Introduction

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  Extensive blunt soft tissue trauma may occur after traffic accidents, falls from significant heights, and crush injuries. It is a common problem after major earthquakes or collapsed buildings (see Chapter 15, Disaster Medicine). Injuries can be closed, open, or both.

  
  
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  Extensive soft tissue trauma following penetrating injuries may occur after high-velocity bullet wounds, closed-range shotgun injuries, and explosions (see Chapter 11, Ballistics).

  
  
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  Severe soft tissue trauma is often associated with systemic complications, local tissue loss, infections, and limb loss.

  
  
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  Meticulous systematic and local examination should be performed to rule out other associated injuries. Locally, the physician should evaluate for underlying vascular, nerve, tendon, and bone injuries, as well as compartment syndrome.

  
  
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  Avulsion type injuries occur when a flap of tissue is separated from underlying tissue structures. The most extreme form of this injury is a degloving injury, which occurs when all the skin and subcutaneous tissues are separated from the underlying fascia. Tissue ischemia and necrosis of the flap segment are common and may lead to areas of large soft tissue defects.

  
  
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  The Morel-Lavallée lesion is a closed, shear-force, degloving injury, which results in separation of the skin and subcutaneous tissue from the fascia over the underlying muscles. This space is filled with blood, lymph, or serosanguinous fluid. It is prone to infection and possible skin loss because of the disrupted blood supply and presence of devascularized tissue (Figure 9.1 A,B).

  
  
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  Mangled extremity injuries often involve soft tissue, neurovascular structures, and bones. These injuries require a multidisciplinary approach because of their complexity and high risk of serious complications, including amputation, renal failure, infection, and death (Figure 9.2, Figure 9.3).

Figure 9.1 A,B Morel-Lavallée lesion of the back (A) and right flank (B).

Figure 9.2 Auto-versus-pedestrian injury with significant tissue loss and an open femur fracture. The wound requires copious irrigation, intravenous antibiotics, and early coverage to reduce the risk of complications such as osteomyelitis.

Figure 9.3 Mangled extremity following a motorcycle collision. There is extensive soft tissue loss, vascular trauma, and fracture. The management of this injury is benefitted by a multidisciplinary team approach.

Complications

Systemic complications may occur after extensive soft tissue trauma:

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   1. Hypovolemic shock due to blood loss externally or into the tissues.

   
   
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   2. Renal failure due to rhabdomyolysis and myoglobinuria.

   
   
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   3. Electrolytic abnormalities, including hyperkalemia, hypocalcemia, and hyperphosphatemia. This specific combination of electrolytic abnormalities is highly cardiotoxic.

   
   
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   4. Hematological changes, including disseminated intravascular coagulopathy due to release of tissue thromboplastin from the injured tissues.

Local Complications

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   1. Compartment syndrome.

   
   
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   2. Infection of open wounds, hematomas, or devitalized tissue. In severe cases, this may progress to necrotizing soft tissue infection.

Investigations and Monitoring

All patients with extensive soft tissue trauma should have serial monitoring of hemoglobin levels, platelet count, coagulation parameters, electrolytes, creatinine phosphokinase (CPK) levels, and recording of hourly urine output, as well as close monitoring for compartment syndrome (Figure 9.4 A,B). Vascular studies (CT angiography, vascular ultrasound, or formal angiography) should be performed as indicated to evaluate for associated vascular injuries.

Figure 9.4 A,B Violent beating on the buttocks and posterior thighs (A). These injuries place the patient at high risk of compartment syndrome, rhabdomyolysis, and renal failure. Note the brownish color of the urine due to myoglobinuria (B).

Management

The initial management should follow ATLS guidelines. The treatment should address local and systemic problems. The local care of large open wounds should be provided in the operating room, usually under general anesthesia. Only minor wounds should be managed in the emergency room. Antibiotic and tetanus prophylaxis should be administered routinely.

Initial local priorities should include hemorrhage control and a neurological exam. Hemorrhage control is best achieved with direct compression or application of a tourniquet. Blind clamping of bleeding vessels in the emergency department is not advised as this can lead to further neurovascular injury. Foley catheter balloon tamponade should be considered in deep bleeding wounds if direct compression is not effective and a tourniquet cannot be applied, such as in junctional injuries, or bleeding wounds in the buttock or neck (see Chapter 3, Neck Injury) (Figure 9.5, Figure 9.6, Figure 9.7 AC).

Figure 9.5 Victim struck by a train, resulting in on-scene amputation. Control of life-threatening bleeding with tourniquet application should be the most immediate priority.

Figure 9.6 Foley catheter balloon tamponade of severe bleeding from a penetrating injury to the buttock. The catheter is inserted in the wound tract and the balloon inflated in various parts of the tract until the bleeding is controlled. A clamp is applied on the catheter to prevent bleeding through the lumen.

Figure 9.7 A–C Mangled extremities. Bleeding control by direct pressure or tourniquet application is the first priority. Many of these cases require amputations. Attempts to salvage severely mangled limbs require a multidisciplinary team, multiple operations, and may result in serious complications and prolonged hospitalization, with ultimately low success rates.

Documentation of neurologic function and extent of tissue damage is important in cases where the extremity is unsalvageable and primary amputation necessary. The options of primary amputation, reimplantation, or limb salvage should be a multidisciplinary decision, taking into account the extent of the injury, other associated injuries, the clinical condition of the patient, hospital resources, and triage issues in mass disasters.

Primary repair of soft tissue wounds should be considered only in selected cases with clean incising wounds. In the majority of cases of extensive soft tissue trauma, the wound should be debrided and left open for delayed closure. In dirty wounds or in the presence of devitalized tissue, repeat surgical debridements in the operating room may be necessary. Negative pressure therapy, with or without an automated irrigation system, is helpful in removing any infected exudate and reducing wound volume (Figure 9.8 A,B). Negative pressure therapy is contraindicated in the setting of incomplete hemostasis because it may worsen bleeding.

Figure 9.8 A,B Extensive soft tissue trauma following impalement. The wounds were managed with negative pressure therapy and delayed closure due to the high risk of infection with primary closure.

In extensive soft tissue trauma, the risk of acute kidney injury can be reduced by early and aggressive fluid resuscitation, urine alkalinization with intravenous bicarbonate to maintain a slightly alkaline urine pH, and diuresis to maintain urine output >1 ml/kg/hour. Mannitol administration should be considered in hemodynamically stable patients with very high CPK levels.

In extremity or buttock soft tissue injuries, the muscle compartments should be monitored clinically, with serial CPK monitoring and compartment pressure measurements. In cases with a compartment syndrome, timely decompressive fasciotomies should be performed to avoid serious systemic or local complications (see Chapter 10, Extremity Compartment Syndrome).