Reconstructive Strategies and Wound Management in Severe Pediatric Injuries of the Lower Limbs: Lessons From a Case Report

Introduction. Severe injuries to lower limbs occurring in the pediatric population represent a unique challenge for reconstructive surgeons. The need for optimal anatomical repair and functional recovery must take into consideration several variables that may remarkably affect overall outcomes, length of hospitalization, and quality of life during recovery. The most appropriate therapeutic strategy should be based on the accurate planning of the least-invasive wound management, in terms of pain or other symptoms, local morbidity, and systemic response. Materials and Methods. With the purpose of discussing these issues, the authors present an illustrative case report of a 5-year-old child affected by a severe traumatic injury to the left leg complicated by wound hemorrhage as the result of a car accident. The vast loss of soft tissue was successfully treated by promptly staged surgical intervention and repair by using a regenerative dermal template. Results. Effective postoperative wound management and good compliance of the patient during hospitalization allowed for a substantial absence of complications and effective treatment of relevant symptoms. Conclusion. Excellent functional recovery at 12-month follow-up was achieved, as well as a good overall quality of life.

  In children, severe injuries to lower limbs represent a unique challenge for reconstructive surgeons. Functional impairment, psychological and emotional trauma, and social consequences of traumatic sequelae are often underestimated concerns.^1-5 Pediatric patients often have a poorer surgical prognosis because of their under-developed ability to face traumas and their immature immune system. If not correctly managed, these injuries may lead to selective amputations and other consequences.^6,7 Prompt surgical repair and accurate functional reconstruction must also be considered relevant to postoperative variables and may remarkably affect overall outcomes, such as length of hospitalization and quality of life, during recovery.^1-8 Unfortunately, literature regarding this topic is still scarce. With the purpose of discussing these issues, the authors present an illustrative case report of a 5 year-old child affected by a severe traumatic injury to the left leg due to a car accident.

An otherwise healthy 5-year-old male patient was admitted at the Pediatric Emergency Department at Padua University Hospital (Padua, Italy) in August 2011 for a severe trauma to the lower left leg due to a road accident. The injury involved the whole lower-third of the left leg, circumferentially, with a complete irregular loss of both the cutaneous and subcutaneous layers that resulted in a massive exposure of underlying fascial and muscular structures. Tibialis posterior muscle and flexor hallucis longus were partially disrupted together with their superficial fascia; no lesions of nerves, large vessels, or tendon structures were assessed and x-rays didn’t report signs of bone fractures. Systemic signs included a mild head trauma and mild dyspnea. Since the patient showed sudden signs of hypovolemic shock, likely due to hemorrhagic losses, he was treated for hemodynamic support with blood transfusions and plasma expanders until stabilization of systemic parameters. Even so, his condition was not considered suitable for major surgical procedures, thus he underwent only an accurate surgical hemostasis with partial wound debridement, myorraphy, repair of the fascial structures, and conservative dressing by means of nonadherent petroleum jelly-based gauze before hospitalization. Other treatments included antibiotic prophylaxis and standard analgesic therapy.

  On the second postoperative day, despite the lack of associated clinical signs or symptoms, a sudden decrease in hemoglobin values (5.9 g/dL) was observed, likely due to continuous petechial bleeding from the open wound. In addition, a concomitant increase of inflammatory markers (ie, C-reactive protein and erythrocyte sedimentation rate) with rising neutrophilic leucocytosis (16,000/mm³) was assessed. Thus, both conditions required prompt surgical intervention to provide an adequate coverage of soft tissue exposures that could limit further blood loss and that could lessen the significant risk of local infection, which, in turn, could have further worsened systemic conditions and the chances for surgical repair of local defects.

