Exposed Brachial Artery Managed with Dermal Substitute as the Savior: A Case Report
Article information
Abstract
Managing crush injuries of upper extremities with severe devitalization of surrounding tissues is often complicated by limited covering options. A 46-year-old male patient presented 4 days after sustaining a crush injury, for which he had undergone vascular repair at another hospital. The patient had extensive necrosis of forearm muscles, with uncertain vascularity of the hand. Debridement of the wound exposed the brachial artery; viability of the hand was still uncertain. Lacking healthy surrounding tissue for coverage, and also to minimize donor site morbidity in a limb with an uncertain prognosis, a dermal substitute was utilized to protect the exposed brachial artery. After the progressive necrosis had stabilized and the dermal substitute had successfully integrated, skin grafting was performed. The patient experienced an uneventful recovery and is now scheduled for functional restoration procedures in the near future. The dermal substitute was instrumental in managing this difficult situation.
Introduction
Crush injury of extremities is a common presentation in trauma. The varying degrees of skin to bone involvement tend to complicate the management of such injuries [1]. Vital structures, including bones, nerves, and blood vessels, are often exposed in these cases. Among such structures, exposed blood vessels carry a significant risk of thrombosis, loss of limb vascularity, desiccation, and even blowout, which can pose serious threats to both limb viability and the patient’s life. Ideally, these exposed vital structures should be covered with well-vascularized tissues from the surrounding areas. However, when local tissues are insufficient, surgeons face the challenge of sourcing alternatives from regional or distant sites [2]. Such tissue transfers, while necessary, often come at the significant cost of donor site morbidity [3]. We present a case of an upper limb crush injury with questionable viability and an exposed brachial artery, accompanied by insufficient surrounding soft tissue for coverage. The wound was initially managed with the temporary application of a dermal substitute, followed by the provision of definitive wound coverage. The patient provided written informed consent for the publication and the use of his images.
Case
The patient, a 46-year-old male, sustained a crush injury to his left arm in a motor vehicle collision. He was promptly transported to a nearby hospital where he received initial resuscitation and stabilization. Clinical evaluation revealed a comminuted fracture of the left distal humerus accompanied by loss of vascularity of the left upper extremity. Additionally, the flexor muscle group in the forearm was exposed. On arrival, the patient was conscious, with stable vital signs, and underwent immediate surgical intervention at the admitting hospital. An external fixator was applied to stabilize the comminuted fracture of the left distal humerus, and microvascular surgery was performed to repair the brachial artery. The forearm muscles were loosely tagged and stay sutures on the skin were applied to the skin for temporary closure. The time interval between the injury and revascularization of the upper limb was 8 hours. Four days after the accident, the patient was referred to us for further management. On examination at arrival, there was severe necrosis of the forearm muscles and vascularity of the hand was uncertain (Fig. 1). The patient had no sensation on the palmar aspect of his hand; neither could he move his fingers, and the left hand was colder than his right hand. Doppler evaluation of the radial artery at the wrist demonstrated only a faint signal, and capillary refill in the fingers was notably delayed. During debridement, all the flexor muscles excluding the pronator teres, flexor carpi radialis and a part of the flexor digitorum superficialis were found to be necrosed and were hence removed along with the sloughed median and ulnar nerves. There was circumferential skin loss in the proximal forearm. During the debridement process, approximately 5 cm of the brachial artery in the cubital fossa was exposed (Fig. 2). Though the hand and the remaining muscles appeared to be viable, this was yet uncertain. Given the uncertain viability of the hand, the absence of suitable local flaps for arterial coverage, and in accordance with the preoperative discussion with the patient, the decision was made to forgo major reconstructive efforts.
Profound necrosis of forearm muscles.
Exposed brachial artery (marked with arrow) during debridement.
The following day, we performed bedside covering of the exposed brachial artery with 2 mm dermal substitute MatriDerm (MedSkin Solutions Dr. Suwelack AG) (Fig. 3). The MatriDerm was hydrated with saline and covered with paraffin gauze and a bulky dressing. Paraffin dressings were changed daily on the MatriDerm, while the rest of the wound was covered with povidone-iodine-soaked gauze dressings. Dressings were changed once daily or whenever they were found to be saturated. At 1 week, there was no further necrosis, and hand and muscle viability were confirmed. By this time, the MatriDerm had successfully integrated, providing effective coverage for the exposed brachial artery (Fig. 4). Split skin graft (SSG) was subsequently performed. The graft demonstrated good uptake across all areas, including the region where MatriDerm covered the vessel (Fig. 5). Daily dressing with paraffin gauze was provided for 2 weeks. At the 3-month follow-up, the patient exhibited no active flexion of the fingers or wrist. However, finger extension power was showing gradual improvement. The patient is currently undergoing physiotherapy to enhance tendon gliding. There is no sensation on the palmar aspect of the hand, but the radial artery is palpable at the wrist. At present, the patient has a stable wound and is scheduled for definitive fixation of the humerus, followed by reconstructive surgeries aimed at improving hand function and restoring sensation (Fig. 6).
Artery covered by MatriDerm (MedSkin Solutions Dr. Suwelack AG).
Incorporated MatriDerm over the brachial artery (marked with arrow).
Definitive cover by skin grafting.
Final stable cover on brachial artery at 3 months.
