[Soft tissue injuries and soft tissue defect in the region of the forehead].
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Child↗
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Hyperbaric oxygen therapy for delayed onset muscle soreness and closed soft tissue injury.
BACKGROUND: Soft tissue injuries (including muscle damage after unaccustomed exercise) are common and are often associated with athletic activity. Hyperbaric oxygen therapy (HBOT) is the therapeutic administration of 100% oxygen at environmental pressures greater than one atmosphere. OBJECTIVES: To assess the benefits and harms of HBOT for treating soft tissue injury, including delayed onset muscle soreness (DOMS). SEARCH STRATEGY: We searched the following in July 2004: CENTRAL, MEDLINE, EMBASE, CINAHL, DORCTIHM and reference lists from relevant articles. Relevant journals were handsearched and researchers in the field contacted. SELECTION CRITERIA: Randomised trials comparing the effect on closed soft tissue injury (including DOMS) of therapeutic regimens which include HBOT with those that exclude HBOT (with or without sham therapy). DATA COLLECTION AND ANALYSIS: Four reviewers independently evaluated study quality and extracted data. Most of the data presented in the review were extracted from graphs in the trial reports. MAIN RESULTS: Nine small trials involving 219 participants were included. Two trials compared HBOT versus sham therapy on acute closed soft tissue injuries (ankle sprain and medial collateral knee ligament injury respectively). The other seven trials examined the effect of HBOT on DOMS following eccentric exercise in unconditioned volunteers. All 32 participants of the ankle sprain trial returned to their normal activities. There were no significant differences between the two groups in time to recovery, functional outcomes, pain, or swelling. There was no difference between the two groups in knee function scores in the second acute injury trial; however, intention-to-treat analysis was not possible for this trial. Pooling of data from the seven DOMS trials showed significantly and consistently higher pain at 48 and 72 hours in the HBOT group (mean difference in pain score at 48 hours [0 to 10 worst pain] 0.88, 95% CI 0.09 to 1.67, P = 0.03) in trials where HBOT was started immediately. There were no differences between the two groups in longer-term pain scores or in any measures of swelling or muscle strength. No trial reported complications of HBOT but careful selection of participants was evident in most trials. AUTHORS' CONCLUSIONS: There was insufficient evidence from comparisons tested within randomised controlled trials to establish the effects of HBOT on ankle sprain or acute knee ligament injury, or on experimentally induced DOMS. There was some evidence that HBOT may increase interim pain in DOMS. Any future use of HBOT for these injuries would need to have been preceded by carefully conducted randomised controlled trials which have demonstrated effectiveness.
Athletic Injuries↗
Imaging of skeletal and soft tissue injuries in and around the knee.
This article addresses the place of MR imaging in the diagnosis of knee injuries. MR imaging of subtle fractures and bone contusions is described with emphasis placed on those types of fractures frequently associated with specific patterns of soft tissue injury. Soft tissue injuries are divided into ligamentous, meniscal, and muscular; each is discussed separately. The MR imaging appearance of these lesions is explained.
Bone and Bones↗
In vivo analysis of microcirculation following closed soft-tissue injury.
