An Alternative Method for Closure of Fasciotomy Wounds: Healing by Secondary Intention

摘要

Although healing wounds by secondary intention is not a new method for wound closure, its application and superior outcome in certain clinical situations is often overlooked. We describe the management and care of large bulging wounds after lower limb fasciotomy in two patients. By allowing the wounds to heal by secondary intention, the patients are discharged from the hospital sooner resulting in a reduced length of stay; in addition they avoid repeated trips to the operating room, and circumvent unnecessary additional scarring that can result from skin grafting. This procedure offers many additional benefits to the patients including the benefit of a normal contour to the extremity and a more rapid return to daily activities following discharge from the hospital. Four-year postoperative follow up examination of the patients in this report revealed improved outcomes as exhibited by no additional need for operations, excellent healing, and minimal scarring. Introduction The most common causes of acute compartment syndrome are fractures and vascular trauma 1 and often result in increased tissue pressure within an enclosed compartment which can lead to ischemic damage of muscles and nerves. Once compartment syndrome has been discovered, fasciotomy is the treatment of choice to relieve tension and enhance tissue perfusion.2 Fasciotomy often results in a large open wound secondary to retraction of skin edges. These open fasciotomy wounds are often a management dilemma faced once surgical release for a compartment syndrome has been performed. Many different methods and techniques have been proposed in the literature for wound healing after fasciotomy and yet no ideal solution has been found; options include skin grafting, delayed primary closure and slow dermal aposition. An ideal treatment regimen for these open wounds would allow the patient to be quickly discharged from the hospital, avoid unnecessary secondary operations and reduce visible scars, and diminish the possibility of developing another compartment syndrome.Skin grafting of a large fasciotomy wound is the most common procedure following fasciotomy, yet it has many associated problems; it requires multiple operations that can lead to aesthetically undesirable scarring both at the site of fasciotomy and the donor site. After the skin graft is in place, subsequent operations and serial excisions are required to remove the skin graft. In addition, while the graft is in place the scar is often insensate. Alternative options to skin grafting, such as delayed primary closure and slow dermal aposition, are often accompanied by lengthened hospital stays and multiple operative procedures. This paper suggests healing by secondary intention as an alternative method for fasciotomy closure that should also be kept in the armamentarium. This alternative allows the fasciotomy to heal based solely on skin contraction. Although healing by secondary intention is not a novel idea, it has never been documented or thoroughly presented in the literature as an alternative method for closure of fasciotomy wounds. This method of treatment can be conducted as an outpatient without concern about recurrent compartment syndrome. In addition, closure by secondary intention would eliminate additional scarring associated with skin grafting, normalize the contour of the extremity, decrease hospital stay, and reduce the need for secondary procedures, thereby reducing the overall costs for the patient. This option is especially practical for responsible patients and would immediately allow them to return to their daily activities while in the process of healing. Materials and Methods The two patients in this case study were discharged from the hospital after they were stable from an orthopedic point of view and after they and their families were comfortable with the wound care and dressing change regimen. Dressing changes varied from once to three times a day depending on the state of the wound. Saline