The use of the original Kirschner wire technique for fasciotomy wound closure

T. Molcanyi, *J. Zivcak, M. Kitka, M. Molcanyi, M. Rosak, J.Magdo, **A. Molcanyiova

Clinic of Trauma Surgery,  **Department of Clinical Biochemistry,

University Hospital of Louis Pasteur, Kosice 

*Department of instrumental and biomedical engineering, Technical University in Kosice

The considerably large number of surgical techniques for closure of the fasciotomy wounds varies one from each other. They can be basically divided into two distinctive groups  - different skin-graft techniques and the tension-applying techniques. The closure of the fasciotomy wound should restore both natural compartmental cover and the original compartmental volume.

    Original prototype – K wires with nylon                                  Modified method – buttons prevent local necrosis

Since 1994, the new and original Kirschner-wire technique (KWT) for closure of fasciotomy wound is used in our clinic of trauma surgery. First, the K wires are inserted subdermally (transversely to the wound edges) in 2 - 3 cm intervals. They serve as the leading component. The tension for approximating the wound edges is achieved by inserting different plastic pulling clips or binding suture threads onto the K wires. We start the approximation of the wound edges 7-10 days after the fasciotomy, after the edema has begun to resolve. The approximation is carried out in operating room in 2-day intervals. During these sessions we controlled the pressure by palpation the muscles during the operation. In 7 patients we measured the intramuscular pressure (IMP), after every approximation using the Whitesides needle technique. Creatine-kinase (CK) levels in blood were controlled 8-12 hours after every approximation.

   Second modification – protective infusion tubes                Currently in use  - plastic clamps on the K wires attached to

                                                                                        dynamic system

The KWT was used in 29 patients with long bone fractures  (4 patients - upper extremity, 25 patients - lower extremity). In 8 patients, who underwent a prophylactic fasciotomy after previous arterial injury, we had to combine this technique with the split skin graft (2 patients - upper extremity, 6 patients - lower extremity). The average age of the patients was 32,2 years (22 - 55 years). The average width of the fasciotomy wound was 5,2cm (4 - 9) on an upper extremity, 10,6cm (5 -16) on a lower extremity. In the above-mentioned group of 7 patients, the average IMP during the approximation procedure was 35 mmHg (30-40) and the average CK concentration was 5,6 ukat/l (1,2-8,8). The average approximation time was 12,2 days (10 - 21). In 1 patient (prophylactic fasciotomy after injury to axillary artery) the approximation was achieved, using the new original plastic clips attached to the leading K wires. In none of the patients we observed neither local inflammation signs nor systemic signs of myonecrosis (visceral projection syndrome was not present).

Open fasciotomy (full length skin & fascia incisions) is mandatory in acute compartment syndrome in order to prevent permanent injury to the soft tissues. There is no skin loss at the time of the fasciotomy but difficulty in closure of the wound (due to retraction of the skin edges away from the underlying exposed tissue). Covering the wound with a split-skin graft has often unsatisfactory results and requires prolonged care. Therefore, many techniques for skin-edges approximation after the fasciotomy have been developed [2, 3, 5, 8, 11]. Almekinders [1] described the placing of staples along the skin edges at the time of fasciotomy and passing interrupted large nylon suture through the staples like shoe eyelet’s. Postoperatively, these sutures were tightened daily and delayed primary closure was possible after 5 to 10 days using simple sutures or steri-strips. A similar technique of gradual closure of fasciotomy wounds using interrupted rubber vessel loops has also been described. This technique involves running a silastic vessel loop through the skin staples placed at the skin edges along the initial fasciotomy incision. Daily tightening of the vessel loop permits gradual approximation of the skin edges [6]. Recent techniques for closure of fasciotomy wounds which utilize the viscoelastic properties of the surrounding skin have emphasized the importance of excessive tension being applied at the points of fixation at the wound edges. The commercially available SureClosure device (Life Medical Sciences Inc, USA) uses multiple intradermal needles [12]. A team of American physicians (Harrah J, Gates R, Carl J, Harrah JD) have recently introduced a very simple, effective method for gradual reapproximation of margins using daily reapplication of Steri-strips [7]. Callanan et Macey [4] passed K wires subdermally along both sides of the fasciotomy before passing elastic bands to share the tension along the wound edges equally. Our method, uses the K wires inserted subdermally (transversely to the wound edges) in 2 - 3 cm intervals. They serve as the leading component that guarantees an excellent planar adaptation of the skin surface during the re-approximation of the wound margins. The tension for approximating the wound edges is achieved by inserting the plastic pulling clips onto the K wires [10]. The approximation speed (frequency of the tightening, tension force) is limited by the threat of iatrogenic compartment syndrome. During, and shortly after the tightening, IMP must not exceed 30 mmHg in normotensive patient [9, 13, 14, 15, 16, 17].