Major loss of tissue is an almost invariable consequence of severe closed soft-tissue injury. Clinically, the extent of soft-tissue trauma determines the outcome of complex injuries and significantly influences bone healing. With use of a new animal model, this study quantitatively analyzed microcirculation, i.e., nutritive perfusion and leukocyte-endothelial cell interaction, in skeletal muscle after standardized closed soft-tissue injury. By means of a computer-assisted controlled-impact technique, a severe standardized closed soft-tissue injury was induced in the left hindlimb of 28 rats. The rats were assigned to four experimental groups (n = 7 per group) that differed by time of analysis (1.5, 24, 72, and 120 hours after injury); rats that were not injured served as controls (n = 7). Intramuscular pressure was measured, and microcirculation in the rat extensor digitorum longus muscle was analyzed by in vivo fluorescence microscopy, which allowed assessment of microvascular diameters, functional capillary density, number of rolling and adherent leukocytes in venules, and microvascular permeability. Edema weight gain was quantified by the ratio of wet to dry weight of the extensor digitorum longus muscle. Microvascular perfusion of the skeletal muscle was characterized by a significant reduction in functional capillary density, which was paralleled by an increase in capillary diameter throughout the 120 hours of observation when compared with the controls. Trauma-induced inflammatory response was reflected by a markedly increased rolling and adherence of leukocytes, primarily restricted to the endothelium of postcapillary venules; this was accompanied by increased microvascular permeability, indicative of a substantial loss of endothelial integrity. The microcirculation surrounding the core of the damaged tissue area resembled that of ischemia-reperfusion injury in skeletal muscle, i.e., heterogeneous capillary perfusion, pronounced microvascular leakage, and adherence of leukocytes. Enhanced vascular leakage and leukocyte adherence (24-72 hours after injury) coincided with the maximum intramuscular pressure (which was not indicative of compartment syndrome) and edema formation. These results demonstrate that initial changes, leading to ultimate tissue death, after closed soft-tissue injury are caused on the microcirculatory level. This standardized model provides further insight into microvascular pathophysiology and cellular interactions following closed soft-tissue injury. Thus, it is an adequate tool for testing novel therapeutic interventions.
Animals↗
Acute treatment of penetrating popliteal artery trauma: the importance of soft tissue injury.
During a 20-year period from 1973 to 1992, 109 patients underwent early operation for acute popliteal artery trauma. Clinical variables were analyzed for their association with amputation. Gunshot wounds accounted for the majority of injuries (73%), followed by shotgun wounds (18%), stab wounds (6%), iatrogenic injuries (2%), and lacerations (1%). Fasciotomies were performed selectively in 41% of patients. Seven patients (6%) lost the injured extremity despite arterial repair. The mean time from injury to arterial repair was not significantly different for patients with or without subsequent amputation (8.6 +/- 3.6 and 9.7 +/- 7.4 hours, respectively; p = 0.69). Delay in diagnosis longer than 6 or 12 hours after the injury did not increase the risk of amputation. Other factors not associated with limb loss were preoperative ischemic neurologic deficit or compartmental hypertension, concomitant fracture, and popliteal vein injury. Severe soft tissue injury (p < 0.0001) or postoperative wound sepsis (p < 0.0001) substantially increased the risk of amputation. Delayed fasciotomies were uncommon (4%) but were associated with a significantly increased risk of amputation (p < 0.0001). Vein grafting for arterial repair (p = 0.0017) and shotgun injuries (p < 0.0001) were associated with amputation to the extent that they were related to severe soft tissue injury. The degree of soft tissue trauma and subsequent infection of devitalized tissue limits the success of popliteal arterial repair. Changes in the mechanism of trauma, liberal use of four-compartment fasciotomies, and aggressive management of soft tissue injury resulted in a significant decline in the amputation rate from 21% (4/19) in the first 5 years to 0% (0/39) in the last 5 years of the study.
Adolescent↗
[Fractures. 10. Injuries of soft tissues and combined bone-soft tissue injuries].
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Fracture Fixation, Internal↗
Soft-tissue injury as an indication of child abuse.
We reviewed the hospital records of 371 children who were suspected of having been physically abused. Our purpose was to determine specific features that might be used to distinguish injuries resulting from abuse from accidental injuries. Soft-tissue injuries were found in 341 (92 per cent) of these children. Ecchymoses were most common, accounting for 555 (62 per cent) of 892 soft-tissue injuries, and very few had a suspicious pattern. Only thirty-four (9 per cent) of the children had a radiographically documented fracture, but radiography was performed for only thirty-seven (10 per cent) of the patients and it rarely was done unless a fracture was clinically obvious. The patterns of injury were age-specific. The forty-four children who were nine months old or less had an average of only one soft-tissue injury; thirty soft-tissue injuries involved the head or face, and seven (16 per cent) of the children had a burn. These children were the most severely injured: two (5 per cent) died and twenty (45 per cent) had a fracture. The sixty-one children who were ten months to two years and eleven months old had an average of two soft-tissue injuries; fifty-four soft-tissue injuries involved the head or face, and nine (15 per cent) of the children had a burn. A fracture was found in eight (13 per cent) of these children.(ABSTRACT TRUNCATED AT 250 WORDS)
Age Factors↗
Management of associated soft-tissue injury.
