Edwin Y. Chang and Kevin C. Chung
DEFINITION
Burns and electrical injuries of the hand and forearm can present as both acute and long-term surgical problems.
High-voltage electrical injury is defined as involving a power source with a voltage greater than 600 volts.
Electrical burns constitute a unique type of injury, because “hidden” local and regional deep tissue damage exists beyond the confines of the cutaneous burn.
Acutely, circumferential or near-circumferential full-thickness burns of the extremity may require escharotomy, in which the unyielding burned tissue is released to reduce soft tissue tension.
Compartment syndrome is a serious sequela that warrants immediate surgical attention.
Contractures are common in burn patients, resulting from loss of normal skin pliability when the skin is replaced by scar tissue after secondand third-degree burns.
Despite aggressive acute care, splinting, and therapy, longterm hand and wrist deformities are common.6
ANATOMY
Compartments are anatomic spaces enveloped by fascia, bones, and interosseous membrane.
The forearm is divided into three compartments: volar, dorsal, and the mobile wad (FIG 1A).
The hand has compartments housing four dorsal interosseous muscles, three volar interosseous muscles, thenar muscle, and hypothenar muscle (FIG 1B).
Postburn scarring and contracture tend to produce the “classic” clawing deformity with flexed wrist and proximal interphalangeal (PIP) joints, extended distal interphalangeal (DIP) and metacarpophalangeal (MCP) joints, and adducted web spaces1 (FIG 1C,D).
PATHOGENESIS
Electrical Burns
Electrical shock produces a complex pattern of injury in which the severity of injury depends on the intensity of the current and the duration of contact.
Tissue damage occurs predominantly by two mechanisms: thermal injury and electroporation.7
As an electrical current travels, heat is generated along its path, leading to thermal damage.
Tissues with high electrical resistance, such as the skin and bone, generate more heat, causing more damage to both themselves and the surrounding tissues.
Electroporation is cellular damage induced by the electric field. The severity of injury is determined by the cell’s size and its transmembrane potential.
Cells with larger surface area, such as myocytes, are more prone to electroporation injury.
In addition, it has been suggested that due to the architecture and orientation, myocytes near a bone may experience increased transmembrane potential compared to those further from the bone.
Secondary to these mechanisms, patients with high-voltage electric burns often sustain extensive deep tissue and muscle injuries that predispose the patient to developing acute compartment syndrome.
FIG 1 • A. Cross-section of midforearm depicting the fascial compartments. (continued)
FIG 1 • (continued) B. Cross-section of the hand showing the intrinsic fascial compartments. C, D. Classic deformities associated with severe hand burn, with flexed proximal interphalangeal (PIP) joint and extended metacarpophalangeal (MCP) and distal interphalangeal (DIP) joints.
Compartment Syndrome
Arteriovenous gradient theory is commonly accepted as describing the relation between increasing soft tissue pressure and decreasing arterial inflow.
In burns, vascular permeability leads to swelling of the soft tissues and, in particular, the muscles.
The inelastic fascia housing each compartment does not allow the edematous muscles to expand. The increased pressure within the compartments eventually interrupts arterial inflow to the muscles.
Although compartment syndrome most often is discussed in relation to fascial compartments, it can occur in fullor near–full-thickness burns because the inelastic skin limits the ability of underlying soft tissue to expand.
The inelastic skin in a circumferential burn acts as a tourniquet, compromising venous return and capillary perfusion, and leading to tissue ischemia distal to the burns.8
Burn Contractures
Increased and disorganized deposition of collagen fibers has been observed in burn wounds, forming compact and shortened scars.6
The amount and severity of hypertrophic scarring and contracture is directly related to the depth of the burn and the time required for wound healing.
Inflammation, pain, and edema from burn injuries promote immobility (in the position of comfort) and cause wound contracture.1
Immobility and abnormal scarring lead to rapid formation of contractures in the pattern described under Anatomy.
NATURAL HISTORY
Evolution of Compartment Syndrome
Acute burn management for large body surface area burns requires aggressive fluid resuscitation. Massive edema is seen within 36 hours of injury.
Intracompartmental pressure can, in turn, elevate rapidly in the early postburn period.