 Keywords:  fasciotomy wound – Kirschner wire technique - intramuscular pressure

1.   Almekinders LC. Gradual closure of fasciotomy wounds. Orthopaedic Rev. 1991;20:82.

2.   Asgari MM, Spinelli HM. The vessel loop shoelace technique for closure of fasciotomy wounds. Ann Plast   Surg 2000;44:225-9.

3.   Berman SS, Schilling JD, McIntyre KE, Hunter GC, Bernhard M. Shoelace technique for delayed primary closure of fasciotomies. The Am J Surg 1994;167:435-6.

4.   Callanan I, Macey A. Closure of fasciotomy wounds: A technical  modification. J Hand Surg 1997;22B:264-5.

5.   Chiverton  N, Redden JF. A new technique for delayed primary closure of fasciotomy wounds. Injury, Int Care Injured 2000;31:21-4.

6.   Cohn BT, Shall J, Berkowitz M. Forearm fasciotomy for acute compartment syndrome. A new technique for delayed primary closure. Orthopedic 1986;10:1234.

7.   Harrah J, Gates R, Carl J, Harrah JD. A simpler, less expensive technique for delayed primary closure of fasciotomies. Am J Surg 2000;180:55-7.

8.   McKenney MG, Nir I, Fee T, Martin L, Lentz K. A simple device for closure of fasciotomy wounds. Am J Surg 1996;172:275-7.

9.   Molcanyi T, Kitka M. Acute compartment syndrome induced by prolonged local pressure with visceral projection syndrome. Uraz Chir 1999;4:18-22.

10. Molcanyi T, Zivcak J, Molcanyi M, Kitka M, Rosak M, Magdo J, Molcanyiova A. A Kirschner wire technique for fasciotomy wound closure. Compartment-syndrome update 2001. International Symposium, March 9th – 11th 2001, Irsee Cloister, Germany: 66-67.

11. Narayanan K, Futrell JW, Bentz M, Hurwitz D. Comparative clinical study of the Sure-Closure device with conventional wound closure techniques. Ann Plast Surg 1995;35:485-91.

12. Narayanan K, Latenser BA, Jones LM, Stofman G. Simultaneous primary closure of four fasciotomy wounds in a single setting using the SureClosure device. Injury 1996;27:449-51.

13. Velhamos GC, Theodorou D, Demetriades D, Chan L, Berne TV, Asensio J, Cornwell EE, Belzberg H, Stewart BM. Complications and non closure rates of fasciotomy for trauma and related risk factors. World J Surg 1997;21:247-53.

14. Wiger P, Tkaczuk P, Styf J. Secondary wound closure following fasciotomy for acute compartment syndrome increases intramuscular pressure. J Orthop Trauma 1998;12:117/21.

15. Zivcak J, Molcanyi T. Clinical experience with compartment syndrome monitoring. MicroCAD 99, Miskolc, Hungary, 1999:54-57.

16. Zivcak J, Molcanyi T. Evaluating the signs of compartment syndrome in limb fractures, the frontiers of medical biophysics of 21st century, Bratislava, Slovakia, 1999:56-59.

17. Zivcak J, Molcanyi T, Slosarcik S.  Sensing system for compartment syndrome measurement. Acta Mechanica Slovaca 2000;2:101-106.