Microsurgical autotransplantation in gunshot wounds of the extremities and their sequelae]

An experience with treatment of 108 patients with extensive deep defects of extremity tissues was generalized. Such wounds made up 42.3% of the total number of patients with wounds of extremities. The introduction of microsurgical autotransplantation of tissues allowed to shorten the terms of medical and social rehabilitation, to reduce invalidism of the patients and to lower the cost of treatment.     

Treatment strategies for gunshot wounds of the extremities

The incidence of gunshot wounds is increasing also in Europe and surgeons in urban trauma centers are more frequently confronted with this type of injury. Since there is no established treatment algorithm for gunshot injuries to the extremities, the surgeon should rely on established soft tissue injury and fracture protocols. Gunshot fractures with minor soft tissue destruction should be treated as closed fractures. The treatment of choice for unstable fractures is early internal stabilization, whereas stable fractures may be treated by functional bracing. The administration of an antibiotic prophylaxis for fractures with minor soft tissue injury is controversial. Gunshot fractures with major soft tissue injury should be treated as open fractures. Debridement of nonviable tissue and external fixation are recommended. Prophylactic intravenous antibiotics are mandatory and prophylactic fasciotomy is often required. Upon definitive internal stabilization, bone grafting should be considered since gunshot fractures are usually associated with a high degree of comminution. Articular gunshot injuries are treated as open joint injuries and require irrigation, debridement, foreign body removal and antibiotic prophylaxis.     

四肢霰弹枪伤的致伤特点和外科处理

目的 探讨四肢霰弹枪伤的致伤特点及外科处理的有关问题。方法 ８２例四肢霰弹枪伤参照Ｓｈｅｒｍａｎ和Ｏｒｄｏｇ的方法,采用改良标准分型。伤道行“切开、引流”初期外科处理,创面闭合分别在初期、延期和二期三个时机。骨折处理方法包括石膏固定、骨牵引、外固定器技术、简单内固定和钢板内固定等。血管伤初期行血管吻合或移植。神经伤的处理分为初期和后期二种。结果 伤道初期闭合者感染率较高,二期闭合者创面愈合时间较长     

Treatment of suppurative-necrotic wounds of the extremities

The article discusses the authors' experience in treating pyonecrotic and poorly granulating wounds of the upper and lower extremities in 158 patients; proteolytic enzymes, application of carbohydrate sorbents, and helium-neon laser radiation were used in 66 cases. With such method of treatment, the wounds healed without cutaneoplasty in 75% of cases. In 25% of cases free cutaneoplasty was performed after preparation of the wound surface. The terms of wound healing reduced 1.5-2 times as compared to that in the traditional methods of treatment.     

Pathomorphological and quantitative bacteriological findings in various forms of primary surgery on gunshot wounds of extremities

It is well-known that ‘wound excision’ is essential in the primary treatment of wounds in war, particularly thorough debridement of the devitalized tissues around the path of a penetrating projectile. Nowadays, the gunshot wounds in peacetime have become prevalent. Instead of the traditional method of ‘wound excision’ (excision), we used the method of ‘incision and drainage’ (incision) in the primary surgery of these gunshot wounds of extremities. To determine the treatment effectiveness of these different surgical methods (incision and excision), two groups of dogs were shot in the proximal part of one hind leg with an American M-16 rifle. One group was treated by the method of ‘excision’; in the other group ‘incision’ were performed. No difference in infection rate was noted between the two groups. Similarly, no difference in bacterial count was found between the two groups during the observation period. Also, there was no difference in healing time; the wounds in both groups had healed by 19.2–21.4 days. Microscopic examination revealed a little normal muscle tissue in the necrotic zone of the incision group which might augment the repair process. These results suggest that there are no differences in the effectiveness in preventing infection between the two methods. ‘Incision’ might be superior to ‘excision’ for the management of the gunshot wounds of extremities in peacetime, as it involves a simple operation and there are advantages for tissue healing. Received: 5 October 2000     

吻合血管的小腿穿支皮瓣修复四肢创面

目的 观察便携式超声仪定位小腿穿支皮瓣血管的效果,以及小腿穿支皮瓣修复四肢创面的效果.方法 自2009年12月至2011年3月,应用便携式超声仪检测定位穿支皮瓣血管,应用吻合血管的小腿穿支皮瓣修复四肢创面31例,其中吻合血管的腓动脉穿支皮瓣24例(其中4例含腓动脉穿支骨瓣),胫后动脉穿支皮瓣3例,腓肠内侧动脉穿支皮瓣2例,腓肠外侧穿支皮瓣2例;切取皮瓣面积最大15.0 cm×8.0 cm,最小1.0 cm×1.5 cm,穿支皮瓣的口径最小0.2 mm,最大1.8 mm;修复部位:手指及虎口创面21例,前臂创面5例,小腿创面5例.结果 超声定位术中符合率为96.8％.31例皮瓣全部成活,创面修复,供区创面小的直接缝合愈合,供区创面较大的植皮修复愈合.结论 便携式超声仪定位小腿穿支皮瓣血管准确、可靠,小腿穿支皮瓣切取方便,厚度满意,供区创伤小,成活率高.     