Classic studies have shown that myonecrosis occurs after 6 hours of ischemia. Once tissue is ischemic for longer than 8 to 12 hours, irreversible functional damage occurs.5,8
Prompt fasciotomy minimizes functional loss and promotes recovery.
If compartment syndrome is left untreated, the result is Volkmann’s ischemic contracture, a late sequela in which muscles and nerves die and are replaced by fibrous tissue.12
Natural Progression of Burn Injury
Proper management of burn injuries includes early excision and grafting, followed by appropriate therapy programs.
Even with splinting, range-of-motion exercises, compression, and positioning, 80% of patients will have decreased joint motion, and up to 10% will have difficulties with activities of daily living.3
PATIENT HISTORY AND PHYSICAL EXAMINATION
Acute Burn Injuries
In addition to routine medical history, it is imperative to obtain the mechanism of the burn injury.
High-voltage electrical burns, burns that occurred in an enclosed space, or burns associated with explosions require trauma and critical care consultation to evaluate for other life-threatening injuries.
Thermal and electrical burns are evaluated for depth.
First-degree burns involve only the epidermis and appear as a painful, erythematous plaque that blanches with pressure.
Second-degree burns involve the epidermis as well as partial thickness of the dermis. Second-degree burns invariably are associated with blistering of the skin that evolve into moist, weepy, and painful wounds after sloughing of the epidermis.
Third-degree burns involve the entire thickness of the skin and are characterized by charred, painless, leathery skin with visible coagulated vessels.
Acute Compartment Syndrome
Clinically, elevated soft tissue pressure presents with severe edema and tightness of the hand, wrist, and forearm distal to the burn.
Treatment for fascial compartment syndrome of the forearm and hand should be initiated based on clinical suspicion.
Compartment syndrome can present with a constellation of symptoms:
Pain with passive muscle stretch
Progressive pain despite immobilization
Nerve ischemia symptoms such as diminished sensation and muscle weakness
Compartments tender and firm to palpation
Compartment and soft tissue pressures can be measured using a pressure transducer (FIG 2).
A simple device for measuring pressure can be made with an 18 or 20-gauge needle attached to a syringe containing saline and a pressure transducer, all connected via a threeway stopcock.
The transducer is set to zero at the level of the soft tissue or compartment to be measured.
After the needle is inserted into the subcutaneous tissue, a small amount (0.2–0.5 mL) of saline is injected to establish a water column.
The transducer is then opened to the needle for pressure monitoring.
Compartment and soft tissue pressures can also be measured using a commercially available device.
The recommended threshold for performing fasciotomy is pressure higher than 30 mm Hg for normotensive patients.
In patients with hypotension, when the compartment pressure rises to within 20 mm Hg of the diastolic pressure, fasciotomy is indicated.9
Secondary Burn Reconstruction and Contracture Release
Preoperative examination for patients undergoing secondary burn reconstruction should include a complete hand examination, focusing on range of motion of the affected joints.
FIG 2 • Pressure transducer adapted for measurement of compartment pressure.
Substantial limitation of active and passive joint motion in the PIP and MCP indicates contracture of underlying joint tissues.4,11
Examination should also focus on the scar and skin quality, because immature scars may still be amenable to nonoperative management.
Poor or unstable skin coverage may limit local tissue rearrangement options and necessitate coverage with a distant flap.
Physical Examination
Vascular examination includes checking pulse and capillary refill.
Pulse is graded as normal, diminished, or absent compared to the contralateral side.
Capillary refill is graded as delayed, normal (2–3 second), or quickened.
Absent or diminished pulse is a late finding in compartment syndrome.
Quickened capillary refill is suggestive of venous congestion.
Delayed capillary refill may suggest increased soft tissue or compartment pressure.
The neurologic examination includes light touch, two-point discrimination, and motor function testing.
Sensibility to light touch is graded as normal, diminished, significantly diminished, and absent.
Two-point discrimination is graded as normal (< 6 mm static, < 3 mm moving), and abnormal.
Motor examination is graded from 0 to 5, with 0 being absent, and 5 normal.
Altered neurologic finding compared to the contralateral limb is an indication of increased compartment pressure.
A passive stretch test should be performed.
Pain with passive stretch is an abnormal finding.
A positive passive stretch test is indicative of muscle ischemia and injury.
