SLR - August 2019 - Christopher Van Damme
Reference: Qiu D, Wang X, Jiao Y, Li Y, Jiang D. Risk Factors for Necrosis of Skin Flap-Like Wounds after Ed Debridement and Suture. American Journal of Emergency Medicine. 2019. 37; 828-831Scientific Literature Review
Reviewed By: Christopher Van Damme, DPM
Residency Program: Maricopa Medical Center/Creighton University – Phoenix, AZ
Podiatric Relevance: Management of emergency room skin flap-like wounds is a common problem amongst all many of the surgical specialty services. Skin flap wounds are characterized by discontinuity and damage to the structures of soft tissue caused by external forces. Due to the commonly irregular shape, these wound flaps are prone to vascular necrosis thus impacting physiological function in many patients. The aim of this study was to identify characteristics of common-flap like wounds and analyze the causes of flap necrosis.
Methods: This is a retrospective review of skin flap-like wounds that came to the emergency department between Jan 1, 2013 – Dec 31, 2016, from a single hospital. 600 hundred patients in total were evaluated and characterized by sex, age, injury reason, size of flap, operation time, and injury site. Intraoperative characteristics included the length-width ration of the wound, thickness of the pedicle, direction of blood perfusion in the flap, and operating methods. External fixation with plaster splint was suggested after limb trauma to reduce secondary injury; if unused patients were instructed to immobilize limbs verbally. Some cases required plastic surgical techniques including 3:1 elliptical repair, excision of beveled flaps with deep and superficial closure, A-T repair, and V-Y repair.
Results: A total of 600 patients were treated. The post-operative necrosis rate was 7.5 percent (45/600). Statistically significant pre-operative factors for flap necrosis included: 1) Operation time earlier or greater than 12 hours from the time of injury 4.8 percent vs 25.6 percent and 2) usage of an external fixator (plaster splint) vs verbal instructions to immobilize [non-lower extremity values excluded] 6.8 percent vs 14.5 percent. Statistically intraoperative influencing factors included: 1) Flaps with vs without adequate subcutaneous adipose tissue 5.7 percent vs 13.2 percent; 2) Length-width ratio of the wound less or greater than 2:1 5.4 percent vs 10.6 percent; 3) repair with plastic surgery techniques vs repair with simple suture in situ without special management 4.8 percent vs 16 percent.
Conclusions: The authors concluded there was a high rate of flap necrosis in patients who were injured greater than 12 hours prior to repair, those who did not agree to plaster splint immobilization, wounds without adequate subcutaneous coverage, skin flap-like wounds with a wound ratio greater than 2:1, and when plastic surgical techniques were not employed to facilitate closure.