Informe de caso: Resultado clínico de TOE conservado después de un evento traumático de pie / Case report: Clinical outcome of TOE preserved after Traumatic event of foot

Introduction: Decision making in determining management of post-trauma patient is very important, especially for traumatic in the small bones, fingers and toes. The global predictor to determine the management of retaining or amputating the limb is using the Mangled Extrimity Severity Score (MESS) scoring system, values above 7 are the indication for amputation. The decision maker have to pay attention for the end result of the actions which were performed in the initial management. Material and Methods: One case is reported from Orthopaedic emergency department Hospital in Makassar, South Sulawesi, Indonesia. A 39-year old male with motor vehicle accident trauma at left foot region since 6 hours before admitted to hospital, later was diagnosed with open comminutive fracture shaft proximal phalang of left 5th toe, the Mangled Extrimity Severity Score (MESS) was 8. Patient underwent emergency debridement and retained the toe by performed Open Reduction Internal Fixation (ORIF) K-Wire. Results: This patient has a good clinical outcome by following up 2 weeks and 8 months after surgery by retain the affected side with debridement and Open Reduction Internal Fixation (ORIF) K-Wire. Patient can ambulate normally with full weight bearing, and there is no difficulty to wearing shoe or sandal. Conclusions: Determination of action by retaining the traumatized limb needs to be considered for the good of the patient, but it is necessary to provide informed consent to the patient and family that there will be a possibility of tissue death with the worst possibility of limb amputation

Caso Clínico: Fractura expuesta grave del dedo índice. Cirugía de rescate con colgajo adipofascial vascularizado homodigital reverso / Case report: Severe index finger open fracture. Surgical rescue with homodigital vascularized adipofascial reverse flap.

INTRODUCCIÓN: Los traumas de mano tienen una alta incidencia alrededor del mundo y representan alrededor del 30% de todos los accidentes y visitas a servicios de urgencias, siendo las lesiones de la punta del dedo un subtipo común de trauma de mano. El manejo inicial y la elección del tratamiento adecuado son importantes, el principal objetivo es la cobertura de tejidos para así evitar amputaciones innecesarias, prevenir complicaciones y pérdida de funcionalidad. CASO CLÍNICO: Paciente masculino de 32 años que sufrió trauma por aplastamiento en mano derecha que produce herida con pérdida de tejido en falanges distales de segundo y tercer dedo y amputación traumática parcial de falange distal del segundo dedo. EVOLUCIÓN: Se realizó técnica quirúrgica de colgajo adipofascial vascularizado homodigital reverso en segundo dedo y manejo conservador de fractura, sin complicaciones. Se llevó un control semanal por 2 meses con resultados funcionales, biológicos y estéticos favorables. El tercer dedo se trató con limpieza quirúrgica y colocación de vendaje suboclusivo con evolución favorable. CONCLUSIÓN: El colgajo adipofascial dorsal homodigital reverso tiene varias ventajas sobre otros tipos de colgajos más convencionales; es una técnica simple, segura y confiable, con buenos resultados postquirúrgicos en cuando a funcionalidad, estética y recuperación, requiere de un solo tiempo quirúrgico y brinda la cobertura necesaria de los tejidos expuestos tanto óseos como blandos, con mínima morbilidad del sitio donante.(au)

BACKGROUND: Hand trauma has a high incidence worldwide, it accounts nearly 30% of all trauma and medical visits to emergency rooms, fingertip injuries are the most common among hand trauma. The initial management and the proper choice of treatment are important, the main objective is to achieve adequate tissue coverage, in order to avoid unnecessary amputation, prevent complications and functionality loss. CASE REPORT: A 32-year-old male patient presented with crush trauma on right hand resulting in injuries with tissue loss on the fingertips of the second and third finger and traumatic partial amputation of the distal phalanx of the second finger. EVOLUTION: Surgical technique of homodigital vascularized adipofascial reverse flap was performed in second finger and the fracture was managed conservatively, without complications. A weekly follow up was carried out for 2 months with favorable functional, biological and aesthetic results. The third finger was treated with surgical irrigation and debridement and placement of a sub-occlusive bandage, with favorable outcome. CONCLUSION: Homodigital adipofascial reverse dorsal flap has advantages over other types of conventional flaps; it is a simpler, safe and reliable technique, with good postsurgical outcomes in terms of functionality, aesthetics and recovery, needing only one intervention and offering the appropriate coverage to exposed bone and soft tissue, with minimal repercussions on the donor site.(au)