Measure subeschar and compartment pressure. Elevated pressure is confirmed if the measured pressure is greater than 30 mm Hg or within 20 mm Hg of the diastolic pressure. Persistently or worsening elevated pressure is an indication for escharotomy or fasciotomy.
Examine MCP range of motion:
Type I: mild limitation in MCP flexion with wrist flexion, more than 30 degrees of flexion with wrist in extension
Type II: severe limitation in MCP flexion with wrist in flexion, less than 30 degrees of flexion with wrist in extension
Type III: severe limitation in MCP flexion with wrist in extension
Type II and III contractures signify underlying joint and ligamentous pathology that cannot be corrected with soft tissue release alone.
Examine PIP range of motion:
Type I: near-normal PIP extension with MCP in flexion
Type II: moderately limited PIP extension with MCP in flexion
Type III: fixed PIP flexion regardless of MCP position
Type II and III contractures signify underlying joint and ligamentous pathology that cannot be corrected with soft tissue release.
IMAGING AND OTHER DIAGNOSTIC STUDIES
Currently, no available imaging modality can detect acute increases in compartment pressure.
For secondary reconstruction of the contracted hand and fingers, plain radiographs should be obtained to evaluate the condition of the joint and determine whether heterotrophic ossification is present, because that requires alternative treatment options.
DIFFERENTIAL DIAGNOSIS
The differential diagnosis for compartment syndrome includes:
Nerve injury
Arterial insufficiency or injury
Venous thrombosis
Burn contractures should be differentiated from:
Intrinsic joint disease
Other scarring or contracture phenomena (eg, Dupuytren disease)
NONOPERATIVE MANAGEMENT
Early in the healing process (usually within 6 months of injury), immature scars are hyperemic in appearance and amenable to conservative measures.
Conservative management includes the use of pressure garments, silicone dressing, and physical therapy.
Pressure garments and silicone have been shown to control hypertrophic scars and must be worn for several months.6
Therapy should focus on aggressive range-of-motion exercises and splinting in an antideforming posture (FIG 3).
SURGICAL MANAGEMENT
Burn débridement, escharotomy, fasciotomy, local tissue rearrangement for linear and web space contracture, and pedicled groin flap coverage for soft tissue defects are discussed in the Techniques section.
Indications for Surgical Management of Acute Burns and Acute Compartment Syndrome
High-voltage injury is an indication for immediate fasciotomy and burn débridement because it is difficult to assess the extent of deep thermal damage.
Patients with thermal burns and low-voltage electric injury require closed monitoring by experienced personnel to assess potential increased soft tissue or compartment pressure, but may otherwise be débrided in 48 to 72 hours to allow for demarcation of burned areas.
FIG 3 • Immature burn scars that are amenable to conservative treatment. A volar intrinsic-plus splint with the thumb in palmar abduction to prevent debilitating postburn contractures.
Elevated soft tissue pressure and fascial compartment pressure are indications for emergent surgical intervention.
Despite the potential utility of pressure monitors, diagnosis of the pathology still relies on clinical judgment.
If there is any doubt regarding the diagnosis, escharotomy and fasciotomy should be undertaken expeditiously.
Fascial compartment syndrome may be masked by elevated pressure of the overlying soft tissue, and it is of the utmost importance to check muscle compartment pressures after an escharotomy.
If elevated compartment pressure is not relieved by escharotomy of the overlying burned tissue, a full fasciotomy is necessary.
After escharotomy or fasciotomy, patients must be observed closely for signs and symptoms of inadequate release, which will require urgent reoperation.
Considerations in Contracture Release and Secondary Burn Reconstruction
Burn injuries cause soft tissue contracture and result in tissue deficiency. The secondary effects of soft tissue contracture are joint and tendon changes that also require release.
Mild volar and dorsal linear scar bands, as well as web space contractures, can be corrected with scar release and local tissue rearrangement.
Basic Z-plasty is a technique of local tissue rearrangement in which two equal triangular skin flaps are transposed (FIG 4A). Z-plasty is ideally suited for linear scar release because it lengthens and interrupts a scar, and also redirects the line of tension.
The theoretical gain in length is proportional to the angle of the Z-plasty. A larger angle provides more lengthening but is more difficult to transpose (Table 1).
However, an adequately sized Z-plasty flap often is difficult to fit into a contracted web space.
