Full recovery of an extreme thermal-crush trauma with nerve injury after aggressive debridement and plastic reconstruction: The essential role of timely cooperation between trauma and plastic surgeon

Abstract text (incl. references and figure legends)

A 26 year-old man was referred to our Centre after an industrial thermal-crush trauma due to a heat press on his thorax, right arm and face.

At the first evaluation in the Emergency Department, main findings were third-degree burns of right ear, right hemithorax and arm, associated with extensive traumatic soft tissue loss (Fig.1A). A total body CT scan revealed sternum fracture, right rib fractures (II-IX) with ipsilateral pulmonary contusion and small pneumothorax.

The patient was resuscitated in the ICU. An extended debridement was performed within 24 hours from admission. We found necrosis of right Latissimus dorsi, Biceps brachii, Teres major, and complete high Median, Ulnar, and Muscolocutaneous nerves transections (Fig.1B).

The reconstructive surgery was performed four days later. An autologous right sural nerve grafting was used to bridge the gap of the Ulnar and Musculocutaneous nerve. The reconstruction of the Median nerve was not performed because its distal end was undetectable. A free anterolateral thigh (ALT) flap was moved to cover the exposed vessel-nerve bundle in the right axillary area. Artificial dermis (INTEGRA) and multiple skin autografts were subsequently applied to cover the thoraco-dorsal region and arm. The exposed auricular cartilage of the ear was buried in a retroauricular skin pocket.

The post-operative course was complicated by surgical site infection and sepsis requiring long-term antibiotics and surgical drainage of purulent collections.

The patient was discharged two months after admission. During the following weeks he underwent physical therapy. At present, 8 months post-injury, the skin loss is covered (Fig.1C) and 90° abduction and flexion-extension have been restored. By contrast, the recovery of pronation-supination elbow movements is not complete and fingers movements have not been restored yet.

Fig.1. A: injury at admission; B: injury after the debridement; C: 8-month follow up

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