在严重合并创伤背景下对一名软组织大面积缺损青少年的手术治疗

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大面积的创伤后伤口涉及功能活跃区，同时并发化脓坏死过程，无论是在创伤急性期的危急情况下，还是在重建手术治疗阶段，都是一个严重的问题。本临床观察报告涉及一名在渡轮交通事故中受伤的16岁女孩的手术治疗。由于货车的碰撞，女孩被压在容器的金属结构上，遭受了严重的合并创伤。诊断：闭合性颅脑外伤，中度脑挫伤，右侧枕骨线性骨折；胸部闭合性损伤，右侧第9-11肋骨骨折；腹部闭合性损伤；右肾破裂，膀胱损伤，右侧腹膜后血肿；闭合性脊椎创伤，L4-L5椎骨棘突骨折；骨盆开放性骨折，右半部骨盆带和髋关节广泛的创伤后伤口。在2天内初诊住院的医院，进行了开腹手术、右侧粉碎性肾切除术、膀胱缝合术、右侧骶臀股区伤口初诊手术治疗和左侧大腿伤口初诊缝合术、使用外固定杆装置进行盆骨外截骨术。术后早期由于创伤软组织坏死、手术感染（耐多抗生素的微生物菌株）而变得复杂，随后导致伤口缺损面积增大，软组织因化脓融化而损失。复杂的手术治疗旨在消除手术感染，使伤口进入再生阶段，包括反复手术治疗、使用现代敷料和负压疗法。由于外伤和对化脓性并发症的手术治疗，形成了广泛的软组织伤口缺损，位于髋关节功能活跃区和骶骨区，需要在这些区域恢复完整的皮肤。本文介绍了手术置换软组织伤口缺损的策略。使用了非游离 （旋转）供血皮瓣：右侧大腿的基于筋膜张肌的真皮-筋膜-肌肉皮瓣和左侧臀部的臀部真皮-筋膜皮瓣。多阶段手术治疗的结果是，可以替代广泛的软组织伤口缺损，恢复髋关节和骶臀部的完整皮肤。这样就可以避免营养障碍和关节挛缩，并在5年的随访期间取得令人满意的外观和功能效果。

作者简介

Valery A. Mitish

Research Institute of Emergency Pediatric Surgery and Traumatology; P. Lumumba Peoples’ Friendship University of Russia; A.V. Vishnevsky National Medical Research Center of Surgery

编辑信件的主要联系方式.
Email: mitish01@mail.ru
ORCID iD: 0000-0001-6411-0709
SPIN 代码: 4529-4044

MD, Cand. Sci. (Medicine), Assistant Professor

俄罗斯联邦, Moscow; Moscow; Moscow

Pavel V. Medinskiy

Research Institute of Emergency Pediatric Surgery and Traumatology

Email: pavmedin@yandex.ru
ORCID iD: 0000-0003-3764-1664
SPIN 代码: 1054-5830
俄罗斯联邦, Moscow

Vladimir G. Bagaev

Research Institute of Emergency Pediatric Surgery and Traumatology

Email: bagaev61@mail.ru
ORCID iD: 0000-0003-3773-5185
SPIN 代码: 1925-8051

MD, Dr. Sci. (Medicine)

俄罗斯联邦, Moscow

Svetlana A. Valiullina

Research Institute of Emergency Pediatric Surgery and Traumatology

Email: vsa64@mail.ru
ORCID iD: 0000-0002-1622-0169
SPIN 代码: 6652-2374

MD, Dr. Sci. (Medicine), Professor

俄罗斯联邦, Moscow

Maria A. Dvornikova

Research Institute of Emergency Pediatric Surgery and Traumatology

Email: marussiadv@gmail.com
ORCID iD: 0000-0002-7397-7416
SPIN 代码: 6235-3671
俄罗斯联邦, Moscow

Anastasia A. Gromova

Research Institute of Emergency Pediatric Surgery and Traumatology

Email: gromova.nas@yandex.ru
ORCID iD: 0000-0001-8628-5710
SPIN 代码: 3115-5413
俄罗斯联邦, Moscow

参考

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2. Fig. 1. Local wound treatment stages in a regional hospital: a — wound in the sacrogluteal region on day 24 postinjury; b — wound after repeated surgical debridement; c — wound on day 63 postinjury

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3. Fig. 2. Patient’s appearance upon admission to the Research Institute of Emergency Pediatric Surgery and Traumatology (2.5 months postinjury): a — front view; b — rear view; c — right view; d — nature of the discharge from the wound on the bandage; e — left view

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4. Fig. 3. Condition of the pelvic bones upon admission to the Research Institute of Emergency Pediatric Surgery and Traumatology and following external fixation device removal (3 months postinjury): a — 3D reconstruction of pelvic CT results upon admission; b — X-ray of the pelvic bones after external fixation device removal; c — reconstruction of pelvic CT results following external fixation device removal

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5. Fig. 4. Local wound treatment result 2 months after hospitalization at the institute: а, b — negative pressure wound therapy; c, d — type of wounds after completion of local treatment

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6. Fig. 5. Marking (a) and formation of a fasciocutaneous–muscular flap based on the musculus tensor fascia lata (b–d)

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7. Fig. 6. The pelvic girdle (a) and right hip (b) after reconstructive surgery

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8. Fig. 7. The flap (a, b, c) on day 2 postsurgery

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9. Fig. 8. Dynamics of ischemic changes in the flap indicated by the formation of marginal necrosis over 10 cm: а — type of wound on day 15; b — on day 20; с — on day 34; d — on day 54

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10. Fig. 9. Stages of wound reconstruction with a rotated gluteal fasciocutaneous flap: a — marking the boundaries of the flap in the left gluteal region; b, c — stages of its formation; d — moving the flap to the wound defect area

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11. Fig. 10. Dynamics of wound healing after replacing a wound defect with a gluteal fasciocutaneous flap: а — type of wound on day 5; b — on day 22; с — on day 49

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12. Fig. 11. The pelvic girdle (a, b) and right hip (c) after final repair: а — plastic surgery of residual wounds; b — rear view after stitches removed; с — right view after suture removal

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13. Fig. 12. X-ray of the pelvic bones before discharge

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14. Fig. 13. The patient 5 years after discharge: а — back view; b — right view; c — left view

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