Between June 1999 and May 2003 we undertook direct primary closure of the skin wounds of 173 patients with Gustilo and Anderson grade-IIIA and grade-IIIB open fractures. These patients were selected from a consecutive group of 557 with type-III injuries presenting during this time. Strict criteria for inclusion in the study included debridement within 12 hours of injury, no sewage or organic contamination, no skin loss either primarily or secondarily during debridement, a Ganga Hospital open injury skin score of 1 or 2 with a total score of ten or less, the presence of bleeding skin margins, the ability to approximate wound edges without tension and the absence of peripheral vascular disease. In addition, patients with polytrauma were excluded. At a mean follow-up of 6.2 years (5 to 7), the outcome was excellent in 150 (86.7%), good in 11 (6.4%) and poor in 12 (6.9%). A total of 33 complications occurred in 23 patients including superficial infection in 11, deep infection in five and the requirement for a secondary skin flap in three. Six patients developed nonunion requiring further surgery, one of whom declined additional measures to treat an established infected nonunion. Immediate skin closure when performed selectively with the above indications proved to be a safe procedure.
Most major Upper limb injuries are invariably associated with significant skin and soft tissue loss. With the recent technical advances, it is possible to cover most defects. This allows salvage of limbs which were being amputated before. Primary reconstruction of composite defects is also possible thereby shortening the reconstructive process. The ten key points are
Debridement is the key to success. The quality of the bed determines the infection rate and the ultimate functional outcome. Good debridement is essential irrespective of the type of skin cover provided. You make it or miss it at this stage. Cover the wound as early as possible, preferably within 48 hours and certainly before infection sets in. Tendons and bones do not tolerate exposure. Dried and dead bones and tendons must be excised before providing skin cover. While providing skin cover, make the complete plan and not decide for the day. The cover provided should facilitate the next stage of reconstruction (bone or tendon graft or transfers) Good skeletal stability is a must before providing skin cover. In the upper limb stable internal fixation is preferable. Loose fixation is the beginning of the end. If secondary procedures are to be done, skin flaps provide better access than fascial flaps covered with graft. Composite defects need not always be reconstructed with composite flaps. One need not try every known flap. Do what you are good at. Repetition is the mother of skill. Having said that one must also recognize the inherent limitation of any technique. Be willing to change or try alternate plans when faced with problems. Don’t forget donor site morbidity. Initial patient satisfaction is dependent on wound healing. Long term satisfaction is dependent upon donor site morbidity. Do not give up reconstruction of a major hand injury for fear of inability to cover the wound. Never hesitate to seek help. A well healed reconstructed hand is functionally far better than the best available prosthesis.
