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 Table of Contents  
ORIGINAL ARTICLE
Year : 2021  |  Volume : 16  |  Issue : 3  |  Page : 441-443

Right upper limb salvage by surgical reconstruction with autologous tissue in a machinery crushed and degloving injury in a post-COVID-19 patient: An original article


Department of General Surgery, Jawaharlal Nehru Medical College, Datta Meghe Institute of Medical Sciences (Deemed to be University), Sawangi (M), Wardha, Maharashtra, India

Date of Submission11-May-2021
Date of Decision20-Jul-2021
Date of Acceptance10-Aug-2021
Date of Web Publication12-Mar-2022

Correspondence Address:
Dr. Sandip Shinde
Department of General Surgery, Jawaharlal Nehru Medical College, Sawangi (Meghe), Wardha - 442 005, Maharashtra
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jdmimsu.jdmimsu_200_21

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  Abstract 


Background: Crush injury occurs as a result of direct physical crushing of the muscles by a heavy weight and usually involves compression of the legs, arms, and/or trunk. Crush injuries are typically associated with accidents but can occur in nontraumatic patients as well. Crush injuries may result in permanent disability or death; therefore, early recognition and aggressive treatment are necessary to improve outcomes. Methods: Skin grafting is the transfer of cutaneous tissue from one portion of the body to another, often used to cover large wounds. The rationale of skin grafts is to take skin from a donor site that will heal and transfer the skin to an area of need. Results: After incorporation, skin grafts provide wounds with protection from the environment, pathogens, temperature, and excessive water loss like normal skin. Conclusion: The current study presents a case of Crush Injury with its entire course and final management in a 51 year old male who presented to ACHARYA VINOBHA BHAVE RURAL HOSPITAL, SAWANGI, (M), WARDHA, with traumatic amputation distal to level of metacarpals and degloving injury involving the arm proximal to elbow.

Keywords: COVID-19, crush injury, split-thickness skin graft


How to cite this article:
Chandak S, Shinde S, Mahawar R, Niveditha S. Right upper limb salvage by surgical reconstruction with autologous tissue in a machinery crushed and degloving injury in a post-COVID-19 patient: An original article. J Datta Meghe Inst Med Sci Univ 2021;16:441-3

How to cite this URL:
Chandak S, Shinde S, Mahawar R, Niveditha S. Right upper limb salvage by surgical reconstruction with autologous tissue in a machinery crushed and degloving injury in a post-COVID-19 patient: An original article. J Datta Meghe Inst Med Sci Univ [serial online] 2021 [cited 2022 Jun 30];16:441-3. Available from: http://www.journaldmims.com/text.asp?2021/16/3/441/339437




  Introduction Top


Crush injury is defined as an injury caused as a result of direct physical crushing of the muscles due to something heavy.

Crush and rupture of muscle cells release myoglobin, which gets converted to metmyoglobin, and finally, acid hematin, which is released into the circulation. Muscles also contain potassium, magnesium, phosphate, acids, enzymes such as creatine phosphokinase (CKMM), and lactate dehydrogenase (LDH). Although essential for cell function, they are toxic when released into the circulation in large amounts.

Casualties deteriorate only after being rescued out of the debris of collapse or entrapment because once the tissue tension is released, reperfusion to the ischemic damaged muscles disrupts sodium–potassium-ATPase mechanism. In turn, this releases myoglobin degradation products, lactic acid, uric acid, and muscle enzymes such as creatinine phosphokinase and aldolase, besides ions such as calcium, potassium, and phosphate into the circulation.

Casualties normal initially; however, they soon go into shock. Petechiae, blisters, muscle bruising, and superficial injuries are seen. Myalgia, muscle paralysis, and sensory deficit are common. Fever, cardiac arrhythmia, pneumonia, “tea or cola” colored urine, oliguria, and renal failure are the sequence of events.

Recognition of crush syndrome and treatment involves a close link among trauma surgeons, physicians, biochemists, and radiologists.


  Materials and Methods Top


The current study presents a case of crush injury with its entire course and final management in a 51-year-old male who presented to Acharya Vinoba Bhave Rural Hospital, Sawangi, (M), Wardha, Maharashtra, India.


  Case Report Top


A 51-year-old male patient presented with alleged H/O his arm getting caught in heavy machinery while at work. The patient, farmer by occupation without any other comorbidities presented with degloving injury of the right upper limb proximal to the level of the elbow, with avulsion of soft tissue, exposed underlying bone, and traumatic amputation distal to the level of metacarpals [Figure 1] as confirmed by the radiograms. The patient complained of severe pain and profuse blood loss.
Figure 1: Initial presentation

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On examination, the patient had reduced mobility at the level of the elbow and the distal radial pulsations were intact. After primarily tending the patient, a color Doppler was done which suggested normal blood flow in the involved limb.

The patient underwent an emergency operative procedure involving debridement, myoplasty, and approximation of the margins to assist the primary closure of the wound.

Postoperatively, the patient was managed with daily dressing and local debridement.