Risk Factors of Amputation in Lower Extremity Trauma with Combined Femoropopliteal Arterial Injury

PURPOSE: The clinical characteristics and results of femoropopliteal artery injury (FPAI) remain unclear. In this study, we evaluated the outcomes and risk factors of limb loss in patients treated for FPAI. MATERIALS AND METHODS: We retrospectively reviewed data from a database of patients who underwent revascularization for an FPAI at a single institution between January 2013 and December 2017. We reviewed and analyzed the characteristics, postoperative results, and factors that influence amputation rates. RESULTS: Twenty-four femoropopliteal arterial reconstructions in 24 patients were included in this study. Among the patients were 20 (83.3%) male with a first-quartile age of 28 years and a third-quartile age of 45 years (range, 15–68 years). The mean injury severity score (ISS) was 16 (range, 4–55), and 5 patients (20.8%) had ISSs of >20 points. The mean mangled extremity severity score (MESS) was 3.8 (range, 1–11), and 8 patients (33.3%) had MESSs of >5 points. In terms of arterial reconstruction methods, autogenous saphenous vein grafting, vein patching, and primary closure were performed in 9 patients (37.5%), 4 patients (16.7%), and 11 patients (45.8%), respectively. Despite arterial reconstruction, 5 patients (20.8%) underwent above-knee amputation. ISSs of >20, MESSs of >7, and orthopedic fixation were statistically significant factors associated with amputation. CONCLUSION: In cases of FPAI with ISSs of >20, MESSs of >7, and orthopedic fixation, amputations should be considered. We were also careful to attempt limb salvage in such cases.

Colgajo fasciocutáneo por pérdida del pulpejo. Presentación de un caso / Fasciocutaneous flap by soft flesh losses. Case Presentation

Introducción: Las pérdidas de sustancia de los pulpejos constituyen uno de los motivos de consulta más frecuentes en las salas de urgencias de traumatología. El pulpejo es el área del dedo con mayor densidad de terminaciones sensoriales, que constituyen el primer eslabón de conexión entre nuestro sistema nervioso central y el medio externo en cuanto a la sensación táctil se refiere. Objetivo: Evidenciar las ventajas del uso del colgajo fasciocutáneo pectoral presentando un caso con lesión del pulpejo del pulgar. Presentación del caso: Un paciente con pérdida traumática del pulpejo del pulgar, a quien se le realiza un colgajo fasciocutáneo pectoral, revisando las particularidades morfofisiológicas del sitio operatorio y el proceder. Conclusiones: Los conocimientos de Morfofisiología Humana tienen importancia y aplicación en diferentes procederes médico-quirúrgicos(AU)

Introduction: Soft flesh losses is one of the most frequent consult's reasons in traumatology's emergency wards. Soft flesh is the at;the finger with higher density of sensorial endings, which constitute the first link between our central nervous system and the external environment in terms of tactile sensation. Objective: to remark the advantage of the use of Pectoral fasciocutaneous flap through a Case Presentation. Case presentation: patient suffering a soft flesh traumatic loss of the tactile pad of the thumb, reviewing the morphophysiological specificities of surgery area and procedure. Conclusions: it is concluded that Human Morphophysiological knowledge are important in several medical-surgical procedures(AU)

Caso Clínico: Amputación Traumática, Manejo Conservador con Vendaje Suboclusivo. / Case Report: Traumatic Amputation, Conservative Treatment with Occlusive Bandage

