COMPREHENSIVE APPROACH TO THE TREATMENT OF CONTAMINATED WOUNDS IN COMBINED LIMB INJURIES
Keywords:
extensive traumatic defects of the hand, crushing injury, tissue contamination, skin-plastic procedures, flaps, vacuum therapy, contaminated wounds, reconstructive hand surgery.Abstract
The relevance of research. Extensive traumatic defects of the hand accompanied by tissue crushing and contamination are among the most challenging injuries in emergency traumatology and reconstructive surgery. The high risk of infectious complications, the threat of loss of hand function, and the potential need for mutilating amputations determine the necessity for a comprehensive staged treatment strategy and early restoration of the skin and soft-tissue envelope.
Purpose of the study. To demonstrate the effectiveness of the differentiated use of skin-plastic procedures in extensive traumatic defects of the hand under conditions of tissue crushing and pronounced microbial contamination.
Material and Methods. The work is based on the results of treatment of patients at the Department of Vascular Surgery with Microsurgery of the Republican Scientific Center for Emergency Medical Care who presented with extensive hand defects resulting from industrial, road, and domestic injuries accompanied by soft-tissue crushing, damage to tendon-bone structures, and wound contamination. Treatment included radical primary surgical debridement, staged revisions using modern methods of local wound management, followed by skin-plastic interventions using local, regional, and free flaps.
Results and Discussion. A comprehensive strategy based on principles of managing contaminated wounds in combined limb injuries reduced the bacterial load in the wound, shortened the time required to prepare it for definitive closure, and created optimal conditions for performing skin-plastic procedures. The application of organ-preserving radical debridement of non-viable tissues, in combination with rational antibiotic therapy and modern local wound treatment technologies, ensured high flap survival rates, reduced the incidence of infectious complications, and decreased the need for repeated reconstructive interventions.
Conclusions. The presented clinical experience shows that a staged, comprehensive approach with early restoration of the skin and soft-tissue cover of the hand using differentially selected skin-plastic procedures enables, in most cases, preservation of the limb, reliable coverage of critical anatomical structures, and satisfactory functional and cosmetic outcomes.
References
1. Bashir MM, Sohail M, Shami HB. Traumatic Wounds of the Upper Extremity: Coverage Strategies. Hand Clin. 2018 Feb;34(1):61-74. doi: 10.1016/j.hcl.2017.09.007. PMID: 29169598. https://doi.org/10.1016/j.hcl.2017.09.007
2. Tos P, Crosio A, Pugliese P, Georgescu AV. Propeller Flaps for Hand and Digit Reconstruction. Semin Plast Surg. 2020 Aug;34(3):192-199. doi: 10.1055/s-0040-1715155. Epub 2020 Sep 22. PMID: 33041690; PMCID: PMC7542211. https://doi.org/10.1055/s-0040-1715155
3. di Summa PG, Davies K, Hart A. The first dorsal metacarpal artery perforator flap for coverage of dorsal finger soft-tissue defects. Case Reports Plast Surg Hand Surg. 2020 Aug 14;7(1):94-97. doi: 10.1080/23320885.2020.1806069. https://doi.org/10.1080/23320885.2020.1806069
4. Christopoulos G, Bruce LK, Morris MP, Swanson M, Kuzon WM, Morrison SD. The Reverse Radial Forearm Flap: A Template for Success. Plast Reconstr Surg Glob Open. 2022 May 17;10(5):e4338. doi: 10.1097/GOX.0000000000004338. https://doi.org/10.1097/GOX.0000000000004338
5. Benanti E, De Santis G, Leti Acciaro A, Colzani G, Baccarani A, Starnoni M. Soft tissue coverage of the upper limb: a flap reconstruction overview. Ann Med Surg (Lond). 2020 Nov 2;60:338-343. doi: 10.1016/j.amsu.2020.10.069. https://doi.org/10.1016/j.amsu.2020.10.069
6. Zhang Y, Gazyakan E, Bigdeli AK, Will-Marks P, Kneser U, Hirche C. Soft tissue free flap for reconstruction of upper extremity defects: a meta-analysis. Microsurgery. 2019 Jul;39(5):463-475. doi: 10.1002/micr.30460. https://doi.org/10.1002/micr.30460
7. Kawaiah A, Thakur M, Garg S, Kawasmi SH, Hassan A. Fracture Dislocations of the Hand. Cureus. 2020 May 26;12(5):e8291. doi: 10.7759/cureus.8291. https://doi.org/10.7759/cureus.8291
8. Yamakawa S, Hayashida K. Radial forearm flap: indications, technique and outcomes. Plast Aesthet Res. 2020;7:24. doi: 10.20517/2347-9264.2020.20. https://doi.org/10.20517/2347-9264.2020.20
9. World Health Organization. Global guidelines for the prevention of surgical site infection. 2nd ed. Geneva: World Health Organization; 2018. Available from: https://www.who.int/publications/i/item/9789241550475