For web space contracture release we prefer a five-flap “jumping man” Z-plasty, which is a combination of two Zplasty flaps with a Y-to-V advancement flap (FIG 4B).
FIG 4 • A. Basic Z-plasty flaps and their theoretical gain in length. B. Five-flap jumping man Z-plasty, which is made up of two opposing Z-plasty flaps and a Y-to-V flap.
Compared to a basic Z-plasty, the additional flaps maximize gain in length. In addition, the Y-to-V flap introduces unscarred skin into the reconstruction, providing more pliability and elasticity to the reconstructed web space.
Even without scar resection, surgical release of burn scars often result in a large soft tissue defect due to tissue deficiency.
Thick splitor full-thickness skin grafts can be used to resurface the soft tissue defect.
Flap coverage may be necessary if contracture release or scar excision leads to exposure of joint structures, tendons, or neurovascular bundles.
Pedicled groin flaps are versatile flaps based on the superficial circumflex iliac artery, useful for coverage of large soft tissue defects in the hand and forearm.
Preoperative Planning
If hand and forearm burns are part of a larger insult, the ABCs (airway, breathing, and circulation) of trauma resuscitation and patient stabilization cannot be overlooked.
Burn débridements may incur a significant amount of blood loss, and blood products should be made available intraand perioperatively.
For secondary burn reconstruction, one must appreciate the structure involved in the deformity.
If tightness of the deep tissue is present, capsulotomy and ligamentous release should be addressed simultaneously.
Positioning
Supine positioning with the affected arm extended on an arm table is adequate for most described procedures.
For secondary reconstruction, an upper arm tourniquet is used.
The ipsilateral upper thigh and lower abdominal quadrant is prepped and draped if a groin flap is planned for soft tissue coverage.
TECHNIQUES
ESCHAROTOMY FOR FULL OR DEEP PARTIAL-THICKNESS BURNS
Escharotomy can be performed at the bedside using electrocautery with the patient under sedation.
A full-thickness skin incision is made the length of the full-thickness burn on the radial aspect of the forearm, along the line connecting the lateral end of the antecubital flexion crease and radial styloid (TECH FIG 1).
The incision is deepened until viable tissue is encountered. The length of the incision spans the entire burn, from normal skin to normal skin.
If the hand and the forearm are still tight after a radial release, a second escharotomy incision can be made along a line just volar to the ulna, spanning the entire burn (see Tech Fig 1).
To perform escharotomy of the hand, one can extend the radial incision onto the hand with the radial incision at the midaxial line over the thenar eminence. The radial sensory nerve will lie along this incision and must be protected.
The ulnar incision can be carried onto the hypothenar eminence as needed.
Circumferential finger burns are treated with a digital escharotomy. A midlateral incision down into subcutaneous fat is made along one side of the finger, from the MCP joint to the fingertip.
If the compartment pressure is still high after escharotomy, fasciotomy should be carried out as described in the following section.
Escharotomy wounds are dressed with a moist dressing.
TECH FIG 1 • Location for radial and ulnar escharotomy incisions. If necessary, the incisions can be carried onto the thenar and hypothenar eminences.
FASCIOTOMY OF HAND AND FOREARM
Intrinsic Compartment Release
Blunt dissection is performed along the ulnar and radial side of the index finger metacarpal to open the first volar interosseous and adductor pollicis muscles.
The second volar interosseous muscle is opened with deep blunt dissection along the radial border of the ring finger metacarpal.
Finally, through the ring finger metacarpal incision, deep blunt dissection along the radial border of the small finger metacarpal releases the third volar interosseous muscle.
Two dorsal incisions centered over the index and ring metacarpals are used to release the interosseous muscle and the thumb adductor muscle compartments (TECH FIG 2A).
Incisions are carried down ulnar and radial to the index and ring extensors. Dissection is continued until the fascia of the dorsal interosseous muscles is encountered. The fascia is opened sharply.
TECH FIG 2 • A. Incisions for intrinsic compartment release of the hand and for release of interosseous muscles through dorsal hand incisions. B. Cross-sectional view of the intrinsic compartments of the hand and incisions for compartment release.
Thenar muscles are released through an incision on the radial border of the thumb metacarpal between the volar glabrous and dorsal pliable skin. The dissection is volar to the metacarpal to expose the fascia of the thenar muscles, which is sharply opened.
