|
Year |
2002 |
|---|---|
|
Question Number |
199 |
|
Category |
Musculoskeletal Trauma |
Question
A young healthy patient sustains a severe crush injury resulting in comminuted midshaft tibia fracture and a 8 x 10 cm medial soft tissue defect with exposed bone. There is no associated vascular injury. Which of the following procedures will most predictable result in successful coverage?
1- Split-thickness skin graft
2- Fasciocutaneus flap
3- Soleus flap
4- Gastronemius flap
5- Free-tissue transfer
Figures
Answer (click for answer)
Preferred Answer 5.
This is an open fracture grade III B.
Gustilo Classification
- Grade I:
- wound less than 1 cm with minimal soft tissue injury;
- usually" inside – out" open fractures
- low energy
- wound bed is clean
- bone injury is simple with minimal minimal comminution;
- Grade II:
- wound is 1- 10 cm with moderate soft tissue injury;
- wound bed is moderatedly contaminated;
- moderate energy
- fracture contains moderate comminution; –
- Grade III:
- wound is more than 10cm
- high energy
- following fractures automatically results in classification as type III:
- segmental fractures
- neurovascular injury
- farmyard injuries
- open more than 8 hours
- high velocity GSW
III A:
- wound greater than 10 cm with crushed tissue and contamination;
- Adequate soft tissue coverage of bone possible;
III B:
- wound greater than 10 cm with crushed tissue and contamination;
- soft tissue is inadequate and requires regional o free flap
III C:
- open fracture in which there is a major vascular injury requiring repair for limb salvage
Soft Tissue Coverage Following Tibial Fractures:
- STSG(split-thikness skin graft):
- includes epidermis and various amounts of the dermis;
- split thickness skin grafts require a tissue bed such as periosteum that is capable of granulating;
- skin graft will not take exposed bone stripped of its periosteum;
- Local muscle flaps:
- wounds located over the proximal third of tibia can usually be covered with local muscle flaps;
- Gastroneumius Flap
- anterior and medial surfaces of tibia usually can be covered w/ medial head of the gastronemius muscle;
- lateral defects are best covered with a lateral gastrocnemius muscle.
- Soleus Flap:
- reserved for defects in the middle third of leg, but blood supply can be unreliable, especially with tibial fractures;
- Dorsalis pedis Fasciocuataneus flap:
- is used for coverage of distal tibia and ankle
- Free Tissue Transfer:
- used for massive defects that cannot be covered by local muscle in middle and proximal thirds of leg or enlarged defects in distal third of leg;
- in the report by AN. Pollak M.D et al. (JBJS 82-A: 1681-91, 2000), 190 patients (195 limbs) required flap coverage and had six months of follow-up. The authors found that use of a free flap to treat limbs with a severe underlying osseous injury was significantly less likely to lead to a wound complication requiring operative intervention than was use of a rotational flap. Quick Access Outline
Reference: Pollak AN, McCarthy ML, Burgess AR: Short term wound complications after application of flaps for coverage of traumatic soft tissue defects about the tibia: The Lower Extremity Assesment Project (LEAP) Study Group. JBJS AM 2000;82:1681-1691.
Browner BD, Jupiter JB, Levine AM, Trafton PG (eds): Soft Tissue Coverage, ed 2. Philadelphia, PA WB Saunders, 1998, pp 419-448.