10. National Institute for Health and Care Excellence (NICE). Surgical site infections: prevention and treatment. NICE guideline NG125. Published 11 April 2019; last updated 19 August 2020. Available from: https://www.nice.org.uk/guidance/ng125
11. Centers for Disease Control and Prevention (CDC). Surgical Site Infection Basics (SSI). Updated 11 April 2024. Available from: https://www.cdc.gov/hai/ssi/ssi.html
12. International Wound Infection Institute (IWII). Wound Infection in Clinical Practice: Principles of Best Practice. London: Wounds International; 2022. Available from: https://www.woundinfection-institute.com/wp-content/uploads/2022/10/IWII-Wound-Infection-in-Clinical-Practice.pdf
13. Eriksson E, Liu PY, Schultz GS, Martins-Green MM, Tanaka R, Weir D, et al. Chronic wounds: Treatment consensus. Wound Repair Regen. 2022 Mar;30(2):156-171. doi: 10.1111/wrr.12994. PMID: 35130362. https://doi.org/10.1111/wrr.12994
14. Shen AZ, Taha M, Ghannoum M, Tyring SK. Biofilms and Chronic Wounds: Pathogenesis and Treatment. J Clin Med. 2025 Nov 2;14(21):7784. doi: 10.3390/jcm14217784. https://doi.org/10.3390/jcm14217784
15. Sen CK. Human Wound and Its Burden: Updated 2023 Compendium of Estimates. Adv Wound Care (New Rochelle). 2023 Dec;12(12):657-670. doi: 10.1089/wound.2023.0150. https://doi.org/10.1089/wound.2023.0150
16. Hurlow J, Bowler PG. Acute and chronic wound infections: microbiological, immunological, clinical and therapeutic distinctions. J Wound Care. 2022 May 2;31(5):436-445. doi: 10.12968/jowc.2022.31.5.436. https://doi.org/10.12968/jowc.2022.31.5.436
17. Thaarup IC, Iversen AKS, Lichtenberg M, Bjarnsholt T, Jakobsen TH. Biofilm Survival Strategies in Chronic Wounds. Microorganisms. 2022 Apr 1;10(4):775. doi: 10.3390/microorganisms10040775. https://doi.org/10.3390/microorganisms10040775
18. Versey Z, da Cruz Nizer WS, Russell E, Zigic S, DeZeeuw KG, Marek JE, Overhage J, Cassol E. Biofilm-Innate Immune Interface: Contribution to Chronic Wound Formation. Front Immunol. 2021 Apr 9;12:648554. doi: 10.3389/fimmu.2021.648554. https://doi.org/10.3389/fimmu.2021.648554
19. Highmore CJ, Melaugh G, Morris RJ, Parker J, Direito SOL, Romero M, Soukarieh F, Robertson SN, Bamford NC. Translational challenges and opportunities in biofilm science: a BRIEF for the future. NPJ Biofilms Microbiomes. 2022 Aug 29;8(1):68. doi: 10.1038/s41522-022-00327-7. https://doi.org/10.1038/s41522-022-00327-7
20. Yang L, Long S, Wang H, Yang W. Biofilm therapy for chronic wounds. Int Wound J. 2024 Feb;21(2):e14667. doi: 10.1111/iwj.14667. https://doi.org/10.1111/iwj.14667
21. Edwards K, Adamtors D. Wound infection assessment: qualitative and quantitative methods. J Plast Reconstr Aesthet Surg. 2022 Nov;75(11):4133-4142. doi: 10.1016/j.bjps.2022.09.013. https://doi.org/10.1016/j.bjps.2022.09.013
22. Bai D, Fan J, Wu L. Chlorhexidine gluconate vs povidone-iodine for infection prevention in chronic wounds: systematic review and meta-analysis. Int Wound J. 2024 Oct 27;21(10):e14463. doi: 10.1111/iwj.14463. https://doi.org/10.1111/iwj.14463
23. Senneville É, Albalawi Z, van Asten SA, Abbas ZG, Allison G, Aragón-Sánchez J, et al. IWGDF/IDSA Guidelines on the Diagnosis and Treatment of Diabetes-related Foot Infections (IWGDF/IDSA 2023). Clin Infect Dis. 2024 Feb 17;78(1):e1-e52. doi: 10.1093/cid/ciad527. https://doi.org/10.1093/cid/ciad527
24. Sartelli M, Coccolini F, Kluger Y, Agastra E, Abu-Zidan FM, Abbas AES, et al. WSES/GAIS/WSIS/SIS-E/AAST global clinical pathways for patients with skin and soft tissue infections. World J Emerg Surg. 2022 Jan 15;17(1):3. doi: 10.1186/s13017-022-00406-2. https://doi.org/10.1186/s13017-022-00406-2
25. Duane TM, Huston JM, Collom M, Beyer-Berjot L, Bennett-Guerrero E, Bisanzo M, et al. Surgical Infection Society 2020 Updated Guidelines on the Management of Complicated Skin and Soft Tissue Infections. Surg Infect (Larchmt). 2021 May;22(4):383-399. doi: 10.1089/sur.2020.436. https://doi.org/10.1089/sur.2020.436
26. Maitz J, Merlino J, Rizzo S, McKew G, Maitz P. Burn wound infections microbiome and novel approaches using therapeutic microorganisms in burn wound infection control. Adv Drug Deliv Rev. 2023 May;196:114769. doi: 10.1016/j.addr.2023.114769. https://doi.org/10.1016/j.addr.2023.114769
27. Alharthi AF, Al Sulaiman K, Alotaibi S, Alqahtani R, Damfu N, Alharbi A, Alomair S, Alhaidal HA, Aljuhani O. Managing Infections in Burn Patients: Strategies and Considerations for Antimicrobial Dosing. Eur Burn J. 2025 Oct 1;6(4):53. doi: 10.3390/ebj6040053. https://doi.org/10.3390/ebj6040053
28. Jumaa PA, Teare L, Hoffman PN, Young AE, Smailes S, Edwards-Jones V, Thomas C, Moore LSP, Booth S, Mugglestone MA, Moiemen NS. Infection prevention and control in burns services. J Hosp Infect. 2025 Nov;155:202-221. doi: 10.1016/j.jhin.2025.06.008. https://doi.org/10.1016/j.jhin.2025.06.008
