Rev. bras. ortop. vol.52 número1

r e v b r a s o r t o p . 2017;52(1):103–106

SOCIEDADE BRASILEIRA DE ORTOPEDIA E TRAUMATOLOGIA

w w w . r b o . o r g . b r

Case

Report

Elastic

suture

(shoelace

technique)

for

fasciotomy

closure

after

treatment

of

compartmental

syndrome

associated

to

tibial

fracture

夽

Paulo

Sergio

Martins

Castelo

Branco

_,

_Mauricio

_Cardoso

_Junior,

_Isaac

_Rotbande,

José

Antonio

Fraga

Ciraudo,

Celso

Ricardo

Correa

de

Melo

Silva,

Paulo

Cesar

dos

Santos

Leal

CasadeSaúdeNossaSenhoradoCarmo,RiodeJaneiro,RJ,Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received6October2015 Accepted14December2015 Availableonline2December2016

Keywords: Fascia/surgery Fractures,bone Tibia

Sutures/utilization

a

b

s

t

r

a

c

t

Thisarticlereportstheuseofelasticsutureasanadjuvantinsurgicalwoundclosurecaused bydecompressivefasciotomyaftercompartmentsyndromeassociatedwithacompound fracture ofthetibia.Widelyusedinothermedico-surgicalspecialties,thistechniqueis unusualinorthopedicssurgery,butthesimplicityoftheprocedureandthesuccessful out-comeobservedinthiscaseallowsforitsconsiderationasindicatedforsituationssimilarto thatpresentedinthisstudy.

©2016PublishedbyElsevierEditoraLtda.onbehalfofSociedadeBrasileiradeOrtopedia eTraumatologia.ThisisanopenaccessarticleundertheCCBY-NC-NDlicense(http:// creativecommons.org/licenses/by-nc-nd/4.0/).

Sutura

elástica

no

fechamento

de

fasciotomia

para

tratamento

de

síndrome

compartimental

associada

à

fratura

da

tíbia

Palavras-chave: Fáscia/cirurgia Fraturasósseas Tíbia

Sutura/utilizac¸ão

r

e

s

u

m

o

Relata-se neste trabalho o usoda sutura elástica como adjuvante no fechamento de ferida cirúrgica provocada por fasciotomia descompressiva apóssíndrome do compar-timento associada a fratura exposta de tíbia. Muito usada em outras especialidades médico-cirúrgicas,atécnicanãoéhabitualemortopedia;entretanto,asimplicidadedo pro-cedimentoeoresultadosatisfatórioobservadonestecasopermitereputá-lacomoindicada parasituac¸õessimilaresàapresentadanestetrabalho.

©2016PublicadoporElsevierEditoraLtda.emnomedeSociedadeBrasileirade OrtopediaeTraumatologia.Este ´eumartigoOpenAccesssobumalicenc¸aCCBY-NC-ND (http://creativecommons.org/licenses/by-nc-nd/4.0/).

夽

StudyconductedatCasadeSaúdeNossaSenhoradoCarmo,RiodeJaneiro,RJ,Brazil.

∗ _{Correspondingauthor.}

E-mail:[email protected](P.S.Branco). http://dx.doi.org/10.1016/j.rboe.2016.11.004

104

Introduction

The elastic suture allows progressive closure of lesions, encompassingallitslevels,restoringnormalanatomyandall containmentandresistancefunctionsoftheskinlayers with-outnewmorbidityfactorsforthepatient.Itwasfirstusedto bringtogethertheedgesofafasciotomyaftercompartmental syndromeintheupperlimb.1

Thisstudy aimedtoreport theuse ofelastic suturefor surgicalwoundclosureinafasciotomyaftercompartmental syndromeinalegwithtraumaticfracturesofthe proximal thirdofthetibiaandfibulaassociatedwithvascularinjury.

Case

report

Malepatient,30yearsold,whohadbeenstruckbya passen-gervehicle,sufferedopenfracturesofthetibiaandfibula.He underwentsurgicaldebridementandlavage,and transartic-ularexternalfixationfromthefemurtothetibiainapublic hospitaloftheStateofRiodeJaneiro,andwasthentransferred toourinstitution.

During clinicaland orthopedicexamination, thepatient presentedmildpain,swelling++++/4+,sutureontheanterior aspectoftheleg,withnormalcapillaryperfusion andthin pulseintheaffectedlimb.Routinelowerlimbandtrauma X-raysweremade,aswellasaCTscanoftheinjuredlimb.The imagesdisclosedisolatedleginjuries,withcomminuted frac-turesoftheproximalthirdofthetibiaandfibula,whichwere aligned,stabilized,andmaintainedbyatransarticular exter-nalfixator(Fig.1).Laboratorytestsindicatedalterationsfrom thenormalparametersforthefollowingitems:neutrophils, 9128;reactiveCprotein,34.4;andcreatinekinase,3940.