Initially, soft-tissue injuries associated with vascular trauma require management according to the general surgical principles of wound care. Antimicrobial prophylaxis should be instituted. The mechanism and extent of injury must be determined, and debridement and irrigation should be completed in the operating room with the intent to preserve vital structures, decrease bacterial contamination, and render the wound free of devitalized tissue. Prompt coverage of exposed vascular repairs is vital in order to minimize the chance for infection and to protect the repair from desiccation and subsequent trauma. Early primary closure of heavily contaminated wounds can have disastrous results. Therefore, questionable wounds should be managed by delayed primary closure after repeated irrigation and debridements, with the definitive decision as to the timing of wound closure being based on quantitative cultures. The plastic and reconstructive surgeon can aid the vascular surgeon in the primary or secondary closure of such wounds by bringing healthy, vascularized muscle to cover the vascular repair. Vascularized muscle has proved superior in the coverage and healing of contaminated wounds. If conditions permit, this can be most readily accomplished by transfer of local muscle. Musculocutaneous flaps are of special value in cases that require increased durability or where extended coverage is necessary. With either of these flap techniques, the surgeon must be thoroughly familiar with the anatomy, blood supply, and function of the local muscles. Free-tissue transfer is to be utilized when local tissue is severely damaged in a way that precludes the use of adjacent muscle or myocutaneous flaps. Strict adherence to the principles and techniques of microsurgery, thorough evaluation of the zone of injury and recipient blood vessels, and understanding of the principles governing local muscle transfer are essential for a successful outcome.
Bacterial Infections↗
The incidence of soft tissue injury in operative tibial plateau fractures: a magnetic resonance imaging analysis of 103 patients.
OBJECTIVES: The goal of this study was to determine the incidence of injury to soft tissue structures of the knee in tibial plateau fractures scheduled for surgery. DESIGN: Prospective cohort. SETTING: Level I academic medical center. PATIENTS/PARTICIPANTS: One hundred three consecutive patients with acute tibial plateau fractures indicated for operative intervention. INTERVENTION: Standard x-ray examinations, including anteroposterior, lateral, and oblique views, were performed in the emergency department. Subsequently all patients had magnetic resonance imaging performed. The Schatzker and AO/OTA classifications were used to classify each fracture pattern based solely on the x-rays. Soft tissue injuries were assessed by magnetic resonance imaging. MAIN OUTCOME MEASUREMENTS: Fifteen categories of injury were determined as positive or negative on each magnetic resonance imaging, which included tears of the cruciates, collateral ligaments, menisci, and posterolateral corner. RESULTS: The overall incidence of injury to soft tissues was higher than previously reported. Only 1 patient (1%) in the series had complete absence of any soft tissue injury. Seventy-nine patients (77%) sustained a complete tear or avulsion of 1 or more cruciate or collateral ligaments. Ninety-four patients (91%) had evidence of lateral meniscus pathology. Forty-five patients (44%) had medial meniscus tears. Seventy patients (68%) had tears of 1 or more of the posterolateral corner structures of the knee. The most frequent fracture pattern was a lateral plateau split-depression (Schatzker II) (60%). No pure depression injuries (Schatzker III, AO/OTA 41-B2) were seen. CONCLUSIONS: The incidence of complete ligamentous or meniscal disruption associated with operative tibial plateau fractures was higher than previously reported. Though the clinical importance of injury to each of these structures is unknown, the treating surgeon should be aware that a variety of soft tissue injuries are common in these fractures. In addition, all fractures had at least 1 cortical split visible on magnetic resonance imaging, implying that pure depression patterns are very rare or may not exist.