大鱼际肌爆炸伤的分型及治疗

目的评估大鱼际肌爆炸伤的分型及疗效。方法１９８０年以来，共收治１６２例大鱼际肌爆炸伤，按其损伤程度分为三型，Ⅰ型：损伤限于肌肉表面，仅作清创缝合即可。Ⅱ型：损伤深达肌肉内，软组织缺损较大时，用皮瓣或游离皮片植皮并修复虎口。Ⅲ型：损伤累及深层的掌骨与关节，常伴有拇指血供丧失和肌肉坏死，以往拇指均作截指术。１９８９年起采用掌浅、深弓转移重建拇指血供。掌长肌腱移位重建拇外展功能，创面用皮瓣覆盖。结果Ⅰ型９７例手功能恢复基本正常。Ⅱ型３９例大鱼际肌肌力４级，拇指对掌功能尚满意。Ⅲ型２６例中，２１例行拇指截指术，重建血供的５例随访２～８年，拇指指腹两点辨别觉为６～１０ｍｍ，拇对掌功能恢复较为满意。结论大鱼际肌爆炸伤根据其分型采取合理的治疗措施，是可以取得手功能恢复较好的疗效的     

The importance of inflammation control for the treatment of chronic diabetic wounds

Diabetic chronic wounds cause massive levels of patient suffering and economic problems worldwide. The state of chronic inflammation arises in response to a complex combination of diabetes mellitus-related pathophysiologies. Advanced treatment options are available; however, many wounds still fail to heal, exacerbating morbidity and mortality. This review describes the chronic inflammation pathophysiologies in diabetic ulcers and treatment options that may help address this dysfunction either directly or indirectly. We suggest that treatments to reduce inflammation within these complex wounds may help trigger healing.     

Experience with 112 shotgun wounds of the extremities

Although shotgun and gunshot injuries are frequently grouped together, shotgun injuries are ballistically and clinically very different from gunshot wounds. Because of the differences between gunshot and shotgun injuries, the clinical records of 85 patients with 112 extremity shotgun wounds treated over a 6-year period were reviewed: 11% had Type I injuries; 30% and 59%, respectively, had Type II and Type III injuries. Overall, 59% had major soft-tissue injuries and 44% had bone or joint injuries, and nerve and vascular injuries were documented in 21% and 26%. The major cause of a prolonged hospital stay was the presence of a major soft-tissue injury, while the presence or absence of a neural injury was the most important determinate of whether the extremity would be functional. In contrast, neither skeletal nor vascular injuries resulted in long-term extremity disability. Thus, we recommend an aggressive operative approach towards early wound closure in these patients to decrease hospitalization time. Further, we believe that the operative determination of the presence or absence of anatomic damage of the nerves in patients with neural deficits is an important component in the long-term management of these patients.     

封闭式负压吸引在四肢创伤中的应用

目的探讨封闭式负压吸引在皮肤或软组织缺损的四肢创伤中的治疗作用。方法对48例有皮肤或软组织缺损的四肢创伤的患者采用封闭式持续负压吸引治疗。7～14d后,在创面上行二期游离植皮或直接缝合伤口。结果45例患者创面肉芽生长新鲜,游离植皮或直接缝合后创面修复。3例发生创面感染,多次引流后行皮瓣转移成功。结论封闭式负压吸引能够促进创面的愈合,减少创面污染,患者痛苦少,且减轻医务人员工作量。     

Choice of anesthesia in gunshot wounds of extremities

The analysis of treatment of 452 victims with wounds of extremities for the period from 1984 to 1994 years was carried out. 171 patients had fire-arm wounds in local conflicts. Surgical wound management in 43% of victims was carried out under local infiltration anesthesia, in 28.3%--under conduction and prolonged conduction anesthesia, 27.8%--under general anesthesia and in 0.9%--under intraosseal anesthesia. The author suggests that as the gravity of firearm wound increases and wound infection progresses, the indications for infiltration and intraosseal anesthesia should be limited. In multiple and combined wounds, damages and tearing off the extremities, followed by shock, blood loss, general anesthesia would be indispensable. Conduction, prolonged anesthesia is quite reliable in mechanical cleansing of wound in process of surgical treatment, in early postoperative period, promotes improvement of regional hemodynamics and favours uneventful wound healing.     

Neutrophil delivery to wounds of the upper and lower extremities

Clinical observations and experimental evidence indicate that wounds of the lower extremity are more susceptible to infection than are wounds located elsewhere on the body. The details of this regional relative immunoincompetence are not described. In this initial study of regional inflammatory response, neutrophil delivery to standard wounds of the upper and lower extremities was measured in 15 human volunteer subjects using a quantitative skin-window technique. Neutrophil delivery proved to be relatively deficient in the lower extremity. Neutrophil delivery (mean +/- SEM) was significantly lower to the lower-extremity wounds (5,890 +/- 590 cells per cubic millimeter) than to the upper-extremity wounds (16,600 +/- 1,680 cells per cubic millimeter). This lower neutrophil response may be a part of the lower extremity's increased susceptibility to infection. Further functional study of regionally collected neutrophils may provide more details of differences in regional inflammatory response. The mechanisms underlying these differences remain undescribed.