INTRODUCCIÓN: Las lesiones de punta de dedo figuran entre las lesiones caseras y laborales más habituales de la extremidad superior y constituyen una causa frecuente de visita al servicio de urgencias. Por lo tanto es crucial implementar pautas de tratamiento factibles y oportunas que permitan definir un manejo inicial de la patología con buenos resultados a largo plazo. CASO CLÍNICO: Paciente de sexo masculino de 26 años de edad sin antecedentes patológicos de importancia, que acudió al Servicio de Emergencias por sufrir un trauma por aplastamiento en la falange distal del tercer dedo de la mano derecha. Al examen físico: se evidenció lesión en pulpejo de tercer dedo de mano derecha con exposición ósea, pérdida de piel y tejido celular subcutáneo y compromiso del lecho ungueal menor al 50%, que correspondió a la zona II de Allen. Se realizó manejo conservador con vendaje suboclusivo. EVOLUCIÓN: El paciente permaneció con vendaje suboclusivo durante 6 semanas, evidenciándose posteriormente cicatrización adecuada con recuperación de piel y uña; recuperó los arcos de movilidad interfalángicos proximales y distales, no presentó alteración sensorial como intolerancia al frio ni neuralgia posterior; el resultado estético fue satisfactorio. CONCLUSIÓN: El tratamiento conservador de las amputaciones de punta de dedo con exposición ósea es una opción válida de tratamiento. Los resultados indicaron que el enfoque conservador conduce a una excelente cobertura, sensibilidad normal, ausencia de dolor, piel estable, adecuado rango funcional de movimiento y un resultado estético aceptable. (au)

BACKGROUND: Fingertip injuries are very common among upper limb wounds; they are usually derived from domestic and labor activities which are a frequent reason to attend emergency departments. It is crucial to enforce feasible and timely treatment regimens which allow define an appropriate intervention with good long-term results. CASE REPORT: A 26-years old male patient with no pathological precedentes attended to emergency department because of a crushing trauma at distal phalanx of the right hand's third finger. Physical examination evidenced bone exposition at finger pad, skin and cellular tissues loss; 50% of nail bed compromised which was considered as Allen's II zone affectation. Conservative treatment with occlusive bandage was performed. EVOLUTION: The occlusive bandage was kept for 6 weeks. Appropriate wound healing with skin and nail recovery was evidenced; distal and proximal interphalangeal mobility arches were recovered. There was not a sensory disorder as intolerance to cold not even neuralgia; aesthetic results was satisfying. CONCLUSION: Conservative treatment of fingertip amputations with bone exposure is a valid choice as definitive treatment. Results showed that conservative treatment aid to an excellent coverage, normal sensitivity, absence of pain, stable skin growth, an adequate functional mobility range and acceptable aesthetic results. (au)

Versatility of the medial gastrocnemius muscle flap in reconstructing lower limb soft tissue lesions / Versatilidade do uso do retalho do músculo gastrocnêmio medial na reconstrução de lesões de partes moles de membros inferiores

Introduction: Covering complex lower limb wounds is a major challenge. The medial gastrocnemius muscle flap is usually indicated for reconstruction of loss of substance of the knee and proximal third of the leg. The objective of this study was to evaluate the results using gastrocnemius muscle flaps in lower limb wounds. Methods: A total of 28 patients with loss of substance in the lower limbs were treated with medial gastrocnemius muscle flaps. Data were obtained from clinical records of patients who underwent surgery from 2003 to 2012. Results: In 28 patients who underwent surgery, the age range was 4 to 57 years, with a mean of 30.6 years. The etiology of the lesions was a motorcycle accident in 16 cases (57.1%), being run over in 8 cases (28.6%), car crash in 2 cases (7.2%), meningococcemia in 1 case (3.6%), and snake bite in 1 case (3.6%). After an average follow-up of 15 months (range: 6 to 26 months), all patients had stable coverage. The mean number of preoperative debridements was 2.4 (range: 1 to 8). In 22 patients, the flaps were made without the release of the muscle origin and in 6 patients the muscle flaps were separated from their origin in the femur. Conclusions: Transfer of a gastrocnemius muscle flap is a simple and safe procedure in the treatment of lower limb injuries. The application of the medial gastrocnemius muscle flap was demonstrated in different situations, with satisfactory results and easy reproducibility.

