Indian Journal of Plastic Surgery Medknow Publications on behalf of Indian Journal of Plastic Surgery ISSN: 0970-0358 EISSN: 1998-376x Vol. 40, Num. 2, 2007, pp. 218-222

Indian Journal of Plastic Surgery, Vol. 40, No. 2, July-December, 2007, pp. 218-222

40 Years Ago

Problems of skin cover in injuries of lower limb with tissue loss

A Ganguli

Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkatta
Correspondence Address: Department of Plastic Surgery, Institute of Post Graduate Medical Education and Research, Kolkatta

Code Number: pl07061

The principles of wound treatment have always evovled out of the material provided by the mass of war casual-ties. In civilian life, however, the number of casualties are much less but the methods of treatment are based on the experience gained in war. This is true for injuries of lower extremity as well.

The object of this paper is to discuss the problems of injuries of the lower limb with tissue-loss and to evaluate the methods adopted in providing skin cover.

This report reviews 27 cases admitted to the Plastic Surgery Unit of this Institute.

Aetiology

Nature of Injury

All the injuries being street accidents were contaminated by dirt and grease.

Types:- The following types of injuries were noted.

1. Loss of skin and subcutaneous tissue Ten cues had such injury with vari-able area of loss,
2. Avulsion of skin and subcutaneous tissue- Five patients had different degrees of avulsions.
3. Avulsion with loss of skin.-Four pat-ients had avulsion with loss of variable area of skin.
4. Major lacerations.--Skin was lacerated into multiple flaps with ragged mar-gins over wide area.

Area Involved

Foot alone was involved in 15 cases, This included the planter surface. Foot and adjoining areas of leg were involved in 10 cases. The leg and the thigh were injured in 2 cases.

Associated Injuries:- The following additonal injuries were present

: I. Injury to the upper limb-1 case.

II. Amputation of toes-2 cases.

III. III. Fracture of (a) one or both malleous- 2 cases, (b) Calcaneum-l case,

IV. TV. Injury to the extensor tendons of foot-3 cases.

Treatment

All the cases reported to the. hospital within a few hours and treatment was instituted within 6-8 hours of injury. Resus citative, anti-infective and anti-tetanic measures were taken in each patient before subjecting them to surgery. Under general anaesthesia the wound and the surrounding areas were cleaned with Cetavlon solution. The wound was then irrigated with normal saline solution. The oppo-site thigh was always kept prepared as a donor site for skin graft. Ade-quate debridement was done and the wound was cleared of foreign materials as far as practicable.

Primary repair of deeper tissue was not done except for setting frac-tures. No internal fixation of frac tured ends of bones was attempted.

Wound cover was provided by the different methods [Table - 1] mentioned below -

1. Primary definitive skin cover: Defi-nitive skin cover was attempted as an immediate procedure. The following methods were adopted:
   a) -Free skin graft- This was done when bones; joints; blood vessels, nerves and tendons were not diret-tly exposed and when pressure bearing area of foot was not involved. When only a small area of bone or tendon was exposed, they were covered by surrounding soft tissue and free skin graft was applied over them. Medium thick-ness skin graft was used.
   b) Cross-leg flap- This form of skin cover was given when bone area of skin loss over heel and adjoining parts. The donor site is covered, with free skin graft joint or tendon was exposed over wider area and when pressure bearing area of foot was involved.
   c) Cross-thigh flap- This type of skin cover was chosen for the same nature of wounds as in cross-leg flap but the area was bigger for cross--leg flap. Conventional method was adopted for having cross-leg or thigh flaps. Flaps were detached at the end of 3 weeks.


2. Temporary free skin graf with secondary definitive cover- This was done when full thickness of skin with subcuta-neous tissue cover was indicated. The wound after debridement was covered with thin free skin graft taken usually from the opposite thigh irrespective of whether bone, joint or tendon was exposed. This was removed after 10-12 days at a second operation and definitive skin cover was given by the following means:
   a) Cross-leg flap [Figure - 1].
   b) Cross-thigh flap.
   c) Thigh tube [Figure - 2],[Figure - 3]- This was used when the area involved was big enough for cross-leg and cross= thigh flap and in cases of thin and very young subject. The skin tube was prepared usually in the opposite thigh by conven-tional method. If the tube was long enough, it was staged by a bridge which was later tubed, After 3 weeks, the lower end of the tube was detached and was reattached directly to one end of the injured area. After further 3 weeks, the tube was completely detached from the thigh, spread out and the area was convened up. Opposite ankle was used in cases where the tube was prepared in the same thigh as that of the injured side.