The hypothenar muscles are released similarly with an incision on the ulnar aspect of the small finger metacarpal (TECH FIG 2B).
Carpal Tunnel Release
The carpal tunnel is released through a standard incision over the palm, along the ring metacarpal.
Incision begins at the Kaplan’s cardinal line (the line connecting the apex of the first web space to the hook of the hamate), and extends 2 to 3 cm proximally (TECH FIG 3).
We prefer to avoid an incision across the wrist joint, to protect the median nerve from exposure.
The palmar fascia is divided sharply to expose the transverse carpal ligament.
The transverse carpal ligament is divided under direct visualization.
Forearm Fasciotomy
We prefer to perform fasciotomy of all three forearm compartments at the same time to avoid lingering doubts regarding inadequate release. Two incisions are used (TECH FIG 4A).
A straight-line incision is made over the first third of the ulnar aspect of the volar forearm, beginning just proximal to the wrist crease and extending to just distal to the ulnar aspect of the elbow flexion crease (TECH FIG 4B).
The incision is carried down through the fascia, into the volar compartment. The fascia is opened along the length of the compartment.
The superficial and deep muscles are examined.
TECH FIG 3 • Incision for carpal tunnel release. Kaplan’s cardinal line is used as a guide for the incision for carpal tunnel release.
TECH FIG 4 • A. Incisions for volar and dorsal fasciotomy. B,C.
The mobile wad and dorsal compartment release is accomplished by placing a middorsal straight line incision beginning 3 to 4 cm proximal to the wrist crease and extending to the radial aspect of the flexion crease at the elbow (TECH FIG 4C).
The compartmental fascia for both compartments are incised over their entire length and the muscles are examined.
After release, the muscles should bulge out over the incision.
The muscles are not débrided until a second-look procedure at 48 hours, because some muscles with questionable viability may recover after fascial release.
The open wounds are packed with moist dressing until the second-look procedure.
Burn Débridement
Burn débridement is performed without a tourniquet and can be carried out with escharotomy or fasciotomy.
Sharp débridement is used to removed partialand fullthickness burns.
For small areas or areas with irregular contour, a no. 15 or no. 10 blade is used to remove burnt tissue, layer by layer, until bleeding tissue is encountered.
For larger areas, a Weck blade with a no. 8 or no. 10 guard is used to tangentially remove burn tissue until punctate bleeding is encountered.
For uncomplicated thermal burns, immediate coverage can be accomplished.
For uncomplicated wounds, a.012-inch split-thickness skin graft can be placed. We typically use unmeshed graft for the hand and over the wrist joint. Forearm burns can be covered with a graft meshed 1 to 1 1 ⁄ 2 expansion.
For deeper wounds with small areas of exposed deep structures (eg, tendons or joints), a dermal substitute such as Integra is used to provide a revascularized dermal foundation. Delayed split-thickness skin grafting is done in 2 weeks.
Large burn wounds with exposed deep structures or exposed neurovascular bundles are temporarily covered with moist dressing changes, and will require local flap, distant flap, or free tissue coverage within 48 to 72 hours.
Electrical burns often have injuries to subcutaneous tissues and muscles in addition to cutaneous burns. After débridement of the cutaneous portion of the burns, as described in Burn Débridement, the subcutaneous tissue and muscles are sharply débrided with a no. 10 blade in a layered manner until bleeding tissue is encountered.
Patients with electrical burns are managed with moist dressing changes and taken back to the operating room for a second look procedure in 48 hours.
SECOND-LOOK PROCEDURE
The second-look procedure is performed without the use of a tourniquet.
Necrotic tissues are aggressively débrided with a no. 10 blade in a tangential manner until bleeding tissue is encountered.
Electrical burns may require multiple débridements every 48 hours until the area of injury is demarcated and all necrotic tissues are removed.
Large wounds with exposed deep structures or exposed neurovascular structures are temporarily covered with moist dressing changes and will require local flap, distant flap, or free tissue transfer coverage within 48 to 72 hours.
For uncomplicated fasciotomy wounds, once adequate débridement has been achieved, moist dressing changes are performed for 7 to 14 days in preparation for primary closure or skin grafting.
With increasing frequency, a negative-pressure dressing is being used for fasciotomy defects as an alternative to traditional wound care.