Adolescent↗
Pentoxifylline in the treatment of radiation-related soft tissue injury: preliminary observations.
Soft tissue or mucosal injuries following radiotherapy of head and neck cancer include ulceration (necrosis), fibrosis, pain, and atrophy. Current management includes analgesics, wound debridement, antibiotics, and physical therapy depending on the type of injury. Pentoxifylline is a methylxanthine derivative that produces dose-related hemorrheologic effects, lower blood viscosity, improved erythrocyte flexibility, and increased tissue oxygen levels. Twenty-six patients with late radiation complications (occurring more than two months after x-ray therapy) were given treatment with oral pentoxifylline: 15 for soft tissue necrosis (STN), six for fibrosis, and five for mucosal pain. Nine of 12 patients with STN completely healed. In all three failures osteoradionecrosis developed. Mucosal pain resolved in all five patients. Fibrosis improved in 67% of those patients. Pentoxifylline appears to accelerate healing of STN and reverse some late radiation injuries. This is the first series to our knowledge that documents activity of this agent in moderate radiotherapy complications such as fibrosis, pain, or mucosal fragility.
Administration, Oral↗
Combined injuries--soft tissue management.
The combination of severe bone and soft tissue injuries challenges all hand surgeons. Immediate restoration of all damaged structures is the goal whenever possible, integrating soft tissue techniques with principles of internal fixation. Debridement must be radical and resulting defects in bone, vessel, nerve, tendon and skin must be reconstituted with the combination of free and vascularized grafts. Rigid internal fixation is mandatory to allow functional restoration of the hand to begin with a stable platform against which motor tendon units and gliding structures to move. The timing of subsequent reconstruction is based on the prerequisites of adequate vascularity and soft tissue coverage. Understanding the reconstructive ladder and the nuances of techniques regarding skin grafting, local and distant flaps and microsurgical reconstruction is necessary to complete reconstruction in a timely and appropriate fashion. Various soft tissue techniques are described; from simple skin grafting to the use of toe to hand transfers. The decision to amputate versus reconstruct is also important, particularly in today's cost conscious health care environment. Finally, a well thought out and directed rehabilitation program will allow patients to ultimately return to functional status after mutilating injuries of the hand. This article provides a comprehensive review of the combined injury.
Adult↗
The radial forearm flap in the management of soft tissue injuries of the hand.
Soft tissue injuries of the hand frequently require flap cover either to preserve structures damaged at the time of injury or to facilitate later reconstruction. Techniques such as the groin flap, the abdominal flap and the cross arm flap require staged procedures and until now, surgeons have had to resort to the more complicated microsurgical techniques required in free flap transfer to obtain soft tissue cover in a single-stage. The radial forearm flap makes local tissue readily available and offers a simple and effective one-stage method of soft tissue reconstruction. Surgery is confined to a single limb permitting early mobilisation and rehabilitation. The vascular anatomy of the radial forearm flap will be described and three cases presented to illustrate this technique in the management of differing soft tissue injuries of the hand.
Adolescent↗
Soft tissue injuries associated with pelvic fractures.
Significant soft tissue injuries often occur as part of high-energy injuries to the pelvis. These soft tissue injuries must be recognized and considered when implementing a treatment plan if complications are to be minimized. Vigilance in diagnosing open fractures must be maintained. Patients with these injuries must be managed aggressively, because they are at high risk for complications and death. Closed pelvic and acetabular fractures also may include soft tissue injury that requires special consideration. Careful evaluation and management of the soft tissues aids in determining appropriate techniques for reduction and fixation of the associated fractures.
Combined Modality Therapy↗
Prolonged superficial local cryotherapy attenuates microcirculatory impairment, regional inflammation, and muscle necrosis after closed soft tissue injury in rats.
