Adjunctive hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries: a systematic review.

PURPOSE: Traumatic crush injuries of the lower limb often accompany severe complications. The incorporation of hyperbaric oxygen therapy to standard trauma care may have the potential to diminish injury-related complications and improve outcome in such cases. This systematic review aims to evaluate the effectiveness of hyperbaric oxygen therapy in the management of severe lower limb soft tissue injuries. METHODS: The electronic databases Medline, Embase and Cochrane Library were searched to identify studies involving patients with crush-associated sever lower limb soft tissue injuries who received hyperbaric oxygen therapy in conjunction with standard trauma care. Relevant data on type of injury, hyperbaric oxygen therapy protocol and outcome related to wound healing were extracted. RESULTS: In total seven studies met the inclusion criteria, involving 229 patients. The studies included two randomized clinical trials, one retrospective cohort study, three case series and one case report. The randomized placebo-controlled clinical trial showed a significant increase in wound healing and decrease in the need for additional surgical interventions in the patient group receiving hyperbaric oxygen therapy when compared to those undergoing sham therapy. The randomized non-placebo-controlled clinical trial revealed that early hyperbaric oxygen therapy reduces tissue necrosis and the likelihood of long-term complications. The retrospective cohort study indicated that hyperbaric oxygen therapy effectively reduces infection rates and the need for additional surgical interventions. The case series and case report presented beneficial results with regard to wound healing when hyperbaric oxygen therapy was added to the treatment regimen. CONCLUSION: Hyperbaric oxygen therapy is generally considered a safe therapeutic intervention and seems to have a beneficial effect on wound healing in severe lower limb soft tissue injuries when implemented as an addition to standard trauma care.

The use of hyperbaric oxygen therapy in the treatment of hand crush injuries.

Hyperbaric oxygen therapy (HBOT) has been used as an adjuvant treatment for crush injury because it can improve tissue hypoxia and stimulate wound healing. However, the actual role of HBOT in crush hand injury is still unknown. This study is to assess the efficacy of HBOT for crush hand patients, as well as the impact of HBOT initiation timing. Between 2018 and 2021, 72 patients with crush hand injury were retrospectively reviewed. The patients were divided into the HBOT and control group, and each group had 36 patients. The average session of HBOT was 18.2 (5-32 sessions) per patient, and no patient had a complication related to the treatment. The two groups had similar demographics, but HBOT group had larger injured area (73.6 ± 51.0 vs. 48.2 ± 45.5 cm2 , p = 0.03). To better control the confounding factors, we performed the subgroup analysis with cut-off injured area of 50 cm2 . In the patients with smaller injured area (≦50 cm2 ), the HBOT group had shorter wound healing time (29.9 ± 12.9 vs. 41.0 ± 18.9 days, p = 0.03). The early HBOT group (first session ≤72 h post-operatively) had shorter hospital stay (8.1 ± 6.4 vs. 15.5 ± 11.4 days, p = 0.04), faster wound healing (28.7 ± 17.8 vs. 41.1 ± 18.1 days, p = 0.08) and less operations (1.54 ± 0.78 vs. 2.41 ± 1.62, p = 0.06) although the latter two didn't achieve statistical significance. HBOT is safe and effective in improving wound healing of hand crush injury. Early intervention of HBOT may be more beneficial. Future research is required to provide more evidence.

Lesiones de punta de dedo: experiencia en el manejo en los últimos 5 años en un centro pediátrico / Fingertip injuries: experience in handling the last 5 years in a pediatric center

Las lesiones de punta de dedo son comunes en pacientes pediátricos que acuden a salas de Emergencia; son causadas por accidentes en el hogar y con aplastamiento en puerta como principal mecanismo de trauma. El tratamiento se realiza individualizado por cirujanos plásticos y cirujanos pediátricos en dependencia de la herida y el compromiso tisular. El propósito de este estudio es describir el manejo de pacientes con lesiones de punta de dedo en un centro pediátrico. Se realizó un análisis de historias clínicas en el período entre enero 2015 y diciembre 2020, se evaluaron 228 pacientes atendidos en el Hospital de Niños Dr. Roberto Gilbert Elizalde, en Guayaquil, Ecuador. Los resultados incluyen un predominio de pacientes en edad preescolar (67%), masculinos (56%) y de mano derecha (53%). Los dedos más afectados fueron el medio y anular. Los procedimientos fueron realizados por cirujanos plásticos (55%) y la técnica electiva fue bajo anestesia general. La extensión del daño involucró tejidos blandos (92%), avulsión de uña (29%) y fracturas asociadas (15%). El 3% de los pacientes presentó complicaciones que requirieron seguimiento. El tipo de reparo se seleccionó en dependencia de la extensión de la herida, se realizaron suturas simples (37%) y suturas complejas con reparo de la uña (27%). Nuestros datos son similares a los descritos en la literatura internacional, con buenos resultados a largo plazo, menor tasa de complicaciones y respuestas similares en los reparos realizados por cirujanos plásticos y cirujanos pediatras.