Overthecourseofafewhours,thepatientdeveloped pro-gressiveandseverepainthatdidnotresolvewithanalgesic use,paresthesiaoftheipsilateral hallux,edema,and tense shinyskin.Decompressivefasciotomywasperformed.During thesurgery,disruptionofthetibiofibulartrunkwasobserved andligated.Thefasciotomywasnotdirectlysutured,andthe incisionsitewasprotectedwithocclusivedressings(Fig.2). Thepatientwasthentransferredtotheintensivecareunitfor rhabdomyolysistreatment.

Thevascularsurgery departmentwas consultedand an arteriographyofthelimbwasperformed,whichshowed dis-ruption of tibiofibular trunk compatible with the trauma (Fig.3);it wasobservedthattheposteriortibialandfibular arterieswereperfusedbyretrogradeflow.

Sevendaysafterfasciotomy,thepatientpresentedaclean wound,withoutsignsofinfection.Atthatmoment,the elas-ticsuturesystemwaspositioned.Anelasticbandforvascular surgerywasattachedtotheskinwithmetalclips,whichwere appliedwithsurgicalstapler0.5cmfromtheincisionedges, startingattheproximalapexandcontinuingtowardthedistal vertex.Thewirewasattachedtoonesideandpassedthrough theincisiontobeattachedontheoppositeside,inasequence thatresemblesazigzagfromtheproximaltothedistalregions –the shoelace technique.After 7days, anoverall approxi-mationofthewoundedgeswasobserved;whentheelastic

Fig.1–(a)Plainlateralviewradiograph;(b)plain

anteroposteriorradiography;(c)lateralview3D

reconstructionCTscan;(d)anteroposterior3D

reconstructionCTscan.

wireandthemetalclipswereremoved,permanentsuturewas madewithnylon2-0thread(Fig.4A–D).

Thefinaltreatmentofthefracturewasconductedwitha hybridexternalfixator(Fig.5).

Discussion

Theidentification ofcompartmentsyndromeisnotalways easy, as peripheral perfusion and arterial pulses are usu-allyobserved,notrepresentinggood parametersforclinical suspicion.Inlaboratorytests,anincreaseincreatinekinase (CK) is observed, which indicates myoglobinuria and sug-gests the diagnosis.2 _{Fracture of the tibial shaft is one of}

the mostfrequentcauses ofcompartmentsyndrome.3 _The

repairofitssurgicalwoundsisperformedwithgraftsorlarge skin flaps; this leads to new wounds, which also demand

rev bras ortop.2017;52(1):103–106

105

Fig.3–Arteriographydisclosingvascularinjury.

treatment. These measures are accompanied by pain, increasedincidenceofinfections, scarretraction,rejection, andfailure.4_{Proximalfracturesofthetibiapresentincreased}

riskforcompartmentsyndrome.5_{Thisconditionismore}

fre-quentincaseswithvascularinjuryand ischaracterizedby increasedblood pressure in regions surrounded by inelas-tic muscle fascia, altering the local microcirculation and underminingtissueviability. Compartmentsyndrome isan

Fig.5–Woundaspect25daysafterelasticsuture.

orthopedicemergency;decompressionfasciotomyisa thera-peuticresourcefordamagecontrolandreducingtheriskof severesequelae.6

Severepainistheearliestobjectiveclinicalfinding,7 _and

increasedpressureandturgidcompartmentmaybeobserved atpalpation.Itsseverityisassociatedtothespeedinwhich thepressureincreases,itsdurationandthedegreeoftissue microcirculationimpairment.8

Thefasciotomyincisionrepresentsitselfaninjurytothe patient; furthermore,it increasestheriskofinfections and the length of hospital stay. Several procedures have been describedforclosingthistypeofincision,usingvarioustypes ofmaterials;thereareevenreportsontheuseofproperly ster-ilizedcommonelasticstringfixatedtotheskinadjacenttothe incisionwithsurgicalsuture,providinggoodapproximationof thewoundedgesinjust5daysaftertheprocedure,withfull

Fig.4–(a)Zero-hourelasticsuture;(b)48hofelasticsuture;(c)skinaspectafterremovaloftheelasticsuturekeptfor7

106

closureoftheskin20daysaftersurgery,withouttheneedfor secondaryskinsuture.9_{Inthepresentcase,theelasticsuture}

effectively assisted thedefinitive closure ofthe fasciotomy incision allowingasecondarysuture, andwaivedthe need foranautograftskin,beingafeasible,easy-to-perform,and low-costtechnique.

Thereisanassociation betweentibialfractures andthe developmentofcompartmentsyndrome.Differential diagno-sisfromearlyrecognitionofsignsandsymptomsisnecessary forinitiatingappropriatetherapy,whichimprovesprognosis andreducesthemorbidityrate.Legfasciotomyclosure10_with

elasticsutureischeapermethodandcontributestoashorter hospitalstaywhencomparedtothevacuumtechnique.11

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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