  Given the general condition of the patient, the authors considered it inadvisable to perform complex reconstructive surgeries as large pedicled or free flaps. In addition, easier surgical solutions offered by the reconstructive ladder, as full-thickness skin grafts or local flaps, were not suitable for a definitive repair due to the limited thickness and size of tissue available. Therefore, with the patient under general anesthesia, a secondary accurate debridement was performed to provide a viable wound bed, together with coverage of exposed soft tissue by means of a regenerative dermal substitute (Integra, Integra Life Sciences Corporation, Plainsboro, NJ). The graft was adequately shaped (10 x 25 cm²) and fixed with absorbable sutures and a tie-over compressive dressing of gauze moistened with saline (NaCl 0.9%) over the protective silicone layer of the substitute (Figure 1). During the following days no relevant complications were observed. In an effort to decrease medication-related pain and stress, dressing changes were scheduled every 2 days and consisted only in the changing of nonadherent wet gauze overlying the silicone layer after proper disinfection. The chosen surgical procedure and dressings allowed the patient partical mobility, thereby improving his compliance to the treatment regimen and quality of life. After 5 days the patient was discharged and dressing changes were done at the outpatient clinic. On the 15th postoperative day, the patient was admitted for final reconstruction by means of a full-thickness skin graft. Early rehabilitation therapy was introduced. A clinical follow-up was scheduled with medical examination every 2 months up to 12 months, at which a complete functional recovery with appropriate repair of subcutaneous and cutaneous layers that appeared smooth and viable was observed (Figure 1). Subjective symptoms were not reported and the aesthetic outcome could be considered good thanks to the absence of a hypertrophic scar.

Severe trauma of the lower limb occurring in children represents an engaging medical challenge from a therapeutic and surgical perspective.^1-8 Despite well-known healing potential and regenerative potential of pediatric patients, these patients still have an immature immune system and their ability to avoid local infections is highly limited during severe traumas.^9-14 Thus, prompt management of the injury is mandatory to decrease the risk of blood loss or infection, and to achieve the best functional outcome.^1,7 Literature regarding secondary procedures and management of complications is scarce.^1-8 As in the reported case, a subcritical general condition of the patient may not allow adequate complex reparative options such as free flaps or pedicled flaps that have been described in literature as salvage procedures for severe pediatric cases.^1,4,6-10 Furthermore, less-invasive treatments offered by the reconstructive ladder, such as standard full-thickness skin grafts or temporary coverage by means of homologous skin grafts, may result in ineffective coverage of exposed tissue. Conservative treatment by standard dressings, advanced dressings, and negative pressure therapy accounts for the same features.

  In the current case, the vast loss of soft tissue in the critical patient was successfully treated by a promptly staged surgical repair using a regenerative dermal template. Regenerative dermal templates have been employed in many different surgical conditions and regions of the body in adult cases, but a growing number of reports describe pediatric cases.^15-17 This strategy, already well-established in traumatic injuries affecting adults, is still at preliminary stages in the treatment of children despite the discussed potential opportunities to enhance the management of severe cases.^18-22

  The authors considered the chosen strategy a valid choice, offering a rapid and less-invasive surgical procedure achieving long-term definitive and effective coverage by means of a full-thickness skin graft to protect underlying exposed tissue from infection, bleeding, or further loss of soft tissue. In addition, multiple reinterventions and painful dressing changes were avoided, which was the authors’ main purpose to ensure a reasonable hospitalization and wound-healing experience for the pediatric patient. The use of the dermal regenerative substrate combined with effective postoperative wound management resulted in the substantial absence of relevant symptoms associated to the dressing changes as well as good pain control during hospitalization and outpatient care. Significantly, this patient did not require any systemic analgesic drug during dressing changes or physiotherapy and specific psychological support. He showed a good compliance to treatments, achieving an excellent functional recovery at the 12-month follow-up. These factors led to an overall valuable quality of life with which the patient’s parents were satisfied. An aesthetically acceptable appearance was also obtained.

  Despite the development of novel effective techniques and procedures, challenging cases of reconstruction of the lower leg are still frequent and debates regarding the most optimal treatment are ongoing. In conclusion, a surgical strategy based on the prompt application of a dermal regenerative template in severe traumatic injuries of the lower limb may represent as valuable a therapeutic opportunity in the pediatric population as in adult patients. Remarkably, this approach may achieve outstanding functional and aesthetic results, reasonably decreasing the rate of complications such as blood loss and infection of the wound, which may affect healing. In addition, it could support a less-invasive wound management protocol which promotes a shorter hospitalization and more optimal quality of life of the young patient during the healing process.

Affiliation: The authors are from the Clinic of Plastic Surgery, Department of Neurosciences, Padua University Hospital, Padua, Italy.

Address correspondence to:
Vincenzo Vindigni, MD, PhD
Clinic of Plastic Surgery
Padua University Hospital
Monoblocco Ospedaliero, 5th floor
2, Via Giustiniani Street
Padua, Italy I-35000
vincenzo.vindigni@unipd.it

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