Fingertip injuries are common in pediatric patients who present to the emergency room. They are usually caused by accidents at home, being door-crush the main mechanism. Treatment is performed on an individual basis, by a Plastic or General Pediatric Surgeon, according to the wound findings and tissue involvement. The purpose of this study is to describe the management on a pediatric center in patients with a fingertip wound. A descriptive and retrospective analysis of medical records was carried out from January 2015 until December 2020. In this period 228 patients were seen in the Dr. Roberto Gilbert Elizalde Children´s Hospital in Guayaquil, Ecuador. A high incidence was found in the preschool age with 67% of cases. The injuries were more common in males (56 %) and more predominant on the right hand (53%). The most affected fingers were the middle and annular. Procedures were mostly performed by Pediatric Surgeons (55%) and the elective technique was under general anesthesia. Damage extension of the fingertip included soft tissues in 92% of patients, nail avulsion in 29% and associated fractures in 15%. Only 3% of patients developed complications that required follow up. The type of repair was selected according to the extension of the injury. Mostly simple sutures (37%) and complex sutures with nail repair (27%)were used.Our data is similar to the one found in international literature, with good long-term outcomes, minor complications and similar results when the repair was performed by a Plastic or Pediatric surgeon

A possible role of endoneurial fibroblast-like cells in the resolution of endoneurial oedema following nerve crush injury / El posible rol de los fibroblastos endoneurales en la resolución del edema endoneural después de una lesión por aplastamiento nervioso

SUMMARY: Endoneurial oedema is a salient feature of all types of neuropathy. Its elimination is crucial during the complications of nerve recovery. The objective was to study a possible role of the endoneurial fibroblasts in the resolution of nerve edema. Forty-two albino male rats aged between 30 and 40 days (weight 200 g to 250 g) were used in this study. The left sural nerves of 36 rats were subjected to crush injury at one to three-week intervals with six animals per interval. The right and left sural nerves of the remaining six rats were used as controls. At the end of the second week after crush injury, the endoneurium showed channel-like spaces that were lined by fibroblast-like cells and collagen bundles that contained degenerated myelin, and were connected to the subperineurial spaces. Flattened fibroblast-like cells were arranged in several layers in the subperineurial, forming barrier-like cellular sheets localizing to the endoneurial oedema in the space. Fibroblast-like cells also wrapped around the regenerating nerve fibres with their branching cytoplasmic processes. During the third week, the flattened fibroblast-like cells formed nearly continuous cellular sheets in the subperineurial spaces. Macrophages were frequently observed between these cellular barrier-like sheets and in the subperineurial. The endoneurial fibroblast-like cells form barrier-like cellular sheets that probably localise the endoneurial oedema in the subperineurial space. It also appear to create endoneurial channel-like spaces containing degenerated myelin and endoneurial oedema, which may be helpful in localizing and resolving such oedema.

RESUMEN: El edema endoneural es una característica destacada de todos los tipos de neuropatía. Su eliminación es importante durante las complicaciones de la recuperación nerviosa. El objetivo fue estudiar un posible papel de los fibroblastos endoneurales en la resolución del edema nervioso. En este estudio se utilizaron 42 ratas macho albinas con edades entre los 30 y 40 días (peso 200 a 250 g). Los nervios surales izquierdos de 36 ratas se sometieron a lesiones por aplastamiento en intervalos de una a tres semanas con seis animales por intervalo. Se usaron los nervios surales derecho e izquierdo de las seis ratas restantes como controles. Al final de la segunda semana después de la lesión por aplastamiento, el endoneuro mostró espacios en forma de canal que estaban revestidos por células similares a fibroblastos y haces de colágeno que contenían mielina degenerada y se conectaron a los espacios subperineurales. Las células aplanadas de fibroblastos se dispusieron en varias capas en el subperineuro, formando láminas celulares de tipo barrera que se localizaban en el espacio del edema endoneural. Las células similares a fibroblastos también envolvían las fibras nerviosas regeneradoras con sus procesos citoplásmicos ramificados. Durante la tercera semana, las células aplanadas de fibroblastos formaron láminas celulares casi continuas en los espacios subperineurales. Los macrófagos se observaron con frecuencia entre estas láminas similares a barreras celulares y en el subperineuro. Las células de tipo fibroblasto endoneural formaban láminas celulares de tipo barrera que probablemente localizan el edema endoneural en el espacio subperineural. También parece que crea espacios en forma de canal endoneural que contienen mielina degenerada y edema endoneural, que pueden ser útiles para localizar y resolver este edema.