The fractures most often associated with skin loss involve the long bones, tibia and, much less frequently, ulna. Before the management of such an injury can usefully be discussed, it is necessary to have an understanding of the principles which underlie its treatment, for the detailed handling of the injury is the expression in practical terms of these principles.
A primary objective in treating such a combined injury is to prevent infection, and this is achieved by fixing the fracture and by providing skin cover to isolate it from the surface.
An X-ray of a fracture gives an incomplete
picture of the total injury in the way that it ignores the soft tissue element.
The severity of this latter element and the form it takes are of major importance when the soft tissues around the fracture site -muscle, fascia and skin -are being assessed for damage and even viability, or as potential sources to provide cover for the bone, fractured or merely bared by the injury.
The injury to muscle can take the form of obvious tearing of muscle fibres, but damage at a less gross level can also occur, resulting in swelling of the muscle belly.
Even so, muscle is unexpectedly resilient in practice, and has been successfully transferred in the form of a flap shortly after the original injury, though its use in this way is not without risk.
The injury to skin takes a different form, seen
most strikingly when part of the injury involves degloving of the skin and superficial fascia.
Degloving as an isolated injury has already been described, but when it is associated with bony trauma it has to be considered also in relation to the extent to which it might be possible to use degloved skin and its underlying layer of fascia as a local flap to cover the surface defect. Before the use of such skin can be considered, there would have to be clear evidence of circulation in the skin area, and even when this criterion has been fulfilled it has not proved a reliable flap source.
The various elements of a mixed skin-bone injury can vary widely in their severity, and the plastic surgeon is liable to have a biased view of the situation. He is likely to see only the injuries at the most severe end of the spectrum, and assume that they are the norm, whereas in fact the less severe injuries are being successfully managed by the orthopaedic surgeon on his own. Nonetheless, if a harmonious and effective relationship is to be built up, the plastic surgeon is best invited to see the patient at the acute stage if the orthopaedic surgeon considers that there is even a remote possibility that he may have to be involved in treatment later.