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      Closed Incision Negative Pressure Wound Therapy in the Management of a Complex Fasciotomy Wound in a Pediatric Patient

      case-report
      1 , , 2 , 3 , 4
      ,
      Cureus
      Cureus
      compartment, syndrome, pediatric, forearm, fracture, fasciotomies, negative pressure wound therapy, wound vac

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          Abstract

          Acute compartment syndrome (ACS) is a known entity that most often occurs in the setting of trauma in both adult and pediatric patients. Fasciotomy remains the gold standard treatment for relieving intracompartmental pressures but is associated with significant complications. Significant variability exists regarding fasciotomy wound management and closure. We present the only known case report on use of circumferentially applied negative pressure wound therapy instill and dwell (NPWTi-d) followed by circumferentially applied closed incision negative pressure wound therapy (ciNPWT) for the soft tissue management of delayed ACS in a pediatric patient.

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          Most cited references18

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          Effects of vacuum-assisted closure on wound microcirculation: an experimental study.

          To study the mechanism through which vacuum-assisted closure (VAC) induces an increase in blood flow and reduces oedema on skin wounds. Thirty-two Japanese large-ear white rabbits were used. A round full-thickness skin defect (retaining the perichondrium), 2 cm in diameter, was created on each dorsal ear. The wound on the left ear was assigned to the experimental group, and the wound on the right ear to the control group. In the experimental group, the sterile foam dressing was trimmed to the appropriate size and geometry for the given wound and placed into the wound defect. The surface of the wound containing the foam dressing was covered with an adhesive drape to create an airtight seal. Afterwards, negative pressures of -5, -10, -15 and -20 kPa were exerted on the same wound, each lasting for 20 minutes, at intervals of 10 minutes. In the control group, the wound was treated with petrolatum gauze only. At different time points, the microcirculation microscope and image pattern analysis were used to observe the variation in wound microcirculation through a detective window. It was found that VAC promoted capillary blood flow velocity, increased capillary calibre and blood volume, stimulated endothelial proliferation and angiogenesis, narrowed endothelial spaces, and restored the integrity of the capillary basement membrane. By increasing capillary calibre and blood volume and by stimulating angiogenesis, VAC could improve blood circulation in wounds. By narrowing endothelial spaces and by restoring the integrity of capillary basement membranes, VAC could decrease the permeability of blood vessels and wound oedema.
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            Angiogenesis in wounds treated by microdeformational wound therapy.

            Mechanical forces play an important role in tissue neovascularization and are a constituent part of modern wound therapies. The mechanisms by which vacuum assisted closure (VAC) modulates wound angiogenesis are still largely unknown. To investigate how VAC treatment affects wound hypoxia and related profiles of angiogenic factors as well as to identify the anatomical characteristics of the resultant, newly formed vessels. Wound neovascularization was evaluated by morphometric analysis of CD31-stained wound cross-sections as well as by corrosion casting analysis. Wound hypoxia and mRNA expression of HIF-1α and associated angiogenic factors were evaluated by pimonidazole hydrochloride staining and quantitative reverse transcription-polymerase chain reaction (RT-PCR), respectively. Vascular endothelial growth factor (VEGF) protein levels were determined by western blot analysis. VAC-treated wounds were characterized by the formation of elongated vessels aligned in parallel and consistent with physiological function, compared to occlusive dressing control wounds that showed formation of tortuous, disoriented vessels. Moreover, VAC-treated wounds displayed a well-oxygenated wound bed, with hypoxia limited to the direct proximity of the VAC-foam interface, where higher VEGF levels were found. By contrast, occlusive dressing control wounds showed generalized hypoxia, with associated accumulation of HIF-1α and related angiogenic factors. The combination of established gradients of hypoxia and VEGF expression along with mechanical forces exerted by VAC therapy was associated with the formation of more physiological blood vessels compared to occlusive dressing control wounds. These morphological changes are likely a necessary condition for better wound healing.
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              Lower limb compartment syndrome: course after delayed fasciotomy.

              To determine the end result of patients who underwent delayed fasciotomy, i.e., more than 35 hours for an established lower limb compartment syndrome. A retrospective review of patients undergoing delayed treatment for a closed injury of the lower extremity, where fasciotomy should ideally have been performed earlier. Nine fasciotomies in five patients were identified where there was a delay of more than 35 hours after the injury. The average ischemic time was 56 hours (range 35-96 hours). One patient died of multiorgan failure and septicemia. The remaining four patients required lower limb amputation, because of local infection and septicemia. The one late amputation was performed 6 months after the injury, because the patient was left with a functionless insensate foot. Where recognition of an established compartment syndrome is delayed for more than 8 to 10 hours, we propose that the traditional inevitable fasciotomy be reassessed.
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                Author and article information

                Journal
                Cureus
                Cureus
                2168-8184
                Cureus
                Cureus (Palo Alto (CA) )
                2168-8184
                25 March 2020
                March 2020
                : 12
                : 3
                : e7413
                Affiliations
                [1 ] Orthopedics, John A. Burns School of Medicine, Honolulu, USA
                [2 ] Orthopedic Surgery, University of Hawaii, Honolulu, USA
                [3 ] Orthopedic Surgery, John A. Burns School of Medicine, University of Hawaii, Honolulu, USA
                [4 ] Orthopedic Surgery, Queen's Medical Center, Honolulu, USA
                Author notes
                Article
                10.7759/cureus.7413
                7182160
                7610b241-1327-43d7-a0ce-39082abe11fa
                Copyright © 2020, Lee et al.

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 7 March 2020
                : 25 March 2020
                Categories
                Pediatric Surgery
                Orthopedics
                Trauma

                compartment,syndrome,pediatric,forearm,fracture,fasciotomies,negative pressure wound therapy,wound vac

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