Fasciotomies are much more easily opened than closed! Once the edematous muscle is released, it’s not easy to get the skin to close over it again. On occasion, an immediate closure can be carried out. But in most cases, the process is performed with one or more additional operations.
Continuous tension across the skin edges is important. This keeps the wound from getting wider while the edema decreases. A number of creative techniques have been employed to keep the wound from widening, including using sutures, vessel loops, and fancy (expensive) plastic fasteners. And although the KCI VAC dressing reduces edema, it does not do much to pull the wound edges together.
Surgeons in the Netherlands came up with a novel technique using a cheap device that can be found in any hardware store and gas sterilized. The Ty-Rap closure device is commonly used to secure chest tubes to their connectors. Bigger versions are used by police in lieu of handcuffs.
The tail of one Ty-Rap is cut off and the hub is placed on the tail end of another. This assembly is placed across the wound, and one staple is placed over it on each side of the wound. This process is repeated for the entire length of the wound (picture). The Ty-Raps are tightened, and then slowly retightened daily until the wound comes together. An additional week to 10 days is allowed for wound healing before removal of the Ty-Raps.
The authors used this technique on 23 extremity fasciotomy wounds. The wounds were closed after an average of 6 days, and the TyRaps were removed after 16 days. There was no skin necrosis, but there were two instances of cellulitis. The cost of the materials (TyRaps and a surgical stapler) was $23, excluding assembly and sterilization.
Bottom line: This is an interesting technique with good closure results. The surgeon does have to plan ahead and get hospital clearance to use these devices, though.
OnSurg thanks collaborative partner Dr Michael McGonigal. Dr McGonigal tweets at @RegionsTrauma.
Reference: Ty-Raps in trauma: a novel closing technique of extremity fasciotomy wounds. J Trauma 69:972-975, 2010.