Budkevich Liudmila, Shurova Lidia, Starostin Oleg, Rybchyonok Veniamin, Burkin Igor

1. MANAGEMENT OF COMPLEX TREATMENT OF
CHILDREN WITH EXTENSIVE WOUND DEFECTS OF
SOFT TISSUES OF VARIOUS AETIOLOGY
Budkevich L.I., Shurova L.V., Starostin O. I.,
Rybchyonok V. V., Burkin I.A.
Pirogov Russian National Research Medical University
(RNRMU)
Ostrovityanov st.,1, Moscow, 117997
phone/fax: (495) 434-0329, 434-6129; e-mail: rsmu@rsmu.ru

2. Relevance
Growth of number of children with heavy
mechanical (fig.1) and thermal injuries (fig.2),
accompanied with extensive wound defects and
increase of number of survived children with
heavy craniocereberal and spinal trauma with
development of generalized neurotrophic damages
(fig.3) , determines increase in patients with
extensive wound defects of soft tissues. It
demands revision of principles of traditional
treatment of this group of patients which will
allow to reduce duration of recovery and exclude
disability of the patients.
fig.1
fig.2
Fig.4

3. Purpose: Development of management of treatment of patients with extensive wounds of
various etiology at stages of conservative and surgical treatment by using modern wound
coverings and early reconstructive plastic surgery.
Materials and methods:According to this technique 17 patients aged 4 to 17 y.o. were
treated. Among them: deep electric trauma of joints (3 children), degloving wounds of
lower extremities resulting from car accidents (8 children), bed sores (6 children after brain
and spinal injuries).
The first stage of treatment was early removal of necrotized tissues by surgical methods
(scalpel, electric knife, radiowave dissector, water jet knife “Versajet”). In the
postoperative period modern wound coverings based on gels, film coverings, atraumatic
gauze dressings were used until the beginning of granulation. After that, surgical treatment
was carried out, characterized by closing wound defect with skin of normal texture. For
this purpose full thickness autologous skin transplants were used as well as skin-and-fat
grafts and muscular transplants on microvascular anastomoses. Long-term immobilization
of operation area with use of devices of external fixing, systemic antibacterial therapy,
infusion-transfusion therapy with rheological preparations were obligatory.

4. Clinical example No. 1
Patient P.,7 of y.o. was traumatized 21.03.11 in T-nd as a result of car running over the left foot.
First aid was given at the spot (primary surgical wound management with following autologous split skin grafting). Due to
the fracture of the bones of the left shin, the extremity was braced with external fixing apparatus. Antibacterial therapy and
bandagings with ointments was carried out. In 7 days after the surgery the necrosis of the skin graft developed.
13.04.11 (16th day after the trauma) the child was referred to the Burns Department of the Children’s Hospital No. 9, Moscow
Wound in an hour after the trauma
Wound after primary surgical
management, autografting and
applying external fixator
Transplant necrosis 7 days after
primary surgical management
and autografting
Beginning of lysis of the transplant
7 days after primary surgical
management and autografting
Lysis of the transplant 16 days
after primary surgical management
and autografting with exposure of
the hucklebone
13.04.11. (The 16th day after trauma) hospitalization in Burns Department of Speransky Children’s Hospital No. 9, Moscow
with the diagnosis: "A granulating wound of the left foot, S=1% of the body surface. Undisplaced closed fracture of the lower
third of the left shin bones. Complete ruprure of extensor tendons and loss of tendons on the level of the ankle joint“.
20.04.11. Operation "Additional correction of the lower left extremity with external fixing device was executed. Full
thickness autografting .
Hucklebone
Results 2 months after
the full thickness
autografting operation
Results 6 months after
the full thickness
autografting operation

5. Results of operation in 2 months – rehabilitation of function of the left knee joint
Type of a wound before operation
«30.05.13: full-thickness
autografting in the area of knee
joint and the split transplants on
the wounds in shin and hip»
Autologous skin graft (full thickness ) Donor wound after suturing
Wound after operation
Clinical example No. 2. Patient Z. 11 y.o. 8.05.13. was hit by a car.
Diagnosis: severe multiple trauma, closed craniocerebral injury, brain concussion, closed injury of an abdomen, subcapsular
rupture of spleen, crush injury of lower right extremety on the level of lower hip, mechanical compression of lower left
extremity, fracture of right hand bones. First professional medical aid was given in Central Regional Hospital of town B-tsy,
Moscow Region (artificial ventilation, right hip amputation, abdominal paracentesis). At admission to Speransky Children’s
Hospital №9 the extensive necrosis was revealed of soft tissues of the left hip, knee joint area and shin
Necrosis of soft tissues of left hip,
knee joint and shin in 5 days
Operation 15.08.13. Extensive fascial necrectomy.
Wound before operation Wound after removal of eschar
Treatment of the
wound of stump of
right hip with vacuum
system

6. Clinical example No. 3. Patient T., 13 y.o. was traumatized 9.08.13. as a result of hitting his foot
against a sharp edge of a metal pipe. He was admitted to Speransky Children’s Hospital #9 with
extensive scalped wound of the dorsal part of the foot. Primary surgical wound management was
carried out
Wound at reception
Wound after Primary surgical wound
management
Wound after formation of
granulation after necrosis of fat
graft

7. 2.10.13. Plastic operation: muscle grafting on vascular anastomoses and
autografting with full thickness transplant
Operation planning
Full thickness
autodermotransplant Donor wound after suturing
Surgical release of rectus
abdominis muscle
Diagram of position
of rectus abdominis muscle
Vascular pedicle of
muscular transplant
Excision of granulation
and releasing vascular pedicle
Diagram of position of recipient
blood vessels

8. Wound closing in the field of the right foot with muscular graft on vascular
anastоmosis and full thickness skin transplant
Creation of vascular anastоmosis
Restoration of blood circulation
in the muscle
Closing muscle with full thickness
autodermotransplant

9. Clinical example No. 4. 7.11.11 patient G., 16 y.o. at sport training received complex cerebro-spinal trauma
(closed dislocation of C4 of vertebra with full anatomic break-up of spinal cord). At the place of residence
(Nizhnekamsk Regional Hospital) surgical treatment was carried out: open reposition of dislocation of C4,
metal osteosynthesis of C4-C5, autologous bone transplantation Referred to Speransky Hospital No. 9 for
surgical closing of pressure ulcers. 8.11.12. Surgical operation "Excision of hypertrophic granulations,
elimination of multiple pressure ulcers in lumbar, sacral and buttocks areas with plastic operations – rotating
skin-fat grafting.
Wounds before operation Formation of skin-fat graft
Defect is closed by skin-fat graft
Pressure ulcer
Graft
Results of operation in 15 days

10. Results:
According to this technique 17 patients aged 4 to 17 y.o. were treated. Among them:
deep electric trauma of joints (3 children), degloving wounds of lower extremities
resulting from car accidents (8 children), bed sores (6 children after brain and spinal
injuries).
There were no complications and there was full taking of the autologous skin
transplants, skin-and-fat grafts, complete rehabilitation of function of extremities and
normal skin.
Summary:
Execution of early reconstructive plastic surgeries on the basis of use of full
thickness skin transplants, skin and fat grafts and muscular transplants on vascular
anastomosis, is an effective way of closing extensive wound defects in active and
functional zones.
Early reconstructive plastic surgeries need to be carried out within the first weeks
after trauma (or diagnosis of wound defect accompanied with neurotrophic
complications) before formation of scars or deformations.