Fasciotomies are much more easily opened than closed! Once the edematous muscle is released, it’s not easy to get the skin to close over it again. On occasion, an immediate closure can be carried out. But in most cases, the process is performed with one or more additional operations.
Continuous tension across the skin edges is important. This keeps the wound from getting wider while the edema decreases. A number of creative techniques have been employed to keep the wound from widening, including using sutures, vessel loops, and fancy (expensive) plastic fasteners. And although the KCI VAC dressing reduces edema, it does not do much to pull the wound edges together.
Surgeons in the Netherlands came up with a novel technique using a cheap device that can be found in any hardware store and gas sterilized. The Ty-Rap closure device is commonly used to secure chest tubes to their connectors. Bigger versions are used by police in lieu of handcuffs.
The tail of one Ty-Rap is cut off and the hub is placed on the tail end of another. This assembly is placed across the wound, and one staple is placed over it on each side of the wound. This process is repeated for the entire length of the wound (picture). The Ty-Raps are tightened, and then slowly retightened daily until the wound comes together. An additional week to 10 days is allowed for wound healing before removal of the Ty-Raps.
The authors used this technique on 23 extremity fasciotomy wounds. The wounds were closed after an average of 6 days, and the TyRaps were removed after 16 days. There was no skin necrosis, but there were two instances of cellulitis. The cost of the materials (TyRaps and a surgical stapler) was $23, excluding assembly and sterilization.
Bottom line: This is an interesting technique with good closure results. The surgeon does have to plan ahead and get hospital clearance to use these devices, though.
Reference: Ty-Raps in trauma: a novel closing technique of extremity fasciotomy wounds. J Trauma 69:972-975, 2010.
By now, everyone probably knows that texting while driving is bad. So legally banning texting is good, right? It seems that way, since everyone is doing it. Thirty states plus the District of Columbia currently ban texting while driving, and a third of those laws were passed just this year.
Talk about the law of unintended consequences. The Highway Loss Data Institute compared collision insurance claims before and after bans were put into effect in four states (CA, LA, MN, WA). Crash rates actually rose in three of the four states after the bans were passed.
How can this be? Unfortunately, the claim data can’t tell us what the increase is due to. They speculate that texting drivers are trying harder to conceal their habit, keeping their phones out of sight and taking their eyes off the road even more. Or, it could just be a statistical fluke.
The federal Transportation Secretary disagrees. He stated that distracted driving fatalities increased from 2005 to 2008, but stopped rising in 2009. I’m not clear on where this data comes from.
In either case, texting remains a bad thing to do. This debate just points out that bans are not the complete answer. Prevention programs and behavior modification need to be developed to comprehensively address this problem.
Arterial bleeding from a pelvic fracture is more common than previously thought. The doctor books used to say that 10% of bleeding was arterial and 90% was venous, so angiographic techniques were seldom used unless there was clinical evidence of blood loss.
It looks like arterial bleeding occurs more frequently than we think. Here are tips that help you identify patients at risk:
What type of mechanism caused the fracture? Anterior-posterior compression and vertical shear are the most common.
Are the vital signs stable? If not, rule out the other four likely sources first (chest, abdomen, multiple extremity fractures, external). Then blame the pelvis.
Is the fracture open? Arterial bleeding is very likely.
How old is the patient? Elderly patients are more likely to have arterial bleeding, especially from gluteal artery branches.
What part of the pelvis is broken? If major sacral fractures, SI joint disruption or separation of the symphysis is present, think arterial bleeding.
Are there CT abnormalities? A vascular blush or large hematoma indicates significant bleeding.
The most common bleeding sites are the gluteal and pudendal arteries. The gluteal is in proximity to the SI joint, so this can be torn if the SI joint is damaged or the sacrum is fractured. The pudendal can be injured with ramus fractures, especially when the symphysis is widened.
If the patient can be reasonably stabilized, then a trip to interventional radiology is mandatory. Operative management is not very successful, so patients with blood pressure lability or controllable hypotension should go to IR. All active bleeding and arterial cutoffs should be embolized thoroughly.
Images: On the left is the portable plain image of a vertical shear pelvic fracture. The arrows on the right point to two areas of vascular blush.
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