Discussion
Stable coverage of vital structures is an integral part of successful reconstruction. Exposed blood vessels require meticulous management to prevent complications, as they are particularly susceptible to desiccation, thrombosis, mechanical injury, and blowout [4]. In severe crush injuries, a deficiency of surrounding healthy tissue is frequently encountered, necessitating the exploration of alternative treatment options. We discussed with the patient the possibility of free tissue transfer using a flow-through flap. However, the patient refused to undergo this major surgical procedure.
A less complicated reconstructive option was to use a SSG, known as a reliable biological dressing. Thione et al. [5] used SSG on exposed pedicles of free tissue transfer to avoid catastrophic compression, exposure and infection. For finger injuries, Han and Min [6] used SSG on 15 free flaps with exposed pedicles, demonstrating successful outcomes in all such cases. Cha et al. [7] used full-thickness skin grafts (FTSGs) on the exposed pedicles of free flaps and replanted fingers, and proposed that FTSG is superior to SSG as it provides a sturdy dermis, a thick layer of coverage and also hidden donor areas in the groin.
Although both options are effective for successful reconstruction, they come with the drawback of donor site morbidity. Furthermore, in this case, the viability of the upper limb distal to the site of exposure remained uncertain even after debridement, adding to our reluctance to perform a skin graft, as the patient may have needed an amputation shortly after. For the same reason we did not opt for free tissue transfer to cover the exposed vessel; this was also discussed with the patient.
Instead, we used readily available material, 2 mm MatriDerm, to cover the exposed brachial artery. Use of MatriDerm eliminates the risk of donor area morbidity, and also provides a thicker layer of reconstruction compared to a skin graft. We were able to perform an SSG to heal the wound once the viability of the extremity was confirmed and MatriDerm had integrated on the vessels.
Turfe et al. [8] utilized Integra (Integra LifeScience) to cover the exposed pedicle of a radial artery forearm free flap (RAFF) during total nasal reconstruction for a gunshot injury to the face. The RAFF was employed for nasal lining, while the forehead flap was delayed during the initial procedure. The silicone layer of Integra was removed after 4 weeks when the pedicle was covered with the matrix. The delayed forehead flap was turned down to cover the cartilaginous support provided in a second attempt.
Leclere et al. [9] used Integra to cover pedicles of ten free flaps for lower limb reconstruction. While they had no flap failure, three of the cases required revision due to hematoma under the dermal substitute. The hematoma was removed in the operating room and a new dermal substitute was applied. A skin graft was performed for these areas after 3 weeks, eventually completing the wound healing. The hematoma collected under this dermal substitute was caused by the impervious silicone layer of the bilayer matrix. Fortunately, the transparent silicone layer allowed the clinicians to detect the color change from the hematoma [9].
Among the variety of dermal substitutes available for reconstruction, we were inclined to focus on single-layer dermal templates, as bilayer dermal substitutes with silicone layers typically take 3 weeks for integration. MatriDerm became our material of choice because it is a single-layer collagen elastin matrix which integrates faster and also because the porous composition of the template reduces the chances of developing hematoma or seroma. MatriDerm can also be chosen in a 2-mm-thick configuration, more robust than any other substitute. However, notwithstanding such advantages, the chance of potential complications with this procedure such as bleeding and blowout still persists. It is essential that the possibilities are discussed with the patient before embarking on this process.
This method of reconstruction has several limitations. First, it has only been performed and documented in a single case. Second, it is inferior to flap coverage, as it cannot achieve the same level of suppleness. Secondary reconstruction using a dermal substitute is inherently more challenging compared to flap coverage. Lastly, the aesthetic outcome falls short when compared to that achieved with flap reconstruction.
The patient has lost most of his flexor muscle mass, rendering the hand nonfunctional. Additionally, the loss of both the ulnar and median nerves has resulted in a complete lack of sensation. The reconstructive journey for this patient is only in its early stages. Once definitive bony fixation of the humerus is done, he will need supple soft tissue coverage on the forearm. The patient will then undergo a series of staged reconstruction, including nerve grafting to recover sensation of his hand and free-functioning muscle transfer for restoring hand movements. Finding a suitable recipient vessel for such procedures is one of the anticipated challenges. We will also need to closely observe the patient’s extensor muscle recovery so that tendon transfer can also be considered as an option.
Dermal matrices have become an integral part of reconstructive procedures. They are now routinely employed for covering vital structures such as bone, tendons, and nerves. The range of indications for these dermal templates has expanded significantly. Notably, they have been successfully utilized in intraoral reconstruction, where, in specific cases, they have eliminated the need for flaps and skin grafts while still yielding equally favorable outcomes [10-12]. The quality of reconstruction and coverage is as stable if not better than traditional methods in most situations, while at the same time minimizing donor area morbidity and reducing the complexity of surgery.
To the best of our knowledge, this is the first documented case where dermal matrix was employed for coverage of a major vessel such as the artery. Further research and long-term follow-up are necessary to assess the quality of reconstruction, which will determine whether this method is a viable alternative to traditional methods of reconstruction.
Crush injury to extremities is challenging as it requires both aesthetic and functional reconstruction. While utilizing autologous tissues to cover the exposed vital structures is the standard treatment, in some difficult scenarios as described in this study, the dermal substitute can be instrumental in managing wound coverage.
Notes
No potential conflict of interest relevant to this article was reported.