Edema often subsides and allows for primary wound closure (TECH FIG 5).
Open defects are covered with a.012-inch split-thickness skin graft.
TECH FIG 5 • Immediate postoperative photograph of a forearm fasciotomy with carpal tunnel release. The skin has been loosely reapproximated.
LOCAL TISSUE REARRANGEMENT FOR RELEASE OF CONTRACTURE BANDS
Basic Z-Plasty
One or multiple Z-plasty flaps are used to break up mild to moderate linear contractures.
The central limb of the Z is planned along the axis of the scar band, and the angle of the Z-plasty can be varied, with a larger angle providing more release. We prefer 45-degree flaps (TECH FIG 6A).
The Z-plasty flaps are elevated just below the dermis, preserving a small cuff of subcutaneous fat on the underside of the flaps.
Foreshortened fibrous bands that require release with scissors or a knife often are present in the underlying soft tissue.
Care is taken to protect the neurovascular bundle.
After release of underlying tissue and extension of the joint, the Z-plasty flaps should fall naturally into a transposed position.
The flaps are sutured in place with nonabsorbable sutures (TECH FIG 6B).
Xeroform (Covidien, Mansfield, MA) strips and bacitracin are applied to the incision, followed by a gauze dressing. A gentle elastic bandage is applied.
The bandage is removed in 2 days, and patients are allowed progressive gentle range of motion. Stretching and scar massage are encouraged to begin 2 to 3 weeks postoperatively.
Five-Flap Z-Plasty for Release of Web Space Contractures
The central limb of the five-flap Z-plasty is designed to lie on the axis of the web space contracture.
The Z-plasty is oriented with the Y-to-V flap occupying normal skin, to maximize advancement of unburned skin into scar tissue (TECH FIG 7).
Skin incisions are made in the central limb as well as the Y-to-V flap. The lateral limbs of the Z-plasty flaps are not incised initially.
The Y-to-V flaps and the skin around the central limb are elevated just below the dermal fat junction.
TECH FIG 6 • A. Design of two Z-plasty flaps for release of a flexion contracture. B. Same flexion contracture after release and flap transposition.
TECH FIG 7 • Design of a five-flap Z-plasty for release of a first web space contracture.
The underlying fibrous tissues are released using a combination of blunt and sharp dissection.
At this point, the Y-to-V flap is advanced into place.
More advancement can be achieved by lengthening the Y-to-V limbs and enlarging the flap. The central limb is lengthened accordingly. Flap size is limited by the size of the web space.
The lateral limbs of the Z-plasty flaps are now incised corresponding to the length of the enlarged Y-to-V flap (now a V-flap).
The flaps are then secured in their transposed position with nonabsorbable sutures.
Xeroform and bacitracin are applied, followed by gauze dressing and a gentle elastic bandage.
The bandage is removed in 2 days, and the patient is allowed progressive gentle range of motion. Stretching and scar massage are encouraged to begin 2 to 3 weeks postoperatively.
Groin Flap for Extensive Burn Contracture
Scar Excision
An incision is made around the contracted scar into the subcutaneous fat and underlying structures. Often, the scar is adherent to underlying fascia, tendons, and joints.
Traction is applied to assist in identifying the areolar plane between scar and normal tissue.
The scar is lifted in its entirety. Tight underlying fibrous bands are broken up with blunt and sharp dissection.
After complete excision of the scar, the affected joints are put under stretched to evaluate the need for capsulotomy or ligamentous release.
Flap Harvest
Attention is then paid to harvest of the ipsilateral groin flap.
Doppler ultrasound is used to identify the superficial circumflex iliac artery.
At the ipsilateral groin, a line between the anterior superior iliac spine (ASIS) and pubic tubercle is drawn, identifying the inguinal ligament. A second parallel line is drawn 2 to 3 cm below as the midaxis of the flap, which should correspond to the course of the superficial circumflex iliac artery.
Using a pattern of the defect, a flap is designed inferior to the ASIS to lie along the previously marked midaxis. If necessary, the flap can be extended lateral to the ASIS for additional length (TECH FIG 8A).
A flap up to 20 × 10 cm can be closed primarily and is sufficient for most hand and wrist defects.
It is important to keep in mind that a small portion of the flap will be tubularized near the pedicle and will have to be included in the design.