Introdução: A cobertura de feridas complexas de membros inferiores é um grande desafio. O retalho muscular do gastrocnêmio medial é comumente indicado para reconstrução de perdas de substância do joelho e terço proximal da perna. O objetivo desse trabalho é avaliar os resultados da utilização do retalho muscular do gastrocnêmio nos casos de ferida em membros inferiores. Métodos: Um total de 28 pacientes com perda de substância de membros inferiores foi tratado com retalho muscular do gastrocnêmio medial. Os dados foram obtidos em registros clínicos dos pacientes operados no período de 2003 a 2012. Resultados: Vinte e oito pacientes foram operados, com idades variando de 4 a 57 anos, e média de 30,6 anos. A etiologia das lesões foi acidente por motocicleta em 16 casos (57,1%), atropelamentos em oito casos (28,6%), acidente automobilístico em dois casos (7,2%), meningococcemia em um caso (3,6%) e acidente ofídico em um caso (3,6%). Depois de um seguimento médio de 15 meses (variação de 6 a 26 meses), todos pacientes mostraram cobertura estável. O número médio de desbridamentos pré-operatórios foi 2,4 (variação de 1 a 8). Em 22 pacientes, os retalhos foram confeccionados sem a liberação da origem muscular e em seis pacientes os retalhos musculares foram separados de sua origem no fêmur. Conclusões: A transferência do retalho muscular do gastrocnêmio é um procedimento simples e seguro no tratamento de lesões de membros inferiores. Foi demonstrada a aplicação do retalho muscular do gastrocnêmio medial em diferentes situações, com resultados satisfatórios e fácil reprodução.

Reimplantes nas amputações por mecanismo de avulsão: táticas e técnicas para o sucesso / Limb replantation after avulsion injuries: techniques and tactics for success

OBJETIVOS: Avaliação retrospectiva criteriosa de casos de reimplantes após amputação por avulsão. Avaliação de técnicas e táticas utilizadas que determinaram evolução satisfatória e bom resultado funcional. METÓDOS: Foram avaliados, retrospectivamente, prontuários de 43 pacientes que tiveram membros amputados por mecanismo de avulsão e reimplantados nos últimos 21 anos. RESULTADOS: A maior parte dos casos envolvia homens adultos jovens. A localização de amputação mais frequente foi do polegar. As técnicas e táticas cirúrgicas utilizadas isoladas ou conjuntamente incluem: enxertos de nervo, enxertos vasculares (veia ou artéria), transposição de feixe vascular digital, encurtamento do membro e reimplante heterotópico. A técnica mais frequentemente utilizada foi o emprego de enxertos venosos. A taxa de sobrevida dos reimplantes foi alta (93%), assim como a satisfação dos pacientes. CONCLUSÃO: Os reimplantes por mecanismo de avulsão dependem do correto diagnóstico de viabilidade anatômica e utilização de técnicas e táticas cirúrgicas apropriadas para cada caso. A experiência da equipe cirúrgica e estrutura hospitalar adequada são fundamentais para obtenção de bons resultados. Existem poucos relatos na literatura sobre indicação, tática, técnicas e resultados de procedimentos de reimplantes em amputações por avulsão. Acreditamos que a avaliação retrospectiva desta série de casos possa trazer novas informações e contribuições no atendimento desta situação de alta complexidade. Nível de evidência IV, Série de casos.

OBJECTIVES: Retrospective evaluation of cases of limb replantation after avulsion injuries. Evaluation of the techniques and tactics used, that contributed to success and good functional results. METHODS: Forty-three patients' records were assessed. All the cases had been submitted to limb replantation after avulsion injuries. RESULTS: The majority of the cases were young men. The most common injury was to the thumbs. The surgical techniques and tactics used were: nerve grafting, vein grafting, transposition of the digital vessels, limb shortening, and heterotopic replantation. The most commonly used technique was vein graft. The limb survival rate was high (93%), as was patient satisfaction. CONCLUSION: Replantation after avulsion injury depends on the correct diagnosis of the limb viability and the use of appropriate surgical techniques and tactics for each case. The experience of the team of surgeons and a good hospital structure are essential for good results. There are few articles in medical literature about the indications, techniques and results of limb replantation after avulsion injuries. We believe that this retrospective evaluation can bring new information and contributions to the correct management of this highly complex situation. Level of evidence IV, Case Series.

