Trauma 2008;22(Suppl):S135–S137. Hankin E, Jeffery S. Challenges of modern military trauma. Wounds UK 2010;6:47–54. Brody GS. Management of stiff metacarpophalangeal and interphalangeal joints. In: McCarthy JG, May JW & Littler JW, eds. Plastic Surgery. 1st ed. Vol. 7 (Part I). Philadelphia, PA: WB Saunders, 1990:4655– 4670. Kairinos N, Hudson DA. The ‘vacsplint’ for hands. J Plast Reconstr Aesthet Surg 2010;63:e425. Epub 2009 Dec 16. Evriviades D, Jeffery S, Cubison T, Lawton G, Gill M, Mortiboy D. Shaping the military wound: issues surrounding the reconstruction of injured servicemen at the Royal Centre for Defence Medicine. Philos Trans R Soc Lond B Biol Sci 2011;366:219 –230. Ahearn C. Intermittent NPWT and lower negative pressures— exploring the disparity between science and current practice: a review. Ostomy Wound Manage 2009;55:22–28. Borgquist O, Ingemansson R, Malmsjö M. Wound edge microvascular blood flow during negative-pressure wound therapy: examining the effects of pressures from ⫺10 to ⫺175 mmHg. Plast Recontr Surg 2010;125:502–509. Borgquist O, Ingemansson R, Malmsjö M. The influence of low and high pressure levels during negative-pressure wound therapy on wound contraction and fluid evacuation. Plast Reconstr Surg 2011; 127:551–559. Gill DRJ, Smith KL, Harvey FJ. Plaster of Paris splintage for the hand: volar or dorsal? Aust N J Surg 1994;64:547–50. Kairinos N, Solomons M, Hudson D. Negative pressure wound therapy I: The paradox of negative pressure wound therapy. Plast Reconstr Surg 2009;123:589 – 600. Kairinos N, Solomons N, Hudson DA. The paradox of negative pressure wound therapy—in vitro studies. J Plast Reconstr Aesthet Surg 2010;63:174 –179. Kairinos N, Voogd AM, Botha PH, Kotze T, Khan D, Hudson D, et al. Negative pressure wound therapy II: Negative pressure wound therapy and increased perfusion. Just an illusion? Plast Reconstr Surg 2009;123:601.
JHS 䉬 Vol A, November
Surgical Technique
SPLINTING OF UPPER LIMB INJURIES WITH PRESSURE WOUND THERAPY