Adhesive Skin Closure Technique for Closure of Fasciotomy Wounds in Pediatric Patients: A Case Series

Background. Closure of fasciotomy wounds poses a challenge, particularly in pediatric cardiac patients who are too high risk for general anesthesia and often require anticoagulant treatment. The adhesive skin closure technique enables wound closure without the need for a secondary procedure such as surgery requiring anesthesia.   Objectives. This study sought to describe a treatment modality that assists in fasciotomy wound edge approximation without the need for surgery, while additionally aiding in achieving fast and aesthetic results in the aforementioned patient population. A case series of 4 pediatric patients with fasciotomy wounds is presented. Materials and Methods. Adhesive skin closure strips (Steri-Strips, 3M, St. Paul, MN) were placed perpendicular to the cleansed wound leaving small gaps for drainage, thus achieving complete propinquity. The strips were replaced sequentially with new strips every 2 to 3 days. Digital pictures of the wounds were obtained until complete closure of the wounds was achieved. Outcome variables included wound closure success rates and complication rates including infection, bleeding, and late scar formation. Results. Patient ages ranged from 2 weeks to 2 years, 9 months (mean: 10.5 months), average period of open wound prior to closure was 6.75 days (range: 5-11 days), treatment duration ranged from 15 to 26 days (mean: 21 days), and average follow-up was 4.5 months. One patient died due to their primary condition. No local infections, wound dehiscence with the treatment regimen, or any other immediate complications were encountered. There was a late complication in 1 patient who presented with a hypertrophic scar. Conclusions. Use of the adhesive skin closure method to close fasciotomy wounds in pediatric patients in which surgical procedures were nonadvisable produced favorable results.

  Performing a fasciotomy to alleviate tissue pressure in compartment syndrome is fairly common.^1-4 Once the compartment pressure has been relieved and stabilized, the fasciotomy wounds should be closed as quickly as possible to avoid later complications. Management of these types of wounds usually consists of coverage with split-thickness skin grafts, tertiary surgical closure of the defects, or healing by secondary intention.^1,2 In addition, advanced dressing regimens, such as hydrofiber dressings or negative pressure wound therapy, are used to cover the wound.^1,4 Tertiary closure usually provides the best outcome in terms of long-term scarring and aesthetic appearance, but is not always feasible due to skin retraction and concomitant residual tissue edema and protrusion,² which prevent the possibility of good approximation of wound edges.

  In some patients, even when tertiary closure is feasible in terms of wound edge mobility, surgical intervention is not advisable due to the patient’s general condition such as hemodynamic instability or a specific mandatory medication regimen such as anticoagulants. A treatment modality that can help in wound edge approximation without the need for surgery may aid in achieving fast and aesthetic results in this patient population. This study presents a case series of 4 pediatric patients whose fasciotomy wounds were treated with a new modality that involves wound edge approximation using sterile surgical tape adhesive strips (Steri-Strips, 3M, St. Paul, MN).

  Between 2010 and 2011, 3 pediatric cardiac intensive care unit (ICU) patients and 1 trauma patient were referred to the Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel HaShomer, Israel for management following a fasciotomy. The underlying reason for the fasciotomies varied from a leak of an intravenous line in a limb, to crush injury, to deep vein thrombosis. One patient being treated for a crush injury and 1 being treated for thrombosis showcased clinical signs of compartment syndrome, such as a decreased peripheral pulse in the affected limb, while 2 patients with line leaks showed only preliminary signs of possible compartment syndrome formation, thus their fasciotomies were performed as a preventive measure. All 4 patients underwent 4-compartment fasciotomies. At time of referral, all 4 patients had bulging tissue present. In 3 patients, upon examination, all wound edges were easily approximated manually without tension. In the fourth patient, only the medial fasciotomy wound was suitable for approximation using adhesive skin closure strips, whereas the other wounds were not and, therefore, were treated conservatively until secondary closure.

