Clinical scenario

A 69 year old woman has slipped and caught her leg on a chair. She attends your emergency department with a large flap laceration to the anterior aspect of her right leg. She has no other injuries, no other significant past medical history, and has good social support. You want her wound to heal quickly so that she may get back to her normal activities as soon as possible. You wonder whether a primary split skin graft or a simpler procedure using the existing flap would be best to achieve this.

Three part question

In [patients with pretibial flap lacerations] is [a primary skin graft better than simple wound edge approximation] at [reducing the time to healing]?

Search strategy

Medline 1966–week 4 March 2005, Embase 1980–week 13 2005, and Cochrane Library Issue 1 2005. Medline: [pre-tibia$.mp OR pretibia$.mp] AND [exp wounds and injuries/OR lacerat$.mp. OR injur$.mp OR exp skin flaps/OR exp skin transplantation] limit to human and English language. A total of 64 articles found. Embase: [pre-tibia$.mp. OR pretibia$.mp.] AND [exp injury/OR lacerat$.mp OR exp skin transplantation/or exp skin graft/or skin flap/] limit to human and English language. A total of 54 articles found. Cochrane Library: Pretibial [all fields]. A total of 23 records found.

Search outcome

A total of 72 papers were found of which only one was relevant and of sufficient quality for inclusion (see table 3).

Comment(s)

Earlier studies only compared primary split skin grafting with grafting after failed conservative management or studied conservative management alone. This study shows that primary split skin grafting under local anaesthetic shortens the time to full healing of pretibial flap lacerations by nearly four weeks though a larger prospective randomised controlled trial would be needed to confirm this. Early mobilisation has been shown to be beneficial in the elderly after such a procedure which makes management as an outpatient the preferred option.

CLINICAL BOTTOM LINE

A primary split skin graft performed under local anaesthetic significantly reduces the healing time for pretibial flap lacerations and can be done successfully as an outpatient procedure.