The flap is oriented to minimize kinking and twisting of the pedicle after inset.
The flap is incised down to the underlying fascia. Inferiorly, the fascia lata and sartorius muscle fascia are identified.
The flap is elevated tangentially off the fascia in a lateral-to-medial fashion until the lateral aspect of the sartorius fascia is encountered (TECH FIG 8B).
The sartorius fascia is incised at its lateral margin and elevated from the underlying muscle, with care taken to avoid injuring the lateral femoral cutaneous nerve.
At this point, scissor dissection is used to identify the vascular pedicle as it traverses out of the femoral triangle and through the sartorius fascia.
A cuff of sartorius fascia is incised superior and inferior to the pedicle to untether the pedicle from the muscle (see Tech Fig 8B).
The proximal portion of the flap is tubularized around the pedicle.
The donor defect is closed primarily. The standing cutaneous deformity at the lateral aspect is excised. A small open area may be left at the base of the flap.
Completion of the Groin Flap
The flap is gently thinned along the margins.
The defect is then brought into the field, and the flap is inset using nonabsorbable sutures (TECH FIG 8C).
The forearm is then secured to the abdominal skin with several large nonabsorbable sutures.
Xeroform and bacitracin are applied, followed by fluffed gauze dressing.
An elastic bandage is wrapped around the hip to further stabilize the reconstruction.
Members of the surgical team must be present at the time of recovery from anesthesia to mitigate the chance of accidental flap avulsion.
TECH FIG 8 • A. Design of a groin flap for a large dorsal hand wound after scar excision. The defect has been traced onto a template and transposed to the groin area. B. Elevation of the groin flap. A cuff of the sartorius fascia has been incised (indicated by the periosteal elevator) and elevated with the flap to improve mobility of the pedicle (superficial circumflex iliac artery; white arrow). The lateral femoral cutaneous nerve (black arrow) is visible just medial to the incised sartorius fascia. C. The groin flap is inset onto the dorsal hand wound. This patient also has soft tissue defects of the ring and small fingers that are buried in subcutaneous pockets for future skin grafting.
POSTOPERATIVE CARE
After acute burn and wound management, the affected upper extremity will require appropriate splinting (intrinsicplus with thumb in palmar abduction), elevation, and early range of motion to prevent secondary complications.
A soft dressing consisting of gauze and an elastic bandage is applied after scar release and local tissue rearrangement. Sutures are removed in 2 weeks.
Early mobilization and therapy are initiated about 2 weeks postoperatively to maintain release.
Abduction or extension splints may be used at night to maintain posture.
Upon completion of the groin flap, elastic bandages are used to strap the arm to the torso for 3 to 4 days. Care is taken to avoid kinking of the pedicle.
During the immediate postoperative period, the flap is monitored for arterial insufficiency or congestion. A kinked pedicle necessitates repositioning of hand or patient. Suture release near the pedicle may be needed for congestion.
If present, the small open area at the base of the flap is cared for with daily Xeroform dressing changes.
Range-of-motion exercises for the nonaffected joint can start immediately postoperatively. Exercises for the affected joints can resume 2 weeks postoperatively.
Before flap division, the pedicle is gently occluded to check for viability.
The flap is divided, thinned, and inset 3 to 4 weeks after the index procedure.
OUTCOMES
When adequately done, the outcome after fasciotomy, in any location, is closely related to its timing. In fasciotomy performed within 12 hours of onset of compartment syndrome, normal function has been reported in 68% of patients. The number decreases sharply, to 8%, if fasciotomy is delayed beyond 12 hours.10
Approximately 30% of fasciotomy wounds can be closed primarily. The rest require skin grafting.2
Several articles describing various local tissue rearrangement procedures for contracture release document low complication rates and good results.
Our experience agrees with published series that pedicled groin flaps provide stable soft tissue coverage of upper extremity defects with low complication rates.
COMPLICATIONS
Complications for escharotomy and fasciotomy include:
Bleeding
Inadequate release
Complications for local tissue rearrangement for contracture release include:
Partial skin necrosis
Dehiscence
Recurrence
Injury to neurovascular bundle
Complications for groin flap include:
Flap necrosis
Avulsion
Excessive bulk requiring revisions
REFERENCES
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