Taken from www.bapras.org.uk
The term trauma refers to any serious, body-altering injury sustained through accident or impact.
Such injuries vary in type and severity, but most commonly involve burns, lacerations, fractures and crush. Plastic surgeons have always been involved in the treatment of trauma, and in the UK plastic surgery grew out of the surgical treatment of facial injuries in WW1 and burns in WW2. Today, the treatment of burns still accounts for a large proportion of plastic surgery procedures in burn centres, while trauma generally accounts for up to 50% of the activity of many plastic surgery units.
As with cancer, the advancement of reconstructive plastic surgery techniques has revolutionised the treatment of trauma. The ability to repair and reconstruct soft tissue defects has led to vastly improved patient outcomes, particularly in cases involving open fractures of the lower limb.
Plastic surgeons are now embedded in all surgical teams dealing with trauma, and a collaborative, multi-disciplinary approach is recognised as being crucial to success in this area. So too is the early involvement of plastic surgeons in trauma
What are the most common trauma injuries?
Along with the general management of burn injuries; injuries to the face, upper limb and lower limb are the trauma conditions most commonly treated by plastic surgeons.
Burns are caused by a variety of external sources and substances. These include hot liquids (scalds), flame, explosion, contact, friction, electricity, exposure to chemicals, freezing and radiation.
In most instances the main problem is a burn to the skin, but in some situations deeper structures are also involved. Depending on the extent and severity of the injury, burns can cause potentially fatal complications. The treatment of burns is a continuum, but may be divided into three main phases, these are:
In severe burns cases, patients will be dealt with immediately upon arrival at a hospital. The initial priority is management of the airway followed by fluid resuscitation.
Early burn surgery
In parallel with resuscitation, surgery is commenced with a view to managing the burn wound. In superficial burns dressings alone may suffice, but in deep burns the burn wound is excised and resurfaced using skin grafts.
Rehabilitation and late reconstruction
Once the patient is healed rehabilitation and return to function is commenced. Splinting and scar control measures are employed along with physiotherapy, occupational therapy and psychological support. Scarred tissue contracts and can cause deformities which may restrict function. Reconstructive surgery may be needed to correct this.
In the UK, the incidence of major facial injuries involving soft tissues and bone has decreased dramatically since the advent of seatbelt legislation. However, injuries such as facial fractures and lacerations do still occur and frequently benefit from the expertise of plastic surgeons. Neurosurgeons, maxillofacial surgeons and ophthalmic surgeons may also be involved in more complex craniofacial trauma cases, and multi-disciplinary treatment is provided to achieve the best possible outcomes for patients.
Facial trauma injuries occur through work and sports related accidents, self inflicted wounds, animal bites, and interpersonal violence. In the UK, a disturbing trend of people biting one another during violent encounters has seen the incidence of traumatic ear loss reach an all-time high.
No other part of the body is as conspicuous, unique or as aesthetically significant as the face. For many people, facial trauma will bring issues of self-image and self-esteem to the fore, and surgeons will treat injuries in this area with a great deal of sensitivity and care. Plastic surgeons will do all they can to minimise the visual impact of facial injuries and the surgery required to treat them, although patients need to be aware that in certain cases some degree of scarring will be unavoidable.
The most common facial injuries include:
- Simple facial lacerations
- Lacerations involving special structures such as the lips, nose, eyelids and ears
- Lacerations involving loss of tissue
- Lacerations involving deeper structures such as nerves and the tear ducts
- Fractures to the lower and upper jaw, cheekbone and orbit
- Fractures to the nose
- Craniofacial injuries involving the skull, base of skull and facial skeleton
Hand and upper limb
Hand trauma can involve a range of injuries, including lacerations, tendon damage, nerve damage, factures, crush injuries and loss of digits. The treatment of hand trauma forms a large part of plastic surgeons’ workload, and frequently requires access to microsurgical facilities for small vessel and nerve repair. Such facilities need to be available on a 24 hour-a-day basis.
At present, this service is best provided in medium-sized or larger plastic surgery units with appropriate operating facilities and follow-up hand clinics, with experienced physiotherapists and occupational therapists on site. This may, therefore, involve transferring patients from other acute hospitals if such facilities and expertise are not available.
Hand trauma surgery varies according to the nature of the injury sustained. Burns and skin loss, for instance, will require surgical flaps and grafts, while the traumatic loss of digits may be treated by microsurgical replantation of the amputated parts.
Injuries to the lower limb are often high energy injuries most commonly sustained in motor vehicle and sporting accidents. In cases where the bone is broken but the surrounding tissue remains undamaged, or closed, surgery can be carried out by an orthopaedic surgeon alone. However, in open fracture cases, where the bone has broken through the tissue, orthopaedic surgeons need to work alongside plastic surgeons to repair the injury.
Open fractures need to be treated urgently, as exposed tissue is vulnerable to infection. If infection sets in at a deep level it can be difficult and complex to treat. Despite the complex and serious nature of open fractures, the best outcomes are achieved by timely specialist surgery, rather than by emergency procedures carried out by less experienced teams.
Most surgical approaches to open fractures involve two key stages. First, the orthopaedic surgeon repairs the broken bone. This can be a simple fixation procedure, or it can be highly complex depending on the nature of the injury. Secondly, once the bone has been fixed, the plastic surgeon will work to repair the damaged tissue using flap reconstruction. Flap reconstruction involves the transfer of a living piece of tissue from one part of the body to another, along with the blood vessel that keeps it alive. Surgeons carrying out flap reconstruction use either local flaps, which remain connected to their blood supply, or free flaps, which are sepa-rated from their source and require reconnecting when placed in the recipient site.
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