  Before first treatment, wounds were cleansed and decontaminated thoroughly using chlorhexidine gluconate. Adhesive skin closure strips were then placed perpendicular to the wound, from one edge to the other, thus achieving complete propinquity. Small gaps were intentionally left between each strip to allow for drainage of possible wound secretions (Figure 1). The adhesive skin closure strips were replaced sequentially with new strips every 2 to 3 days to avoid reopening of the wound (ie, each adhesive skin closure strip was replaced with a new one before the adjacent one was removed). During dressing changes, wounds were again decontaminated to prevent future infection. Dressing changes took place in conjunction with the adhesive skin closure strips removal and reapplication at the bedside in the ICU, or in the outpatient clinic if the patient had been discharged, during which time the adhesive skin closure strips were replaced and digital pictures were taken of the wound. The dressing regimen was ceased following complete closure. Measured outcome variables included wound closure success rates and complication rates including infection as defined by redness, warmth, secretion, or fever; bleeding; and late hypertrophic/keloid scar formation.

Figure 1. Fasciotomy wound in shin (A) prior to treatment; (B) after the initial application of the adhesive skin closure strips; (C)11 days after application of the strips; and (D) at the 4-month follow-up visit.
 

  The patient demographics are summarized in Table 1. Patients ranged in age from 2 weeks to 2 years, 9 months (mean: 10.5 months). The average period of time the wound was open prior to closure was 6.75 days (range: 5-11 days) and treatment duration ranged from 15 to 26 days (mean: 21 days). The average follow-up was 4.5 months and all the wounds treated healed uneventfully (Figure 2). One patient initially showed positive signs of healing with the dressing regimen but later died during hospitalization from a pre-existing cardiac condition. No local infections or wound dehiscence with the treatment regimen or any other immediate complications were encountered. Late complications occurred in 1 patient who presented with a hypertrophic scar on the dorsum of the foot and distal anterior shin during follow-up. This patient was treated with silicone sheeting and pressure garments and additional physical therapy was commenced.

Figure 2. Fasciotomy wound in thigh (A) prior to treatment; (B) 8 days after the initial application of adhesive skin closure strips;and (C) at the 4-month follow-up visit.

  Conservative treatment of fasciotomy wounds typically consists of wet-to-dry dressings until tertiary closure is possible or until secondary closure is achieved. Such treatment results in a higher rate of infection, longer hospitalization length, and poorer aesthetic results in comparison with other techniques.^1,2

  Split-thickness skin grafting is a quick and popular technique, but sometimes requires eventual scar revision or resection for cosmetic reasons due to the resulting deformation and unsightly, depressed scars.¹ Tertiary closure results in a more functional and aesthetic outcome with less morbidity, but can often be difficult to achieve due to residual muscle edema, skin retraction, and skin edge necrosis.¹ Negative pressure wound therapy can promote wound healing by reducing wound edema, increasing microcirculation, and causing stimulation of granulation tissue, thus hastening wound healing and possible eventual secondary healing or definitive closure either by tertiary closure or by skin grafting.² All of these solutions are often associated with a return trip to the operating theatre, a prolonged hospital stay, or both.

  Several methods have been described as alternatives for the closure of fasciotomy wounds, most of them using a dermatotraction technique.³ The dermatotraction technique with vessel loops involves a process where the vessel loops are placed intraoperatively during the compartment release and are attached to the wound margins using standard skin staples. Another option, the skin approximation system, uses the fixation of plates to both wound edges with staples while covering the wound, progressively applying traction until wound tension is relieved. A third method consists of a prepositioned intracutaneous suture which allows gradual tightening of the suture until sufficient approximation is achieved. Ty-Rap cable ties (Thomas & Betts, Memphis, TN) have also been used for patients with trauma to close fasciotomy wounds by placing them intraoperatively, similar to vessel loops, with the advantage of greater availability, lower cost, and a minimal need for secondary procedures.⁴ Some of these methods also result in a need to perform a skin graft or a second surgery for tertiary closure of the wound.⁵