BACKGROUND: Closed soft tissue injury induces progressive microvascular dysfunction and regional inflammation. The authors tested the hypothesis that adverse trauma-induced effects can be reduced by local cooling. While superficial cooling reduces swelling, pain, and cellular oxygen demand, the effects of cryotherapy on posttraumatic microcirculation are incompletely understood. STUDY DESIGN: Controlled laboratory study. METHODS: After a standardized closed soft tissue injury to the left tibial compartment, male rats were randomly subjected to percutaneous perfusion for 6 hours with 0.9% NaCL (controls; room temperature) or cold NaCL (cryotherapy; 8 degrees C) (n = 7 per group). Uninjured rats served as shams (n = 7). Microcirculatory changes and leukocyte adherence were determined by intravital microscopy. Intramuscular pressure was measured, and invasion of granulocytes and macrophages was assessed by immunohistochemistry. Edema and tissue damage was quantified by gravimetry and decreased desmin staining. RESULTS: Closed soft tissue injury significantly decreased functional capillary density (240 +/- 12 cm(-1)); increased microvascular permeability (0.75 +/- 0.03), endothelial leukocyte adherence (995 +/- 77/cm(2)), granulocyte (182.0 +/- 25.5/mm(2)) and macrophage infiltration, edema formation, and myonecrosis (ratio: 2.95 +/- 0.45) within the left extensor digitorum longus muscle. Cryotherapy for 6 hours significantly restored diminished functional capillary density (393 +/- 35), markedly decreased elevated intramuscular pressure, reduced the number of adhering (462 +/- 188/cm(2)) and invading granulocytes (119 +/- 28), and attenuated tissue damage (ratio: 1.7 +/- 0.17). CONCLUSION: The hypothesis that prolonged cooling reduces posttraumatic microvascular dysfunction, inflammation, and structural impairment was confirmed. CLINICAL RELEVANCE: These results may have therapeutic implications as cryotherapy after closed soft tissue injury is a valuable therapeutic approach to improve nutritive perfusion and attenuate leukocyte-mediated tissue destruction. The risk for evolving compartment syndrome may be reduced, thereby preventing further irreversible aggravation.
Analysis of Variance↗
[Therapy of soft tissue injuries--biological strategies].
The traumatic soft tissue injury plays a central role in fracture healing. The knowledge of pathophysiological mechanisms has completely changed the management and therapy of injuries accompanied by soft tissue lesions. Treatment is aiming for prevention of the circle of hypoxia, microvascular perfusion disturbance, increased membrane permeability and potential infections. General therapeutic principles are decontamination, debridement, revascularisation and decompression. Modern methods of soft tissue treatment take these principles into consideration.
Debridement↗
Soft tissue injuries of the neck.
Soft tissue injuries of the neck are a frequent and important cause of disability and as such deserve close attention and concern. Patient management following this injury should not be left to the therapist but instead should be controlled closely by the physician to promote rapid recovery and avoid psychosomatic problems. Despite all methods of treatment there are patients who continue to complain of neck symptoms and others who develop degenerative disk changes in the years after injury.
Accidents, Traffic↗
Managing soft tissue injuries.
The management of soft tissue injuries of the face is best approached in an organized manner. The goal is early functional and cosmetic rehabilitation. The steps to be undertaken should be: initial evaluation, planning, repair and follow-up. Thorough cleansing with minimal debridement, use of fine suture material and early suture removal are some of the important principles.
Dermatologic Surgical Procedures↗
Soft-tissue injuries and muscle tears.
Soft-tissue injuries and muscle tears occur frequently in athletes. The mainstay of treatment in most cases is nonoperative management and aggressive rehabilitation. Most injuries result from direct trauma or contusion or indirect stretch injury. It is important to keep in mind the possibility of other potentially more serious conditions, such as compartment syndrome. More research is needed to define optimal treatment patterns and potential strategies for injury prevention.
Athletic Injuries↗