The Use of Multiple Negative Pressure Wound Therapy Modalities to Help Manage Extensive Wounds Caused by a Crush/Sheer Injury

Terri Reed, BSN, RN, CWON

Disclosures

Wounds. 2020;32(12):369-371. 

In This Article

Case Report

This is the case of a 22-year-old male, who was in his normal state of health at the time of the vehicular run-over accident. During a college celebration, the patient fell off a parade float and was run over by the next float in the parade. The injuries were severe and life-threatening, so the patient was rushed to the local hospital and stabilized. From there, the patient was flown by helicopter to a level 1 trauma center where he underwent emergency surgery to evaluate and repair the most life-threatening injuries and to assess for internal bleeding The patient's injuries included multiple facial fractures and lacerations, bilateral acetabular fractures, superior and inferior pubic rami fractures, left sacral fracture, left compartment syndrome, and degloving injury of the scrotum and perineum with distraction of the testicles from the scrotum (Figure 1).

Figure 1.

Complex wound resulting from crush/sheer force. (A) Anterior view showing the wound region encompassing the legs and inguinal area; (B) magnified anterior view of the wound showing the extent of the upper leg wound encompassing the perineal and scrotal regions; and (C) an inferior view showing the perineal, rectal, and scrotal areas of the wound.

Initially, treatment focused on stabilization. The plastic surgery service was consulted as well as vascular surgery, orthopedic surgery, an ear nose and throat specialist, and the trauma service. At 3 days post injury, the patient underwent open reduction and internal fixation of the left parasymphyseal fracture, left muscle flap for coverage of the exposed femoral artery patch, and a diverting colostomy due to the exposed perineum (Figure 2). At 10 days post injury, the patient was taken back to the operating room for debridement of the necrotic and infected pubic bones bilaterally, placement of the right rectus abdominus pedicle muscle flap for coverage of the left groin, scrotal debridement, and pouching of the right testicle in the upper right thigh (Figure 3). Negative pressure wound therapy was applied to maintain the integrity of the tissue after this debridement and changed every 3 days, most of the time in the operating room.

Figure 2.

Approximately 3 days post injury, an inferior view of the wound bed is shown in the operating room.

Figure 3.

Approximately 10 days post injury, the wound underwent muscle flap reconstruction before the placement of acellular skin.

The patient developed wound complications, including increased white blood cell count and fever, indicating a possible wound infection, which would be potentially life-threatening in this already compromised patient. At approximately 32 days post injury, the decision was made by the plastic surgeons to apply NPWTi-d (V.A.C. VERAFLO Therapy; 3M + KCI) (Figure 4). The device was applied by intermittently instilling 60 mL of normal saline with a 10-minute dwell time, followed by negative pressure at -125 mm Hg for 3.5 hours; NPWTi-d was applied for 11 days with dressing changes every 2 to 3 days.

Figure 4.

Approximately 32 days post injury and 9 days following placement of the acellular artificial skin. Upon developing complications, the patient was transitioned to negative pressure wound therapy with instillation and dwell time for 11 days.

At approximately 41 days post injury, the patient's surgeons determined the wounds were ready for grafting. The patient underwent split-thickness skin grafts to the left thigh, perineum, right thigh, and right arm (Figure 5). Traditional NPWT (V.A.C Therapy; 3M + KCI) then was applied using a special 4-chamber pump because there were multiple wounds to cover. The NPWT dressing served as a bolster to achieve adherence of the skin grafts. At 49 days post injury, NPWT was discontinued, and Polymem WIC Silver (Ferris Mfg. Corp.) dressing was applied on all skin graft sites. The dressing was changed daily at the patient's bedside until discharged to a rehabilitation facility at 80 days post injury.

Figure 5.

Approximately 41 days post injury, the recipient graft site is shown.

Due to the extent of the injuries and major life alterations that they caused, the patient struggled emotionally with the fear of possibly not being able to walk, hesitations involving body image issues, and concerns over the whole recovery process. The patient's parents were very involved in their son's care regimen, especially learning to care for the colostomy. The patient became depressed, not wanting to eat or engage in conversation. The psychology service was consulted, and the patient was prescribed an anti-depressant that helped improve mood and change his outlook on life—the patient realized that if the patient was going to get better, he had to want to get better.

The patient achieved full recovery after spending almost 4 months in the hospital and a rehabilitation facility. The patient has resumed all activities of daily living (Figure 6).

Figure 6.

(A) Patient at the 5-month follow-up visit; and anterior views of the patient's (B) upper left thigh, and (C) inguinal region are shown.

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