Reconstrução parcial de orelha pós-trauma: técnicas simples e eficazes / Partial reconstruction of the external ear after a trauma: simple and efficient techniques

O crescente número de traumas de orelha impõe soluções simples e eficazes. Objetivo: Ser capaz de reconstruir uma orelha parcialmente lesada por trauma, mesmo num pequeno hospital. Muitas técnicas podem ser usadas, porém a solução pode ser a utilização de um retalho cutâneo ou condrocutâneo. Métodos: Para reconstruir o 1/3 superior e/ou médio da orelha, um retalho cutâneo de mastoide associado ou não ao enxerto de cartilagem, ou um retalho condrocutâneo foi utilizado. Estes foram escolhidos levando-se em consideração o tamanho do defeito e a necessidade ou não do enxerto cartilaginoso. Resultados: Os pacientes puderam usar óculos e ficaram felizes com seus resultados. A maioria apresentou bom contorno de hélice e do arcabouço cartilaginoso. Alguns apresentaram cicatrizes hipertróficas das áreas enxertadas e dois solicitaram retoques tardios. Conclusão: O uso do retalho cutâneo de mastoide ou condrocutâneo local pode ser uma boa solução para as perdas parciais de orelha pós-trauma. A maioria dos pacientes apresentava expectativa muito alta sobre o que esperar da reconstrução da orelha. Isto determina um grande desafio técnico para o cirurgião e requer informações prévias sobre as reais possibilidades de resultados.

The growing number of ear trauma cases has brought about the need for simple and efficient solutions. AIM: To be able to rebuild an ear partially injured by trauma, even in a small hospital setting. Many techniques can be used; however, the solution can be the use of cutaneous or chondrocutaneous flaps. Methods: To reconstruct the ear upper or middle thirds we used a mastoid cutaneous flap with or without a cartilage graft or a chondrocutaneous flap - chosen considering the size of the defect and the need for a cartilage graft. Results: The patients were able to wear glasses and were pleased with the results. Most of the patients ended up having a good helix and cartilaginous contour. Some had hypertrophic scars on the grafted areas and two required a second procedure. Conclusion: Mastoid cutaneous flaps or local chondrocutaneous flaps can represent a good solution for partial ear loss after trauma. Most of the patients had very high expectations concerning the procedure. This poses a major technical challenge for the surgeon and requires prior discussion with the patients regarding the true possibilities of outcome.

Replantation of Amputated Digits in Elderly Patients

PURPOSE: As the mean life expectancy of people has been prolonged, and the elderly people who participate in the production activities has been increasing, it is expected that the demand on the replantation of amputated digits in elderly patients would increase. But, there are few studies about the replantation of amputated digits in elderly patients. Therefore, we report treatment outcomes of replantation of amputated digits in elderly patients. METHODS: From 1998 to 2008, the replantation was performed in 51 completely amputated digits of 33 patients aged 60 years or older. We performed the replantation in the usual manner. Under the brachial plexus block, the surgical procedures carried out in the following sequence: internal fixation using Kirschner wire, tenorrhaphy, arteriorrhaphy, neurorrhaphy and venorrhaphy. If the arterial ends could not be approximated without tension, a vein graft was performed. RESULTS: Of a total of 51 digits, 46 digits (90%) survived. 13 patients (40%) had underlying medical problem preoperatively. But, in all the patients, there were no postoperative medical complications. As the postoperative surgical complications, excluding five cases of the total necrosis of digit, there were three cases of venous congestion, two cases of arterial insufficiency, seven cases of infection and 16 cases of partial necrosis. CONCLUSION: Age alone does not affect the survival of replanted digits. Type of injury is the most important factor that affects the survival of replanted digits.

Reattachment of Amputated Auricle using Postauricular Subcutaneous Pocket

PURPOSE: There are several modalities to reattach the amputated auricle. Although microvascular replantation can achieve the best outcome, it is technically difficult. Conventional composite graft is technically easy, but uniformly unsuccessful. Our successful experience of reattachment using postauricular subcutaneous pocket is presented. METHODS: The amputated tissue was placed in its anatomical position with buried sutures. The amputated part is dermabraded to remove the epidermis and outer layer of dermis(Fig. 1, Center, left). Postauricular skin flap was then raised and the reattached dermabraded ear was buried beneath the flap(Fig. 1, Center, right). Two weeks after the original surgery, the buried ear was removed from its pocket(Fig. 1, Below, left). RESULTS: The ear was reepithelialized spontaneously in 7 days. In 3 months, the reattached ear shows satisfactory appearance without contour deformity(Fig. 1, Below, right). CONCLUSION: This technique provides increase in contact surface between the amputated segment and the surrounding tissues which supply blood, serum, oxygen and nutrients, maximizing the probability of "take". Minimally injured dermis can be healed from spontaneous reepithelialization and provides minimal contour deformity. We have used this non-microsurgical technique with very satisfying outcome.