3. Avulsed flap was stitched back after debridement with or without free skin graft depending upon whether associated skin loss was present or not.


4. Avulsed flap was excised and was replaced by medium thickness free skin graft as a permanent skin cover. Additional local rotation flap was taken to cover joint, bone, tendon, blood vessel and nerve when necessary,


5. Local repair- Direct apposition of lacerated flaps. after debridement was done.


6. The lacerated flaps were excised and was replaced by medium thickness free skin graft.

Discussion

Twenty seven cases with various types of injuries of the lower limb treated by different methods have been ana1ysed.

It was observed that street injuries were always contaminated and cleansing the wounds to one's satifaction is extremely difficult if not impossible. Furthermore, dub ions nature of the vascularity of the tissues made debridement a problem. It became difficult at times to differentiate dead from living muscles. Skin flaps apparently vas-cular (noted by colour and bleeding) later became devascularised. Similar observations have also been made by Brown ^[1] and Chahal. ^[2]

These are further substantiated when the mechanism of injury is analysed. Such injuries are usually caused by different grades of violence over an wide area. The injured area may be divided into two zones -(a) An area subjected to an impact of great violence causing the wound; (b) Sur-rounding area affected by a blunt impact of lesser violence causing certain amount of crushing of the superficial tissues.

The combined effect of both the factors lead to an altered local haemodynamics. This is frequently evidenced as a local haema toma or vascular thrombosis in the surround-ing tissue at operation. So it A not quite justified in accepting the surrounding tissues, as normal even if they look so.

These problems frequently make pri-mary 6efinitive cover by skin flap a fafiure. The flap usually gets detatched due to the following reasons: (1) Inevitable infection with dead tissue at the depth of the wound, (2) Necrosis of big flap lifted without a delay procedure. (3) Due to necrosis of the skin margin of the wound to which the flap is attached. Pre-existing poor health of the patient further complicates the above factors.

These observations were borne out by the results of 8 cams where primary defini-tive skin cover were given as shown in [Table - 1]. Only one case with free skin graft had good result, whereas result of the rest of the cases were unsatisfactory [Figure - 4].

In view of the problems mentioned, it was decided to provide definitive skin cover after a delay of 10-12 days. The object of this was to allow the infection to settle down and to let that tissues with doubtful vascu-larity to be obvious. The wound was prima-rily covered with thin skin graft pending secondary definitive cover to avoid the hazards of an open wound. Ganguli ^[3] suggested the use of preliminary skin graft only when primary definitive cover could not be given due to some cause but he did not mention the results of immediate definim five cover In cams when large area had to be covered with full thickness skin with subcutaneous tissue, a skin tube in the thigh was preferred to abdominal tube so that one end of the tube could be attached directly to the injured area. This reduced a stage of operation.

Ten cases with different types of injuries were treated on this principle [Table - 1]. One case of cross-thigh flap had partial separation of flap xith moderate infection, whereas the rest of'the cases had good result.

All the replaced avulsed flaps necrosed [Figure - 5]. Such skin. flaps are not only avulsed, they are subjected to some degree of shea ring as well, which further interfere with their vascularity.

Local rotation flaps in injured lower limbs do not stand well. This is abvious from [Table - 1] and are better avoided.

Local repair of major lacerations ulti-mately dough out. Tissues which show evidence of vascularity (bleeding from the margin) at operation later become dead. This is due to delayed vascular thrombosis perhaps brought about by the effect of'concomittant blunt injury to the tissues surrounding the wound. Better results were obtained when they were excised. Analysis of the results of different methods of treatment indicate that lower limb injuries with tissue loss are better covered with temporary thin free skin graft to be replaced by definitive cover with full thickness skin and subcutaneous tissue, where necessary after 10-12 days. This forms a better bed and surrounding for any form of flap. Apparently this process is time consuming. But the initial time loss is compensated in the end by way of early healing and early mobilization with gratifying results.

Summary

Twenty seven cases of different types of injuries of the lower limb with skin loss trea-ted by various means have been reviewed. The various methods of treatment have been evaluated and the rnethods giving the best result have been stressed^[4].

Acknowledgment

References

Copyright 2007 - Indian Journal of Plastic Surgery

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