CHALERMPONG CHATDOKMAIPRAIChief of Plastic Surgery Division

FACULTY OF MEDICINE, RAMATHIBODI HOSPITAL

MAHIDOL UNIVERSITY

COMPLEX WOUND MANAGEMENTEXPOSED TENDON

Annual meeting of Burn and Wound healing Association1-3 May 2017“Go Together for Best Practice in Wound and Burn Care”

Grasping/Pinching

JOINT/BONE

MOTOR/SENSORYMUSCLE/TENDON

Hand function Foot function

Walking/stopping

JOINT/BONE

MOTOR/SENSORY

MUSCLE/TENDON

Heal padding

Anatomical structures that connect bone to muscle

Nourished by blood vessels and synovial fluid

Ability to glide within tendon sheath creates joint movement

Tendons

Initial

• get rid of infection, FB, necrotic tissue

• Vascular and skeletal stabilization

Delayed

• Nerves

• Musculotendinous

• Skin & soft tissue

Post op

•Rehabilitation

•Late reconstruction

Management

Initial Rx

Underlying and associated injury

Injured structures

Degree of contamination

Vascular and skeletal

stabilization

Decision for initial management

Initial management

Initial Rx

Underlying and associated injury

Injured structures

Degree of contamination

Vascular and skeletal

stabilizationDebridement

Primary or secondary

repair

Skin and soft tissue

coverage

Bone

•Fixation technique

Tendon

•Primary

•Delayed

Nerve

•Motor

•Sensory

Skin/soft tissue

•Graft

•Flap

Delayed management

Initial Rx

Underlying and associated injury

Injured structures

Degree of contamination

Vascular and skeletal

stabilization

Primary closure

Graft Flap

Skin and soft tissue coverage

Immediate or delayed

Wet dressing

Silver sulfadiazine

Negative pressure wound therapy

Silver-impregnated absorbent

Wound dressing for delayed coverage

Extravasation injury

After 2-week silver sulfadiazine

NPWT

Pressure ulcer

Day 0

Day 7 Day 104

Fixation

Necrotizing fasciitis

Day 0

Day 386

4 years and 6 months

Degloving injury

Day 0 Day 30

Day 44

Immediate

Primary

Graft

Staged

Delayed

Primary

Graft

Staged

Tendon transfer

Tendon repair

Coverage of exposed tendon

Dead tendons, fascia

Reversed RFF

Reversed posterior Interosseous

Abdominal flap

Mutilated hand

{

Chronic ulcer with Abscess at 2nd toe

Extravasation ulcer

Day 0 Day 13

Day 132

Medial head of gastrocnemius

LD+graft

ALT

ALT / sural flap

Form and function

restoration

Operation

Rehabilitation

Post-operative management

Initial

• get rid of infection, FB, necrotic tissue

• Vascular and skeletal stabilization

Delayed

• Nerves

• Musculotendinous

• Skin & soft tissue

Post op

• Rehabilitation

• Late reconstruction

ConclusionAdjacent structures

skinbone/jointneuro-motor