Abstract and Introduction
Introduction: Vehicular run-over accidents cause crushing and sheering forces that can result in fractures and cause extensive damage to the cutaneous layer of the skin and underlying soft tissues. These types of injuries present immense challenges that often require numerous treatment modalities for wound management. A complex case in which 2 distinct negative pressure wound therapy (NPWT) modalities were instrumental in helping manage extensive wounds resulting from extreme crushing/sheering forces is presented.
Case Report: A 22-year-old male without prior medical history presented to the treating facility after falling and being crushed by a parade float. The patient had multiple fractures to the facial area and pelvic region, including the left side of the sacrum. The injuries encompassed the entire perineum, rectal area, scrotum, and both upper legs. After stabilizing the patient, attention was directed to the extensive wound and eventual closure. Following muscle flap reconstructions to help protect the left and right femoral arteries, an acellular artificial skin was placed to cover the perineum, bilateral medial thighs, and left groin region. Upon developing wound complications, NPWT with instillation and dwell time (NPWTi-d) was applied by intermittently instilling 60 mL of normal saline solution with a 10-minute dwell time, followed by negative pressure at -125 mm Hg for 3.5 hours. The therapy was applied for 11 days with dressing changes every 2 to 3 days. The patient then underwent split-thickness skin grafting to the left thigh, perineum, and right thigh. Due to the extensive nature of the wounds and the multiple anatomical locations, a novel 4-channel NPWT system was used as a bolster over the skin grafts. Continuous NPWT was applied at -125 mm Hg for 2 weeks with dressing changes occurring every 2 to 3 days. There was complete take of all skin grafts 17 days post-grafting, and the patient has since healed. The patient is now walking and has resumed normal daily activities.
Conclusions: For this case, combining treatment modalities was beneficial in healing a patient's complex trauma wounds and shows a potential treatment strategy in this population of wounds.
In 2014, the World Health Organization estimated that 5.8 million people die of injuries worldwide, which is a small proportion of the number of people injured.[1,2] Traumatic injuries can be classified as being caused by blunt trauma, penetrating trauma, crush injury, blast injury, burns, degloving injury, and animal bites. These wounds vary greatly in their severity—from soft tissue injuries to extending to the bone and internal organs.
Managing extensive wounds caused by crush/sheer injury can require several treatment modalities to effectively treat and ultimately heal the wounds. Negative pressure wound therapy (NPWT) has been utilized for many years to achieve wound healing at a quicker rate. With the addition of instillation wound therapy, wounds can be treated and closed even sooner, resulting in greater patient satisfaction as well as decreased cost.
By using NPWT as an intervention in wound care, clinicians have the opportunity to facilitate wound healing. The device applies negative pressure to the wound bed, which increases tension to the tissue and capillary blood flow. Granulation tissue and the growth of new blood vessels are the result of this application. This therapy also is thought to reduce the bacterial burden in the wound by removing wound exudate that contains enzymes that are involved in inflammation and decreasing edema.
While standard NPWT has been used for many years and found to be very effective in healing wounds, the addition of the instillation of fluids and allowing them to dwell for a specific time in the wound bed is increasingly being used with much success. Negative pressure wound therapy with instillation and dwell time (NPWTi-d) may help manage bacterial bioburden by removing exudate and cleansing the wound bed.
In this report, the author presents a complex case in which 2 distinct NPWT modalities were instrumental in helping manage extensive wounds resulting from extreme crushing/sheering forces.
Wounds. 2020;32(12):369-371. © 2020 HMP Communications, LLC