Classification of lower limb trauma

Accurate, simple, and reproducible classification of lower limb injuries facilitates communication between healthcare professionals, allows application of a standard treatment algorithm, and provides a platform for conducting detailed audit. The Gustilo and Anderson grading is widely used and is relatively simple but has poor inter-rater reliability and is best applied after wound excision. Other more comprehensive classifications (such as the AO system) are best used for audit and in outcomes databases.

Biodegradable Temporizing Matrix reconstruction of complex perineal burn wound: A Case Report

This case report details our experience using two-stage Biodegradable Temporizing Matrix (NovoSorb® PolyNovo Ltd) and autograft for acute reconstruction of a complex perineal burn wound in an elderly co-morbid patient. A 77-year old man sustained 42% full thickness burns extending circumferentially from bilateral thighs and buttocks, across the entire perineal and genital regions up to his mid-trunk, following self-immolation using an accelerant. Early total burn wound excision was carried out with acute application of Biodegradable Temporizing Matrix to all affected sites. Excellent integration and vascularisation of Biodegradable Temporizing Matrix took place despite the challenge of intermittent faecal contamination affecting the perineal and buttock burn sites and matrix colonisation with multi-drug resistant organisms. Delamination and serial split thickness skin autografting was carried out 42 days after first matrix application with complete and robust graft take. Perineal burns present a reconstructive challenge due to the proximity of specialised structures such as the genitalia, urethral and anal orifices. Restoration of complex anatomy and function may be required after debridement with increased risks of infection, contracture formation and mortality compared with burns affecting other anatomical sites.Two-stage Biodegradable Temporizing Matrix represents a reliable reconstruction option for complex extensive perineal wounds in frail elderly patients, despite an unfavourable local microbial environment.

Burns Management In Tertiary Health Care Centre

In rural places of our country, burns have become frequent accidents due to the use of floor-based stoves & kerosene lamps. Suicides due to burns are also quite usual in our country. The objective of this study is to evaluate the necessity of early excision of the burn wound and skin grafting to decrease the morbidity, mortality, complications of burns and stay at the hospital. Calculate pressure garment efficacy in preventing burn scar and contracture formation. To lay out cost-effective management for patients at rural hospitals. 50 patients were included in this study presenting with burn injuries, admitted in the department of plastic surgery from June 2019 to December 2020. In a recent study, Females (52%) suffered more as compared to males. Scalds were the prime root cause of the burns constituting the 52% of the cases. Infections of Burn wound was seen in 20 patients (40%). Pseudomonas was prime organism isolated. Wound excision was required in 19 patients (38%). Around 6 to 12 days, elapsed between the injury to the surgical excision. 19 patients required (38%) covering of wound permanently with STSG. The mean admission period in hospital for burns of 41-60% was 62 days, 33.4 days for 21-40% burns and 19.6 days for <20%. Amongst 50 patients, 3 died accounting to 6% of overall cases. This study concluded that initiation of resuscitation with untimely wound excision and permanent coverage with grafting can bring significant fall in mortality, painful debridements, limiting complications, decreasing the duration of stay at a hospital, curtailing the cost of health care and time apart from work.

Outcome of primary tendon grafts for open Zone 3 extensor tendon injuries

Open injuries of the extensor mechanism in Zone 3 (dorsum of the proximal interphalangeal joint) have poor outcomes. We retrospectively analysed the outcomes of treating 19 Zone 3 extensor tendon injuries in 17 patients. The treatment comprised wound excision and debridement, primary tendon graft to reconstruct the damaged/missing extensor tendon, skeletal fixation when required, local flaps to vascularize the zone of injury and immediate short arc motion therapy. Using the criteria defined by Geldmacher et al., the outcome was predicted to be poor in nine, satisfactory in seven and good in three cases. In this study the outcomes were excellent in 10, good in six and satisfactory in three cases. Mean range of motion was 75° (range 25°–115°) at the proximal interphalangeal joint. We conclude that using the protocol described there should no longer be the perception of a dismal outcome for these complex Zone 3 extensor tendon injuries. Level of evidence: IV

Timing of Soft Tissue Reconstruction

Soft tissue cover of a meticulously and comprehensively excised (debrided) wound is the cornerstone of achieving infection-free fracture union. Planning of the soft tissue reconstruction should ideally occur at the time of wound excision. Definitive soft tissue reconstruction should be performed within 72 hours of the injury unless precluded by patient factors, and at the same time as internal fixation of the fracture. Free flap reconstruction is ideally performed on scheduled lists in specialist orthoplastic centres.

Temporary Wound Dressings

Temporary dressings are used to cover the wound from the time of first aid through to definitive soft tissue closure. Frequent dressing changes should be avoided to reduce contamination by nosocomial organisms. Therefore, the initial dressing should be simple to apply and maintain tissue viability by preventing desiccation, e.g. gauze soaked in normal saline and covered with an occlusive film as per the National Institute for Health and Care Excellence guidance. Following wound excision, a simple non-adherent dressing can be used. Negative pressure wound therapy should not be used to downgrade the requirement for definitive soft tissue reconstruction, which should be achieved within 72 hours of injury. Following internal fixation, definitive soft tissue reconstruction should be performed at the same time.

Timing of Wound Excision

The aim of wound excision is to remove contaminating debris and all devitalised tissue. This should reduce both the bacterial burden and available substrate for microbial colonisation, resulting in fewer deep surgical site infections. In turn, this will lead to improved patient outcomes. The timing of wound excision has been the subject of intense debate. In the past, guidelines have favoured wound excision within 6 hours based on historical animal and human studies. Current data suggest that timing of wound debridement should be determined by the degree of contamination and severity of injury.