The patient developed difficulty in breathing and cough, given the current pandemic, the patient was tested for SARS-COV-19 and tested positive for the same.

Following the positive test, the patient was managed for COVID-19 accordingly, but the daily dressing and local debridement were continued with all due precautions.

Following the quarantine period, the patient underwent split-thickness skin grafting (STSG) with autograft from the patient's thigh after achieving a healthy and vascular bed for the graft placement [Figure 2] and [Figure 3].
Figure 2: Intraoperative image

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Figure 3: Postoperative image

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After confirming the take of graft, the patient was discharged.[2],[3],[4],[5],[6]


  Discussion Top


Crush and rupture of muscle cells release myoglobin, which gets converted to metmyoglobin, and finally, acid hematin, which is released into the circulation. Muscles also contain potassium, magnesium, phosphate, acids, enzymes such as creatine phosphokinase (CKMM), and LDH. Although essential for cell function, they are toxic when released into the circulation in large amounts. Regional ischemia caused by occlusion of micro-and macrocirculation to muscles the following crush releases sodium, calcium, and fluids leading to raised muscle volume and tension. CK and ATP are exhausted. The nitric oxide system is activated and this further contributes to muscle vasodilatation and aggravation of hypotension.

Casualties deteriorate only after being rescued out of the debris of collapse or entrapment because once the tissue tension is released, reperfusion to the ischemic damaged muscles disrupts sodium–potassium-ATPase mechanism. In turn, this releases myoglobin degradation products, lactic acid, uric acid, and muscle enzymes such as creatinine phosphokinase and aldolase, besides ions such as calcium, potassium, and phosphate into the circulation.[1] Myoglobin is filtered out of the glomerulus, but once the renal threshold is exceeded, it precipitates in the distal convoluted tubules causing obstruction. It has also been noticed that an element of vasoconstriction of the afferent arterioles induced by myoglobin degradation products adds to this setting of tubular destruction.

In the scenario of crush injuries, we are dealing with rescue, resuscitation, recognition of the syndrome, treatment, and rehabilitation. Resuscitation should ideally commence at the site of injury. Casualties are often in shock and may lose liters of extracellular fluid into the injured extremity.

STSG, by definition refers to a graft that contains the epidermis and a portion of the dermis, which is in contrast to a full-thickness skin graft which consists of the epidermis and entire dermis. Unlike flaps, skin grafts do not have their own blood supply, so they must rely on a well-vascularized wound bed for graft in-growth. STSGs are obtainable from multiple sources (autograft, homograft, allograft, or xenograft), multiple anatomical locations, and in various thicknesses. Most commonly, STSG autografts are taken from the lateral thigh, as well as trunk, as these sites are both esthetically hidden, as well as easy to harvest from due to their broad surfaces.

Surgeons should assess each wound individually and utilize the reconstructive ladder to find a wound closure solution that is ideally the simplest, the fastest, and with the best esthetic outcome.

STSGs play an integral part of the reconstructive ladder. They are indicated when simpler methods of wound closure will not suffice, such as healing by secondary intention, primary closure, or negative pressure wound therapy. A prerequisite of skin grafting includes available donor sites and recipient sites that are well-vascularized and clean. Typically, skin grafts are used to cover deep partial-thickness skin defects, full-thickness skin defects, or placement over muscle; however, they can survive on any wound bed with vascularity including tendon with intact paratenon (forearm, hand, and fingers), cartilage with intact perichondrium (ears), bone with intact periosteum (skull), and even vascularized biologic dressings. If these thin vascular layers are not in place, STSGs will fail.

STSGs are otherwise indicated in acute skin loss (burn wounds, traumatic wounds, and infection), chronic skin loss (leg ulcers), and as adjuncts to other procedures (to cover a muscle flap).


  Conclusion Top


Crush injuries can cause a handicap leading to the loss of livelihood and ability to carry the essential activities in day-to-day life and can be life-threatening depending on the affected site. Early assessment and appropriate management are necessary to reduce the disability and threat to life. In the above scenario, limb reconstruction and split skin grafting played a vital role in the swift management of a extensively damaged upper limb despite the complications and technical difficulties created by the ongoing pandemic of SARS-COV-19.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N Engl J Med 2006;354:1052-63.  Back to cited text no. 1
    
2.
Bywaters EG. 50 years on – The crush syndrome. BMJ 1990;301:1412-5.  Back to cited text no. 2
    
3.
Johnson TM, Ratner D, Nelson BR. Soft tissue reconstruction with skin grafting. J Am Acad Dermatol 1992;27:151-65.  Back to cited text no. 3
    
4.
Rudolph R, Klein L. Healing processes in skin grafts. Surg Gynecol Obstet 1973;136:641-54.  Back to cited text no. 4
    
5.
Smahel J. The revascularization of a free skin autograft. Acta Chir Plast 1967;9:76-7.  Back to cited text no. 5
    
6.
Kirsner RS, Mata SM, Falanga V, Kerdel FA. Split-thickness skin grafting of leg ulcers. The University of Miami department of dermatology's experience (1990-1993). Dermatol Surg 1995;21:701-3.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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