Wound closure and decompression in upper limb replantation

Limb replantations and revascularizations with a significant muscle bulk may be dangerous and even have life-threatening complications. This is intimately related to the period of muscle anoxia which may lead to postischemia (crush) syndrome with its associated pathological conditions. Once blood circulation is reestablished, every step must be taken to maintain optimal blood flow and to avoid secondary ischemia within the revascularized part, due to increased pressure within muscle compartments as a consequence of traumatic and postanoxic edema formation (compartment syndrome). Therefore, wound closure and primary decompression require particular attention and experience. Methods to achieve optimal primary decompression and wound closure are described. Special emphasis is put on the importance of radical skeletal shortening, initial fasciotomies, primary excision of damaged musculature and effective skin release using the mesh graft principle.