  A systematic review and meta-analysis of management of surgical incisions compared adhesive skin closure strips with sutures, staples, tissue glue, or a combination of several methods.⁶ The results indicated adhesive skin closure strips were associated with faster healing and less redness. No significant difference in dehiscence rate was reported. One study found a higher rate of re-suturing among the adhesive skin closure strips group.⁶ A lower incidence of redness was also found in a study comparing the use of adhesive skin closure strips with sutures for closure of sternotomy wounds.⁷ However, the meta-analysis excluded all studies in the pediatric population. A review of the existing literature regarding fasciotomy wound closure in the pediatric population identified 1 randomized controlled trial that found no statistically significant differences in complications while comparing a tissue adhesive (Dermabond, Ethicon US, LLC, Somerville, NJ) to adhesive skin closure strips for closure of trocar wounds.⁸ Three additional articles regarding pediatric compartment syndrome either 1) did not mention method of fasciotomy closure,⁹ 2) reported the use of skin grafts,¹⁰ or 3) reported the use of vacuum-assisted closure and sutures, or leaving the wound for tertiary closure.¹¹

  In some patients, even when tertiary closure is feasible in terms of wound edge mobility, surgical intervention is not advisable due to the patient’s general unstable condition or use of anticoagulants. Pediatric cardiac patients are often hemodynamically unstable, especially immediately after heart surgery, and many require anticoagulant treatment. These patients are also prone to intravenous catheter leaks and deep vein thrombosis, which may lead to compartment syndrome and subsequently result in an open fasciotomy wound.

  The adhesive skin closure technique offers physicians a simple, nonsurgical way of treating fasciotomy wounds, especially in the pediatric patient population. It enables wound closure without the need for a secondary procedure and, unlike other methods, it can be applied without anesthesia and without the need to purchase or to presterilize special equipment.

  In all cases in the current study, wounds were closed in a short period of time except in 1 patient who died during their stay in the pediatric ICU as a result of respiratory and hemodynamic instability after extubation. Another patient developed a hypertrophic scar; however, this may be attributed to the location of the scar over a joint and perhaps to the patient’s scar-forming tendency.¹²

  The authors note the adhesive skin closure strips brand used in this study was the most accessible in their facility; however, they think the use of adhesive skin closure strips as a technique, rather than a particular brand, is of importance. The authors caution not all fasciotomy wounds are suitable for tertiary closure due to possible aforementioned edema and skin retraction and, hence, this closure method is not always suitable.

  Following this case series, the authors recommend the adhesive skin closure strips method as an option for closure of fasciotomy wounds in pediatric patients in whom surgical procedures are not advisable and wound edge approximation is feasible. This method has been demonstrated to be efficacious, easy to perform, and complication free. However, it has been examined only in the pediatric population, and it is likely to be less successful in adults with large wounds due to reduced pliability of the tissue compared with that of small children. Furthermore, due to the limited sample size, further studies need to be done in order to reach statistically significant conclusions.

*Oren Weissman, MD; *Noga Goldman, MD; Demetris Stavrou, MD; Liran Barzilai, MD; Gil Grabov Nardini, MD; Nimrod Farber, MD; Isaac Zilinsky, MD; Eyal Winkler, MD; and Josef Haik, MD, MPH are from the Department of Plastic and Reconstructive Surgery, Sheba Medical Center, Tel HaShomer, Israel. Oren Weissman, MD, is also the 2015 Dr. Pinchas Borenstein Talpiot Medical Leadership Program at The Chaim Sheba Medical Center, Tel HaShomer, Israel; and Josef Haik, MD, MPH, is from The Talpiot Medical Leadership Program at The Chaim Sheba Medical Center, Tel HaShomer, Israel

*These authors contributed equally to this work.

Address correspondence to:
Liran Barzilai, MD
Department of Plastic and Reconstructive Surgery
Sheba Medical Center
Tel Hashomer, 52621
Israel
liran.barzilai@gmail.com

Disclosure: The authors disclose no financial or other conflicts of interest.